International Federation of Gynecology and Obstetrics Working Group on Best Practice on Maternal-Fetal Medicine presents 8 guidelines for good practice: 1) Screening for chromosomal abnormalities and NIPT, recommending first line screening be by combined test and that cfDNA be offered in combination with combined test from 11-13 weeks. 2) Preconceptional folic acid for prevention of neural tube defects, recommending all women of childbearing age take 400ug daily. 3) Cervical length screening and progesterone for prediction and prevention of preterm birth, recommending universal cervical length screening at 19-23 weeks and progesterone for women with short cervix.

1. International Federation of Gynecology and Obstetrics
Working Group on Best Practice on Maternal-Fetal Medicine
Presented by
NARENDRA MALHOTRA MD,FICOG,FRCOG
Committee member
President Elect ISPAT
Past President FOGSI,India
Sec SAFOG

2. OUR PUBLICATION AT
FIGO

4. ABSTRACT

5. This is often not the test that is good or bad
but the way we use it
FIGO GUD PRACTICE ADVISES

6. PREMISES

7. Why good practice advises
• Too many recent developments
• Many asumptions for best managements of
pregnancy and child birth
• FIGO’s attempt to give a clearity for the
applications of new techniques and clinical
options
• These issues apply univesally
• More important in inndustrializesd and semi
industrialized countries
• Authoritative guidance is urgently needed to
establish best practice

8. FIGO RECOMMENDATIONS

9. FIGO GUIDELINES
PRESENT 8 GOOD
PRACTICE ADVISES
• 1.SCREENING FOR CHROMOSOMAL
ABNORMALITIES AND NIPD
• 2.PRECONCEPTIONAL FOLIC ACID FOR THE
PREVENTION OF NEURAL TUBE DEFECTS
• 3.CERVICAL LENGTH AND PROGESTERONE
FOR THE PREDICTION AND PREVENTION OF
PRETERM BIRTH
• 4. & 5.MAGNISIUM SULPHATE USE IN
OBSTETRICS
• 6.ULTRASOUND EXAMINATION IN PREGNANCY
• 7.THYROID DISEASE IN PREGNANCY
• 8.HYPERGLYCEMIA IN PREGNANCY

10. 1.FIGO RECOMMENDS FOR
SCREENING FOR CHROMOSOMAL ABNORMALITIES AND
N.I.P.T.
• MATERNAL AGE HAS LOW
PERFORMANCE AS A
SCREENING TOOL FOR FETAL
CHROMOSOMAL
ABNORMALITIES DETECTION
RATE OF 30-50% AND FALSE
POSITIVE OF 5-20%(INVASIVE
TESTING SHOULD NOT BE
CARRIED OUT BY ONLY
MATERNAL AGE)
• FIRST LINE SCEENING FOR
TRISOMIES 13-18-21 SHOULD
BE BY COMBINED
TEST( AGE+FETAL
NT+FHR+MATERNAL SERUM
Bhcg and PAPP-A) the detection
rates are 90 % for 21and 95%for
18 and 13 with a falso positive of
5%

11. Cont….
• Combined test could be
improved by using additional
USG markers( nasal
bone+ductus venosus
+tricuspid flow) when all
these are added the
detection rate is 95% with
less than 3% false positive.
• Screening by cfDNA has a
detection rate of 99% for
21,97%for 18 and 92% for
13 with a false positive of
0.4%

12. Cont….
• So as of now the cfDNA should be in
combination to the combined test at
11-13 weeks

13. FIGO recommends
the following
stratergy for prenatal
diagnosis
• The patients with combined test risk
over 1:100 can be offered cfDNA or
invasive testing
• Combined test risk of 101-2500;pts
can be offered the option of cfDNA
• Combined test risk lower than 1 in
2500:there is no need for further
testing)

14. 2. FIGO RECOMMENDS
PRECONCEPTIONAL FOLIC ACID FOR THE
PREVENTION OF NEURAL TUBE DEFECTS
• All women who plan to become
pregnant or women of child bearing
age not on contraceptives should
utilize 400 ug(0.4 mg) of synthetic
folic acid,at least 30 days before
conception and continue throughout
first trimester
• All women coming for any medical
appointment should be advised on the
benefits of folic acid

15. Cont……….
• Health care providers should
inform and council women a)
benefits of folic acid in pregnancy
is not only prevention of NTD but
also for IUGR,autism,preterm and
cleft palate defect
prevention,b)folic acid 0.4 mg(400
ug) can be taken for years without
any know adverse effects and
c)effects of high doses of folic
acid are not known except
complicating diagnosis of vit B 12
deficiency,hence the dose of daily
folic acid supplimentation should
be kept below 1 mg except in
women at high risk of NTD

16. Cont………
• Women with high risk factors for NTD should be
advised 4000 ug daily at least 30 days before
conception and continued in first trimester
• The high risk factors are
a)NTD in previous pregnancy
b)Partner affected by NTD
c)First degree relative affected by NTD
d)Prepregnancy diabetes
e)Pts. on antiepileptic(valproic acid or
carbamazepine)
f)pts. on folate
antagonists(methotrexate,sulfonamides etc)

