gonzalez hot topics in maternal-fetal medicine...the membranes, no ultrasound examination in the...

Hot Topics in Maternal‐Fetal Medicine

Juan M. Gonzalez Velez, MD, PhDAssociate Professor

Maternal‐Fetal Medicine Department of Ob/Gyn & RS

University of California, San Francisco

•No financial disclosures.

From: Elsevier's Integrated Pathology, 2007

Single deepest vertical pocket or amniotic fluid index as evaluation test for predicting adverse pregnancy outcome (SAFE trial): a multicenter, open-label, randomized controlled trial

S Kehl, A Schelkle, A Thomas, A Puhl, K Meqdad, B Tuschy, S Berlit, C Weiss, C Bayer, J Heimrich, U Dammer, E Raabe, M Winkler, F Faschingbauer, MW Beckmann, M Sutterlin

Volume 47, Issue 6, Date: June (pages 674–679) 2016

Journal Club slides prepared by Dr Shireen Meher(UOG Editor for Trainees)

Introduction• Amniotic fluid volume is an integral part of assessment of

fetal wellbeing.• No consensus on the best method to assess amniotic fluid

volume.• RCTs in high-risk, post-term and intrapartum women show

that both techniques are poor predictors of adverse pregnancy outcome.

• There is less knowledge on the usefulness of these techniques in low-risk and term pregnancies.

SDP or AFI as evaluation testS Kehl et al., UOG 2016

Aim of the study


• To determine, in both high-risk but and low-risk pregnancies, which technique for estimating amniotic fluid volume (AFI or SDP) is the best test to predict adverse pregnancy outcome.

• Study design– Multicenter, open-label RCT

• Setting– Four hospitals in Germany (July 2012 to September 2013)

• Participants– Included: women with a singleton pregnancy at term and cephalic

presentation, presenting for delivery or pre-labor examination. – Excluded: women with primary Cesarean section, premature rupture of

the membranes, no ultrasound examination in the last 7 days, structural/chromosomal fetal malformation, intrauterine fetal death, placenta previa or any contraindication to vaginal delivery.


Methods

• Intervention – Women randomised to AFI or SDP measurement for estimation of

amniotic fluid volume– The diagnosis of oligohydramnios (AFI ≤5.0 cm or absence of SDP

measuring at least 2 × 1 cm) was followed by labor induction• Primary outcome

– Postpartum admission to neonatal intensive care unit (NICU)• Other outcomes:

– Rate of perinatal death, oligohydramnios, induction of labor (for oligohydramnios or without specific indication), umbilical artery pH

ResultsBaseline characteristics

In the AFI group, fewer women had • gestational diabetes• a previous Cesarean section


Results


• Primary outcome: postpartum admission to NICU– No significant difference between AFI and SDP groups

4.2% (n=21) vs 5.0% (n=25); RR, 0.85 (95% CI, 0.48–1.50); P=0.57

• Secondary outcomes with statistically significant differences– Increased risk of diagnosis of oligohydramnios in AFI group

(9.8% (n=49) vs 2.2% (n=11); RR, 4.51 (95% CI, 2.37–8.57); P

Results: high-risk vs low-risk pregnancies


• In low-risk pregnancies• Increased diagnosis of oligohydramnios using AFI

9.9% vs 2.0%; RR 5.03 (95% CI, 2.39–10.58))• More labor inductions for oligohydramnios using AFI

15.3% vs 3.9%; RR, 3.89 (95% CI, 1.84–8.27))• More cases of arterial pH < 7.10 seen in SDP

3.5% vs 1.2%; RR, 0.34 (95% CI, 0.12–0.94))

• In high-risk pregnancies• None of the above findings were significantly different between the

AFI and SDP groups• The only significant difference between AFI and SDP groups was a

lower arterial pH in the AFI group (7.25 ± 0.08 vs 7.28 ± 0.07)

• Neither the AFI nor SDP technique was superior in predicting adverse pregnancy outcome.

