The 10 recommendations

Aboubakr Elnashar

Benha university, Egypt

Society for Maternal-Fetal Medicine

(SMFM)

Established in 1977

Mission

• improving maternal and child outcomes

• raising the standards of prevention, diagnosis,

and treatment of maternal and fetal disease

through:

• support for the clinical practice of maternal-

fetal medicine

• research

• education/training

• advocacy

• health policy leadership

Evidence-based recommendations

1. Don’t perform

maternal serologic screening for CMV and

Toxoplasmosis as part of routine ante natal

testing.

1. Poor predictive value of these tests

2. Potential harm due to false positive results.

Serologic screening during pregnancy for both

should be reserved for:

Clinical or

Ultrasound suspicion of maternal or fetal

infection.

U/S: F toxoplasmosis

No findings: 80%

Specific findings:

1. Hydrops

2. Ventriculomegaly

3. Intracranial calcifications (periventricular)

Non specific findings:

1. Ascites

2. Hepatomegaly

3. liver calcification

4. Pericardial /pleural effusion

5. Oligohydramnios, IUGR, placental thickness

Severe ventriculomegaly

Ascites

Hepatic calcifications

US F CMV:

1. Ascites and hydrops

2. Microcephaly

3. IUGR

4. Ventriculomegaly

5. Intracerebral calcification.

2. Don’t do

inherited thrombophilia evaluation for women

with histories of

RM

IUGR

PET

Abruption.

Scientific data supporting a causal association

are lacking.

Testing for antiphospholipid antibodies, when

clinically indicated, should be limited to

1. Lupus anticoagulant

2. Anticardiolipin antibodies

3. beta 2 glycoprotein antibodies.

Thrombophilia

Predisposition to thrombosis

Causes:

I. Acquired:

antiphospholipid syndrome (APS).

II. Inherited

1. Factor V Leiden mutation (FVL) (homozygous or

heterozygous)

2. Prothrombin (FII) G20210A mutation

(Pm) (homozygous or heterozygous)

3. Deficiencies of the endogenous anticoagulants

Antithrombin (AT)

Protein C

Protein S.

4. Hyperhomocysteinemia (C677T) mutation Methyl tetrahydrofolate reductase (MTHFR C677T)

RCOG, 2011

Inherited Thrombophilia: 2nd TRM 1. Factor V Leiden mutation

2. Prothrombin gene mutation

3. Protein S deficiency

Turkish Germany Association, 2016

Factor V Leiden, prothrombin G20210A mutation,

and protein S deficiency:

2nd TRM

Impact on other pregnancy complications:

conflicting.

No definite association between protein C and

antithrombin deficiency and adverse pregnancy

outcome, primarily due to their low prevalence.

Egyptian studies

Mohamed et al, 2012

The prevalence of thrombophilic mutations is higher

in cases of RM than control:

Factor V leiden

Prothrombin, and

Methylene tetra hydro folate reductase

Osman and Abulata, 2015

Methyl tetrahydrofolate reductase (MTHFR

C677T) polymorphism

FVL mutation

significantly higher in cases than controls in a

group of Egyptian women with un RM

3. Don’t screen for

IUGR with Doppler blood flow studies.

1. Inconsistent results.

2. No standards for the optimal definition of

Abnormal test

Best gest age for the performance of the test

Technique for its performance.

However, once the diagnosis of IUGR is

suspected:

antenatal fetal surveillance, including umbilical

artery Doppler flow studies, is beneficial.

RCOG, 2013

Screening for IUGR

1. At booking for risk

factors

1 major risk factor:

At 26-28 W:

Serial US for

fetal size and

Um A D

3 minor risk factors:

At 20-24w:

Ut A D:

Abnormal [PI]

>95th centile:

At 26-28w: Serial US for

fetal size

Um A D

4. Don’t offer

noninvasive prenatal testing (NIPT) to

low-risk patients or

make irreversible decisions based on the

results of this screening test.