17. 3.FIGO recommends Cervical
length and progesterone for
prediction and prevention of
PRETERM birth
• Sonographic cervical length measurement should
be performed for all pregnant women at 19-23
weeks of gestation by TVS as a part of the
ANATOMICAL SURVEY scan
• Women with short cervix <25 mm diagnosed in
mid trimester should be offered daily vaginal
micronised progesterone therapy for prevention
of preterm birth and neonatal morbidity
• Vaginal micronised progesterone 200 mg soft
capsule nightly or 90 mg micronized progesterone
gel each morning

18. Cont………
• Universal cervical length and vag
progesterone is a cost effective model
for prevention of preterm births
• In cases where TVS is not available
,other devises may be used for
screening and measuring cervical
length objectively

19. THESE THREE ADVISES HAVE BEEN ENDORSED BY
THE FIGO BOARD AND ALSO PUBLISHED in 2014-2015

20. MAY 2015 :5 NEW GOOD
PRACTICE ADVISES WERE
ENDORSED BY FIGO BOARD in
2015
• PREPARED BY FIGO
WORKING GROUP
• AND RELEASED AT
VANCOUVER FIGO
CONGRESS OCT 2015

21. THESE ARE
• MAGNISIUM SULPHATE USE IN OBSTETRICS(2)
• ULTRASOUND EXAMINATION IN PREGNANCY
• THYROID DISEASE IN PREGNANCY
• HYPERGLYCEMIA IN PREGNANCY

22. 4.& 5. FIGO RECOMMENDS
MAGNISIUM SULPHATE USE IN
OBSTETRICS
• intravenous/intramuscular mag sulphate is
indiacted during labour and post partum for all
women diagnosed with severe p.i.h.
• for elective c.s. in such pts mag sulf is given
atleast 2 hrs before the operation
• the dose iv mag sulf 4-6 g diluted in 100 ml
ns/dw5 over 15-20 mins with maintainance of 1-2
g per hour……for im mag sulf 10 g can be
undiluted 50 % solution divided into each
buttocks followed by 4-5 g every 4 hrly

23. Cont……..
• Mandatory monitoring of respiratory rate,deep
tendon reflexes and urinary output ,particularly in
oligouric patients…..mag toxicity is treated by
10% 10 ml calcium gluconate
• In women with normal renal functions half time for
excretion of magnisium is 4 hours
• There is no association of mag sulf use with
congenital birth defects

24. Cont………..
• Very long term infusion may be related to
sustained hypocalcemia in fetus and may
result in congenital rickets and adverse
bone mineralisation
Neonatologists should be alerted to look
for neonatal neurologic depression,resp
depression,muscle weakness and
hyporeflexia in fetus born to women on
mag sulf infusion

25. 5.MAGNISIUM SULPHATE USE IN
FETAL NEUROPROTECTION
• For imminent preterm birth (active labour with or
without PROM) or elective preterm birth for
maternal or fetal indication….antenatal mag sulf
should be considered for fetal neuroprotection
• Antenatal mag sulf should be considered from
viability to 31 + 6 days gestation
• Mag sulf should be discontinued if delivery in no
longer imminent or after max of 24 hours of
therapy

26. Cont…….
• Mag Sulf loading dose 4 g over 30 mins,ideally 4-
6 hours before delivery followed by infusion of
1g/hour until delivery occurs .however there may
be still benefit even if given less than 4 hours
• There is insufficient evidence of use of a repeat
course
• Delivery should not be delayed in order to
administer antenatal mag sulf if there is a
maternal and fetal indication for emergency
• Maternity care provider should use the standard
monitoring protocols same as in PIH/ECLAMSIA
• Neonatologist should be alerted to asses neonate
for effects of mag sulf

27. 6. FIGO RECOMMENDS
ULTRAOUND EXAMINATION IN
PREGNANCY• ultrasound in pregnancy should be
performed by specially qualified
operators and undergoing continous
medical education and quality
assurance programs
• current equipments should have the
capability to perform tvs and doppler
and these equipment subjected to
adequate maintainance
• All pregnant women should be offered at
least 2 ultrasound screening exams( 11-
13 week+6d and at 18-22 weeks ….but
optimally at least one from 20 weeks
onwards

28. Cont………• Medically indiacted ultrasound in
pregnancy is safe,proper
councelling and proper report and
images
• First trimester ultrasound
recoginizes 5 aims and objectives
1.asses viabilty 2.asses
gestational age 3.diagnose and
characterize multiple gestation
4.anatomical malformation screen
for anomalies detectable at this
stage 5.measure NT
• First trimester ultrasound should
include visualisation of both
ovaries

29. Cont…….
• Mid trimester ultrasound also recognises 5 aims
and objectives 1. asses gest age if not yet been
done 2.asses fetal biometry 3.conduct anatomical
survey to screen for anomalies 4.asses placenta
and cord insertion 5.measure cervical length by
TVS as a part of risk assesment for preterm births
• Ultrasound and DOPPLER should be liberally
used in the third trimester to asses AMNIOTIC
FLUID,CERVICAL LENGTH,FETAL GROWTH and
FETAL WELLBEING