• Using AFI method resulted in increased diagnoses of oligohydramnios, and subsequent induction of labor for oligohydramnios.

• Abnormal CTG was seen more often using AFI compared to SDP technique.

• In low-risk pregnancies, the rate of oligohydramnios was higher with AFI compared to SDP measurement, but this was not significantly higher in high-risk pregnancies - possibly due to smaller sample size in the group.

• In low-risk pregnancies, an umbilical arterial pH < 7.10 was found more often when SDP technique was used. Since arterial base excess < –12.0 and 5-min Apgar score < 7 were not different between groups, this finding was not considered clinically relevant.

Discussion


• A Cochrane review similarly showed – AFI method for fetal surveillance increased the risk for induction of

labor (RR, 1.92 (95% CI, 1.50–2.46); 4 trials; 2138 pregnancies)– there was no difference between the two groups for rate of admission

to NICU (RR, 1.04 (95% CI, 0.85–1.26); 5 trials; 3226 babies)

• The Cochrane review also found increased risk of Cesarean section for fetal distress when AFI technique is used (RR, 1.46 (95% CI, 1.08–1.96)). This study found increased risk of abnormal CTG but not Cesarean section.

– As there were more women with gestational diabetes and previous Cesarean section in the SDP group, it remains possible that Cesarean-section rate could have been higher in this study in the AFI group if these risk factors were balanced in the two groups.

Discussion: comparison with other studies


Conclusions


• Use of the AFI method in routine obstetric assessment resulted in more women being diagnosed with oligohydramnios and being induced for an abnormal amniotic fluid volume without improving the perinatal outcome.

• The SDP method is therefore the favorable method to estimate amniotic fluid volume, especially in a population with low-risk pregnancies.

Discussion points

• Should the use of AFI technique for assessment of amniotic fluid volume be abandoned, for both low- and high-risk pregnancies?

• What is the clinical significance of increased rate of abnormal CTG seen with the AFI method in this study and increased Cesarean sections for fetal distress in the Cochrane review? Could AFI be identifying a more vulnerable population of babies?

• There is a need to explore alternative methods for amniotic fluid volume assessment that have better correlation with adverse pregnancy outcomes.

Future perspectives


Illustration by Alex Baker, DNA Illustrations, Inc.

Methods

• Multicenter, randomized, controlled, parallel‐group, unmasked trial• Low‐risk nulliparous women between 34w0d‐38w6d• Live singleton, cephalic fetus• No contraindications to vaginal delivery

• No planned cesarean deliver• Low‐risk

• No maternal or fetal condition that would be an indication for delivery

SMFM

• It is reasonable to offer elective IOL to low‐risk, nulliparous women at or beyond 39 weeks and 0 days of gestation. We recommend that providers who choose this approach ensure that women meet eligibility criteria of the ARRIVE trial.

• We recommend against offering elective IOL to women under circumstances that are inconsistent with the ARRIVE study protocol unless performed as part of research or quality improvement.

• We recommend that further research be conducted to measure the impact of this practice in settings other than a clinical trial.

www.pinterest.com/icpcare/icp‐awareness‐month‐intrahepatic‐cholestasis‐of‐pr/

Background

• Intrahepatic cholestasis of pregnancy (ICP) is associated with adverse perinatal outcome

• The association with the concentration of specific biochemical markers is unclear

• Quantified the adverse perinatal effects ICP in women with increased serum bile acid concentration

• Determined whether elevated bile acid concentrations were associated with risk of stillbirth and preterm birth

Method • Systematic review / meta‐analysis

• Studies that reported perinatal outcomes for women with ICP and serum bile acid concentrations• Inclusion criteria

• ICP definition based upon pruritus and elevated serum bile acid concentrations, with or without raised liver aminotransferase concentrations

• Case‐control, cohort population‐based studies and RCTs• Minimum 30 participants | Perinatal outcomes and bile acid concentrations available

• Exclusion criteria• Case reports, non‐cohort studies• Selection bias such as exclusion of patient groups with poor outcomes• ‘Letters to the Editor’ without clear peer review