A scientific breakthrough came in 1997 with the

recognition of fetal cell-free DNA (cfDNA) contained

in maternal plasma.

1. Fetal sex determination.

2. Rhesus typing.

3. Screening for autosomal aneuploidies: trisomy

21, 18 and 13

4. Microdeletion syndromes.

5. Sex chromosome aneuploidy.

6. Single gene disorders.

7. Pregnancy complications.

1. NIPT has only been adequately evaluated in

singleton pregnancies at high risk for chromosomal

abnormalities: •Maternal age >35 •Positive screening •US suggestive of aneuploidy •Translocation carrier at increased risk for trisomy 13, 18 or 21, or •Prior pregnancy with a trisomy 13, 18 or 21.

2. Utility in low-risk pregnancies: unclear

3. False positive and false negative results,

particularly for trisomy 13 and 18.

4. Any positive NIPT result should be confirmed with

invasive diagnostic testing prior to a termination of

pregnancy.

Pretest counseling: to explain the benefits and limitations.

5. Don’t order

serum aneuploidy screening after fetal cell

free DNA aneuploidy screening has already

been performed.

1. Both serum biochemistry and cell free DNA:

screening tests for fetal aneuploidy.

2. Low-risk results on either test: limited clinical

value of performing the other screen.

3. While serum screening may identify some

aneuploidies not detected by cell free DNA, the

yield is too low to justify this test if cell free DNA

screening has already been performed.

Serum biochemistry screening:

From 11 to 14 w and 14 to 20 w

–Integrated test

NT

Pregnancy-associated plasma protein A

PAPP-A +hCG,

AFP,

uE3,

inhibin A

–Serum integrated test

PAPP-A +hCG,

AFP,

uE3,

inhibin A

6. Don’t perform

routine cervical length screening for PTB risk

assessment in asymptomatic women before

16 w or beyond 24 w.

1. Before 16 w:

The predictive ability of cervical length

measurement: limited.

2. Beyond 24 w:

has not been proven to be effective.

It should be performed, when indicated, between

16 and 24 w.

Society for Maternal –Fetal

Medicine 2012

7. Don’t place

women, even those at high-risk, on activity

restriction to prevent PTB.

1. No studies documenting an improvement in

outcomes

2. Many studies:

untoward effects on the mother and family,

including negative psychosocial effects.

8. Don’t use

progestogens for PTB prevention in

uncomplicated multifetal gestations.

No reduction

9. Don’t place

cerclage in women with short cervix who are

pregnant with twins.

Meta-analysis of data:

cerclage in this clinical situation not only is not

beneficial, but may in fact be harmful,

i.e., associated with an increase in PTB

10. Don’t perform

antenatal testing on women with GDM who

are

well controlled by diet alone

without other indications for testing.

Risk of SB due to uteroplacental insufficiency is

not increased.

Antenatal testing

BPP

NST

The 10 recommendations

1.Don't perform maternal serologic studies for CMV

and toxoplasma as part of routine prenatal

laboratory studies.

2.Don’t do an inherited thrombophilia evaluation for

women with histories of pregnancy loss, IUGR,

preeclampsia and abruption.

3.Don’t screen for IUGR with Doppler

blood flow studies.

4. Don’t offer noninvasive prenatal testing to low-

risk patients or make irreversible decisions based

on the results of this screening test.

5. Don't order serum aneuploidy screening after cell

free DNA aneuploidy screening has already been

performed.

6. Don't perform routine cervical length screening

for PTB risk assessment in asymptomatic women

before 16 w or beyond 24 w of gestation.

7. Don’t place a cerclage in women with short cervix

who are pregnant with twins.

8. Don’t use progestogens for PTB prevention in

uncomplicated multifetal gestations.

9. Don't place women, even those at high-risk, on

activity restriction to prevent PTB.

10. Don't perform antenatal testing if GDM is well

controlled by diet alone and no other indications

for testing.