30. • Biometric tests (tests to measure size)
• Biometric tests are designed to
predict size and growth
AC, EFW

31. 08/18/16 DR.PRASHANT 31
Ask for serial
measurements and plot the
findings in growth chart –
not single USG
reading

32. The anatomical survey in second
trimester
At a glance
Head Intact cranium
Cavum septi pellucidi
Midline falx
Thalami
Cerebral ventricles
Cerebellum
Cisterna magna
Face Both orbits present
Median facial profile
Mouth present
Upper lip intact
Neck Absence of masses (e.g. cystic
hygroma)
Chest/Heart
Normal shape/size of chest and
lungs
Heart activity present
Four-chamber view of heart in
normal position
Aortic and pulmonary outflow
Abdomen
Stomach in normal position
Bowel not dilated
Both kidneys present
Cord insertion site
Skeletal
No spinal defects or masses
(transverse and sagittal)
Arms and hands present, normal
relationships
Legs and feet present, normal
relationships
Placenta
Position
No masses present
Accessory lobe
Umbilical cord
Three-vessel cord
Genitalia
Male or female

33. Placenta and cervix
Guidelines for maturity and
position
+
+
+
+
+
+
• Women with a history of uterine surgery and low anterior placenta or
placenta previa are at risk for placental attachment disorders. In these
cases, the placenta should be examined for findings of accreta, the
most sensitive of which are the presence of multiple irregular placental
lacunae that show arterial or mixed flow
• Abnormal appearance of the uterine wall–bladder wall interface is
quite specific for accreta, but is seen in few cases. Loss of the
echolucent space between an anterior placenta and the uterine wall is

34. Maternal anatomy
Guidelines
• Currently, there is
sufficient evidence to
recommend routine
cervical length
measurements with a
transvaginal scan at the
mid trimester even in an
unselected population
• Uterine fibroids and
adnexal masses should
be documented

35. Cont……..
• The results of a screening ultrasound in first and
second trimester can generate refferal for
specialised or focused ultrasound
• In multiple pregnancy choionicity should be
optimally determined before 15 weeks
• The use of ultrasound in labour should be
encouraged to determine fetal and placental
position as well as prior to instrumental delivery
• The use of ultrasound should be encouraged in
postpartum period to evaluate non physiologiccal
bleeding and infections

36. Thyroid Disorders in
Pregnancy
Thyroid disease is the second most
common cause of endocrine
dysfunction in women of child bearing
age.
Hypothyroidism is more common during
pregnancy than hyperthyroidism.

42. Pearls for Practice

43. 7.FIGO recommends for
THYROID diseases in
pregnancy• Screening for thyroid function recommended in
first trimester particularly in idodine deficient
countries and in symptomatic cases.TSH is
superior method of screening ,free T4 and TPO
Ab are not recommended for screening.TSH is
best done by C.I.A or 3rd
generation RIA. NOTE
THAT NORMAL THYROID VALUES CHANGE IN
EACH TRIMESTER
• Treatment of Hypothyroidism is recommended
when TSH levels and >2.5 and >3 in
first/second/third trimesters.only treat with L-
thyroxine.treating subclinical hypothyrodism is
debatable. Women on L thyroxine before
pregnancy should increase the dose by 30-50 %

44. Cont……….
• Treatment of hyperthyroidism due to Grave’s
disease is by antithyroid drugs
(PROPYLTHIOURACIL-PTU or
CARBIMAZOLE/METHIMAZOLE.its not
recommended to change the drug during
pregnancy.sometimes symptomatic treatment with
b-blockers for short time may be needed
• Primary prevention of hypothyroidism is by a
healthy diet and iodised fortified salt

45. Cont……
• If the patient has a thyroid nodule she should be
evaluated and treated during pregnancy.thyroid
ultrasound scan and FNA.Surgery should be
preferably deffered to post partum period
• Follow up and post partum TSH evaluation and
reduction of L-thyroxine dose to prepregnant
levels

46. International Federation of Gynecology and Obstetrics
Working Group on Best Practice on Maternal-Fetal Medicine

48. International Federation of Gynecology and Obstetrics
Working Group on Best Practice on Maternal-Fetal Medicine
• All pregnant women should be tested for
hyperglycemia. Universal testing by all member
associations
• WHO(2013) and IADPSG(2010) criteria for
diagnosis of gestational diabetes must be used
• Diagnosis of HDP should be on properly collected
venous plasma samples. In developing countries
a plasma calibrated hand held gluocometer is
acceptable
• Management of HDP should be in accordance
with available national resources and

52. International Federation of Gynecology and Obstetrics
Working Group on Best Practice on Maternal-Fetal Medicine
• Nutrition and physical activity counselling is a
must and continue after birth also
• Insulin is added if lifestyle and diet modification
does not control Hyperglycemia. Metformin and
or glyburide may be used in 2nd
and 3rd
trimesters.
Oral drugs may be first choice in 2nd
and 3rd
trimester
• Postpartum 8 weeks visit counselling and life
style modifications for mother and child is
necessary
• Public health measures to increase awareness
and acceptance of preconception counselling
Cont…….

53. THANK YOU