• Statistical Analysis• ICP and adverse perinatal outcomes: Random effects meta‐analysis to determine risks• Associations between biochemical markers and adverse outcomes

• Logistic and stepwise logistic regression, using individual patient data

Result

23 studies available for meta‐analysis (out of 109)5,557 ICP cases |165,136 controls27 study authors provided individual patient data (5,269 ICP cases)

• ICP and association with stillbirth (p=0.0016)• ICP: 0.91%• Control: 0.32%• odds ratio (OR) 1.46 (95% CI, 0.73–2.89)

• ICP was associated with higher risk:• spontaneous preterm birth (OR 3.47) • Iatrogenic preterm birth (OR 3.65) • Meconium stained fluid (OR 2.60) • NICU admission (OR 2.12)

Results

For singleton pregnancies, stillbirth risk was associated with maximum total bile acid concentration (not ALT)

Treatment with ursodeoxycholic acid did not significantly affect this association

Results

Stillbirth prevalence in ICP higher with total bile acids ≥100 μmol/L•

Conclusion

• Limitations• Possibility of incomplete data and significant number of iatrogenic PTD

• Risk of stillbirth with ICP increases compared to a general population when serum bile acid concentrations are ≥100 μmol/L

https://www.uabmedicine.org/patient‐care/treatments/pregnancy‐and‐congenital‐heart‐clinic ©California Department of Public Health, 2017; supported by Title V funds. Developed in partnership with California Maternal Quality Care Collaborative Cardiovascular Disease in Pregnancy and Postpartum Taskforce. Visit: www.CMQCC.org for details

CA-PAMR Top 5 Causes of Death 2002-2006 (N=257)

Grouped Cause of Death, per CA-PAMR Committee

Pregnancy-Related Deaths N (%)

Cardiovascular disease 64 (25)Cardiomyopathy 42 (16)Other cardiovascular 22 (9)

Preeclampsia/eclampsia 45 (18)Obstetric hemorrhage 25 (10)Sepsis 23 (9)Venous thromboembolism 22 (9)TOTAL 257

CVD Pregnancy-Related Mortality Rate: 2.4 deaths /100,000 live births

Alison Young, USA TODAYUpdated 3:58 p.m. PST Mar. 6, 2019

Objectives and Methods

• Describe the clinical characteristics of stroke and opportunities to improve care in a cohort of preeclampsia‐related maternal mortalities in California.

• California Pregnancy‐Associated Mortality Review retrospectively ‐• Cohort of preeclampsia pregnancy‐related deaths CA (2002 to 2007) • Stroke cases were identified among preeclampsia deaths• Case summaries were reviewed with attention to clinical variables, particularly hypertension.

Results

• 54 preeclampsia pregnancy‐related deaths • 33 were attributed to stroke • SBP exceeded 160 mm Hg in 96% of cases, and DBP was 110 or higher in 65% of cases.

• HELLP was present in 38% (9/24) • Eclampsia occurred in 36% of cases• Headache was the most frequent symptom (87%) preceding stroke. • Elevated liver transaminases were the most common lab abnormality (71%).

Conclusion

• Stroke is the major cause of maternal mortality associated with preeclampsia or eclampsia.

• All but one patient in this series of strokes demonstrated severe elevation of systolic blood pressure

• Antihypertensive treatment was not implemented in the majority of cases. Opportunities for care improvement exist and may significantly affect maternal mortality.

https://www.cmqcc.org/

Number 212 Pregnancy and Heart Disease

Presidential Task Force on Pregnancy and Heart DiseaseCommittee on Practice Bulletins—Obstetrics. This Practice Bulletin was developed by the American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins–Obstetrics in collaboration with the Presidential Task Force on Pregnancy and Heart Disease members

May 2019

©California Department of Public Health, 2017; supported by Title V funds. Developed in partnership with California Maternal Quality Care Collaborative Cardiovascular Disease in Pregnancy and Postpartum Taskforce. Visit: www.CMQCC.org for details

