1.
TREATMENT GUIDELINES
2019
Prof. Aboubakr Elnashar
Benha university, Egypt
ABOUBAKR ELNASHAR

2.
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
ABOUBAKR ELNASHAR

3.
CONTENTS
1.PREECLAMPSIA
2.PLACENTA ACRETA
3.TWIN TWIN TRANSFUSION SYNDROME
4.HYDROPS FOETALIS
5.AMNIOTIC FLUID EMBOLISM
6.PRETEM BITH
7.FETAL ANAEMIA
ABOUBAKR ELNASHAR

4.
1. PREECLAMPSIA
(SMFM, 2013)
 Magnesium sulfate in obstetrics.
1. Prevention and treatment of seizures in women
with PET or eclampsia
2. Fetal neuro protection before anticipated early
preterm (≤32 w) delivery
3. Short term prolongation of pregnancy (up to 48 h)
to allow for the administration of antenatal
corticosteroids in pregnant women between 24w
and 34 w who are at risk of preterm delivery within
7 days.
 FDA advises against the use of magnesium sulfate injections for more than
5-7 days to stop preterm labor in pregnant women.
 Based on this, the drug classification was changed from Category A to
Category D, and the labeling was changed to include this new warning
information
ABOUBAKR ELNASHAR

5.
 Severe PET before 34 w
(SMFM, 2011)
 expectant management of selected patients
 can improve neonatal outcomes
 requires careful in hospital maternal and fetal
surveillance.
 delivery is often required for worsening
maternal or fetal condition.
ABOUBAKR ELNASHAR

6.
 Patients who are not candidates for expectant
management
1. eclampsia
2. persistent symptoms of severe PET
3. pulmonary edema
4. DIC
5. renal insufficiency
6. abruptio placentae,
7. HELLP syndrome
8. abnormal fetal testing,
ABOUBAKR ELNASHAR

7.
 Severe preeclampsia before the limit of viability
 expectant management has been associated with
 frequent maternal morbidity
 minimal or no benefits to the newborn.
ABOUBAKR ELNASHAR

8.
2. PLACENTA ACCRETA.
(SMDM, 2011)
 Placenta previa overlying a uterine scar should be
 evaluated for the potential diagnosis of placenta accreta.
 reevaluated in 3rd T
 When the diagnosis of placenta accreta
 hysterectomy should be anticipated
 delivery in a center with adequate resource
 including those for massive transfusion.
 Intraoperatively, attention should be paid to
 Abdominal and vaginal blood loss.
 Early blood product replacement, with
 consideration of volume, oxygen carrying capacity, and
coagulation factors, can reduce perioperative
complications.
ABOUBAKR ELNASHAR

9.
3. TWIN TWIN TRANSFUSION SYNDROME
(SMFM, 2013)
 Serial sonographic evaluation
 beginning at16 w
 continuing/2 ws until delivery.
 Screening for congenital heart disease
ABOUBAKR ELNASHAR

10.
 Extensive counseling including
 Natural history of the disease
 stage I:
 more than three fourths of cases remain stable or
regress without invasive intervention
 perinatal survival of about 86%.
 many patients may often be managed expectantly.
 stage ≥III
 Bleak
 reported perinatal loss rate of 70100%, particularly
when it presents <26 w.
 Management options and their risks and benefits.
ABOUBAKR ELNASHAR

11.
 Fetoscopic laser photocoagulation of placental
anastomoses
 Best available approach for stages II, III, and IV
TTTS in continuing pregnancies at <26 w, but
 MA data show
 no significant survival benefit
 longterm neurologic outcomes in the Eurofetus
trial were not different than in non laser treated
controls.
 Laser treated TTTS is associated with
 perinatal mortality rate of 30-50%
 5-20% chance of longterm neurologic handicap.
ABOUBAKR ELNASHAR

12.
 Steroids for fetal maturation
 should be considered at 24 0/7 to 33 6/7 w
 particularly in
 pregnancies complicated by stage ≥III TTTS
 those undergoing invasive interventions.
ABOUBAKR ELNASHAR

13.
4. Management of Hydrops foetalis
(SMFM, 2015)
 Evaluation with
 antibody screen (indirect Coombs test) to
determine if it is nonimmune
 detailed sonography of the fetus and placenta:
 echocardiography
 assessment for fetal arrhythmia
 middle cerebral artery Doppler evaluation for
anemia
 fetal karyotype and/or chromosomal microarray
analysis
regardless of whether a structural fetal anomaly is identified.
ABOUBAKR ELNASHAR

14.
 Recommended treatment depends on
 Underlying etiology
 Pestational age
 Preterm delivery is recommended only for obstetric
indications including development of mirror
syndrome.
 Corticosteroids&
 Antepartum surveillance those with
 an idiopathic etiology
 an etiology amenable to prenatal or postnatal
treatment
 those in whom intervention is planned if fetal
deterioration occurs.
ABOUBAKR ELNASHAR

