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
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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
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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.
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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,
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7. Severe preeclampsia before the limit of viability
expectant management has been associated with
frequent maternal morbidity
minimal or no benefits to the newborn.
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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.
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9. 3. TWIN TWIN TRANSFUSION SYNDROME
(SMFM, 2013)
Serial sonographic evaluation
beginning at16 w
continuing/2 ws until delivery.
Screening for congenital heart disease
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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.
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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.
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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.
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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.
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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.
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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.
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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)
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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)
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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)
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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).
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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
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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.
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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.
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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.
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25. Don’t use
progestogens
for PTB prevention
in uncomplicated multifetal gestations.
No reduction
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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.
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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
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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
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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
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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.
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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.
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