CVD Assessment Algorithm For Pregnant and Postpartum Women



End-diastolicVolume & Pressure

B Type Natriuretic Peptide (BNP)

Neurohormone secreted by the cardiac ventricles in response to ventricular volume expansion and pressure overload

End-diastolicvolume & pressure

in ventricles

BNP

Pro-BNP

Inhibits renin-angiotensin-aldosterone system

Relaxes vascular smooth muscle

Increases natriuresis and diuresisImage Credit: Afshan Hameed, MD. Used with permission


BNP in Pregnancy

Pregnancy is a state of physiologic volume overload

LV wall mass and the diastolic dimensions increase

Lev-Sagie A, Bar-Oz B, Salpeter L, Hochner-Celnikier D, Arad I and Nir A. Plasma Concentrations of N-Terminal Pro-B-Type Natriuretic Peptide in Pregnant Women near Labor and during Early Puerperium. Clinical Chemistry. October 2005; 51 (10):1909-10.

Katz R, Karliner JS, Resnik R. Effects of a natural volume overload state (pregnancy) on left ventricular performance in normal human subjects. Circulation. 1978;58(3 Pt 1):434-41.


BNP Levels in Normal Pregnancy Median longitudinal BNP in 72 healthy pregnancies: 1st trimester: 19.5 pg/mL 2nd trimester: 18.0 pg/mL 3rd trimester: 26.5 pg/mL Postpartum: 18.5 pg/mL

No statistically significant difference was noted in BNP levels throughout pregnancy and postpartum

There is a statistically significant difference (p


Key Clinical Pearls (continued) Pregnancy or postpartum women with significant risk factors

should be counseled regarding future CVD risk.

Women with known CVD should receive pre‐ & inter‐conception counseling by an experienced perinatologist and cardiologist.

Contraception choices should be tailored to the individual.

Provider and patient education is essential.

High index of suspicion, early diagnosis, appropriate referrals and follow up are the key elements to a successful outcome.

Hameed AB, Morton CH, and A Moore. Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum Developed under contract #11-10006 with the California Department of Public Health, Maternal, Child an Adolescent Health Division. Published by the California Department of Public Health, 2017.

Recommendations

• Baseline BNP level during pregnancy in women at high risk of or with known heart disease may be helpful.

• All pregnant and postpartum patients with chest pain:• standard troponin testing • electrocardiogram

May 2019

Recommendations

• Avoid pregnancy severe heart disease• ejection fraction less than 30% or class III/IV heart failure• severe valvular stenosis• Marfan syndrome with aortic diameter more than 45 mm, • bicuspid aortic valve with aortic diameter more than 50 mm• pulmonary arterial hypertension.

May 2019

Recommendations

• Patients with known or suspected CV Dz should proceed with further evaluation by a Pregnancy Heart Team. Patients with moderate and high‐risk cardiovascular disease should be managed in medical centers with a multidisciplinary team.

• All women should be assessed for CV Dz in the antepartum and postpartum periods using the California Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum toolkit algorithm.

May 2019

Recommendations

• Women with stable cardiac disease can undergo a vaginal delivery at 39 weeks of gestation, with cesarean delivery reserved for obstetric indications.

• A postpartum follow‐up visit (early postpartum visit) with either the primary care provider or cardiologist is recommended within 7–10 days of delivery for women with hypertensive disorders or 7–14 days of delivery for women with heart disease/cardiovascular disorders.

May 2019

Conclusions

Conclusion

• Review the 15 things that the physicians and patients should questions from the

• Do not use amniotic fluid index to make the diagnosis of oligohydramnios in the third trimester.

Conclusions

• It is reasonable to offer elective IOL to low‐risk, nulliparous women at or beyond 39 weeks and 0 days of gestation.

• Recommend against offering elective IOL to women under circumstances that are inconsistent with the ARRIVE study protocol unless performed as part of research.