15.
 Delivery
 at a facility with the capability to stabilize and treat
critically ill newborns.
 Prognosis depends on
 etiology
 response to therapy if treatable
 gestational age at detection and delivery.
 aneuploidy confers a poor prognosis
 even in the absence of aneuploidy, neonatal
survival is often <50%.
 Mirror syndrome
 a form of severe preeclampsia that may develop in
association with fetal hydrops and in most cases
 necessitates delivery.
ABOUBAKR ELNASHAR

16.
5. AMNIOTIC FLUID EMBOLISM: AFE
(SMFM, 2016)
 Consideration of AFE in the differential diagnosis of
sudden cardiorespiratory collapse in the laboring or
recently delivered woman
(GRADE 1C)
 No need for any specific diagnostic laboratory test to
either confirm or refute the diagnosis of AFE; at the
present time
{AFE remains a clinical diagnosis}
(GRADE 1C)
ABOUBAKR ELNASHAR

17.
 Immediate high quality cardiopulmonary resuscitation
with
 standard basic cardiac life support and
 advanced cardiac life support protocols
(GRADE 1C)
 Multidisciplinary team
 anesthesia,
 respiratory therapy
 critical care
 maternal fetal medicine
(Best Practice)
ABOUBAKR ELNASHAR

18.
 Immediate delivery in the presence of a fetus ≥23 w
of gestation
(GRADE 2C)
 Adequate oxygenation and ventilation
 when indicated by hemodynamic status, the use of
vasopressors and inotropic agents in the initial
management of AFE.
 Excessive fluid administration should be avoided
(GRADE 1C)
ABOUBAKR ELNASHAR

19.
 Early assessment of clotting status
 Early aggressive management of clinical bleeding
with standard massive transfusion protocols
{coagulopathy may follow cardiovascular collapse with AFE}
(GRADE 1C).
ABOUBAKR ELNASHAR

20.
6. PRETEM BIRTH
(SMFM, 2012)
 singleton gestations, no prior PTB, and short CL ≤ 20
mm at ≤ 24 w:
 vaginal progesterone
 90mg gel or
 200mg suppository
 reduction in
 PTB
 perinatal morbidity and mortality
ABOUBAKR ELNASHAR

21.
 Singleton gestations with prior PTB 20-36 6/7 w:
 17alphahydroxyprogesterone caproate
 250 mg IM weekly
 starting at 16-20 w
 until 36 weeks
 if TV CL shortens to < 25 mm at < 24 w
 cervical cerclage.
ABOUBAKR ELNASHAR

22.
 Progestogens have not been associated with
prevention of PTB
 multiple gestations
 preterm labor
 preterm premature rupture of membranes.
 There is insufficient evidence to recommend the
use of progestogens in women with any of these
risk factors, with or without a short CL.
ABOUBAKR ELNASHAR

23.
Society for Maternal –Fetal
Medicine 2012
ABOUBAKR ELNASHAR

24.
 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.
ABOUBAKR ELNASHAR

25.
 Don’t use
progestogens
for PTB prevention
in uncomplicated multifetal gestations.
No reduction
ABOUBAKR ELNASHAR

26.
 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
Don’t place a cerclage in women with short cervix who are pregnant with twins.
Women with a short cervical length who are pregnant with twins are at very high risk for
delivering preterm, but the scientific data, including a meta-analysis of data published on this
issue, shows that cerclage in this clinical situation not only is not beneficial, but may in fact be
harmful, i.e., associated with an increase in preterm births.
ABOUBAKR ELNASHAR

27.
7. FETAL ANAEMIA
(SMFM, 2015)
1. Middle cerebral artery peak systolic velocity
(MCAPSV)
be used as the primary technique to detect fetal
anemia
2. Amniotic fluid delta OD450
not be used to diagnosis fetal anemia
ABOUBAKR ELNASHAR

28.
3. MCAPSV assessment be
 reserved for those patients who are at risk of
having an anemic fetus
 proper technique for MCAPSV evaluation includes
 assessment of the middle cerebral artery close
to its origin, ideally at a zero degree angle
without angle correction
ABOUBAKR ELNASHAR

29.
4. if a fetus is deemed at significant risk for severe fetal
anemia
 MCA greater than 1.5 multiples of the median or
 Hydropic
 fetal blood sampling be performed with preparation
for an intrauterine transfusion, unless the
pregnancy is at a gestational age when the risks
associated with delivery are considered to be less
than those associated with the procedure
ABOUBAKR ELNASHAR

30.
5. if a fetus is deemed at significant risk for severe fetal
Anemia
patient be referred to a center with expertise in
invasive fetal therapy
6. MCAPSV
 determine the timing of a second transfusion in
fetuses with anemia
 a predicted decline in fetal hemoglobin may be
used for timing the second procedure
7. pregnancies with a fetus at significant risk for fetal
anemia
be delivered at 37-38 weeks of gestation unless
indications develop prior to this time.
ABOUBAKR ELNASHAR

31.
 Foetal blood sampling
 When invasive testing is planned for suspected
 severe fetal anemia or
 thrombocytopenia:
 recommended as the procedure of choice,
 with availability of immediate transfusion if
confirmed.
 Not recommend for indications in which other less
invasive, and therefore lower risk, alternatives are
available.
ABOUBAKR ELNASHAR