• Risk of stillbirth with ICP increases compared to a general population when serum bile acid concentrations are ≥100 μmol/L

Conclusion

• Total bile acid concentrations of 100 μmol/L or more, delivery should probably occur by 35–36 weeks of gestation

• UDCA for symptom relief in women with ICP however there is no reduction in stillbirth

• Stroke is the major cause of maternal mortality associated with preeclampsia or eclampsia and timely antihypertensive treatment is key.

Conclusion

• Referral to a hospital setting that represents an appropriate maternal level of care is recommended for all patients moderate to high risk cardiac conditions.

• Patients with known or suspected CV Dz should proceed with further evaluation by a Pregnancy Heart Team

• It is helpful to get a baseline BNP.

• All patients with chest pain should get an EKG and troponin.

Don’t do an inherited thrombophilia evaluation for women with histories of pregnancy loss, intrauterine growth restriction (IUGR), preeclampsia and abruption.Scientific data supporting a causal association between either methylenetetrahydrofolate reductase (MTHFR) polymorphisms or other common inherited thrombophilias and adverse pregnancy outcomes, such as recurrent pregnancy loss, severe preeclampsia and IUGR, are lacking. Specific testing for antiphospholipid antibodies, when clinically indicated, should be limited to lupus anticoagulant, anticardiolipin antibodies and beta 2 glycoprotein antibodies.

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.

Don’t offer noninvasive prenatal testing (NIPT) to low-risk patients or make irreversible decisions based on the results of this screening test.*NIPT has only been adequately evaluated in singleton pregnancies at high risk for chromosomal abnormalities (maternal age >35, positive screening, sonographic findings suggestive of aneuploidy, translocation carrier at increased risk for trisomy 13, 18 or 21, or prior pregnancy with a trisomy 13, 18 or 21). Its utility in low-risk pregnancies remains unclear. False positive and false negative results occur with NIPT, particularly for trisomy 13 and 18. Any positive NIPT result should be confirmed with invasive diagnostic testing prior to a termination of pregnancy. If NIPT is performed, adequate pretest counseling must be provided to explain the benefits and limitations.

Don’t screen for intrauterine growth restriction (IUGR) with Doppler blood flow studies.Studies that have attempted to screen pregnancies for the subsequent occurrence of IUGR have produced inconsistent results. Furthermore, no standards have been established for the optimal definition of an abnormal test, best gestational age for the performance of the test or the technique for its performance. However, once the diagnosis of IUGR is suspected, the use of antenatal fetal surveillance, including umbilical artery Doppler flow studies, is beneficial.

Don’t use progestogens for preterm birth prevention in uncomplicated multifetal gestations.The use of progestogens has not been shown to reduce the incidence of preterm birth in women with uncomplicated multifetal gestations.

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These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

Society for Maternal-Fetal Medicine

Fifteen Things Physicians and Patients Should Question

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Released February 3, 2014 (1–5); February 1, 2016 (6–10) and May 1, 2019 (11–15)

* This recommendation is currently under review by SMFM

Don’t perform routine cervical length screening for preterm birth risk assessment in asymptomatic women before 16 weeks of gestation or beyond 24 weeks of gestation.The predictive ability of cervical length measurement prior to 16 weeks of gestation for preterm birth risk assessment is limited. It should be performed, when indicated, between 16 and 24 weeks of gestation. Routine cervical length screening for preterm birth risk assessment in asymptomatic women beyond 24 weeks of gestation has not been proven to be effective.

Don’t perform antenatal testing on women with the diagnosis of gestational diabetes who are well controlled by diet alone and without other indications for testing.Monitoring of glucose levels and maintaining adequate glycemic control for gestational diabetes are paramount to decreasing adverse outcomes, including stillbirth. If nutritional modification and glucose monitoring alone control maternal glycemic status such that pharmacological therapy is not required, the risk of stillbirth due to uteroplacental insufficiency is not increased. Thus, the use of routine antepartum testing (e.g. biophysical profile (BPP) or nonstress test (NST)) in the absence of other co-morbidities is not indicated.

Don’t place women, even those at high-risk, on activity restriction to prevent preterm birth.There are no studies documenting an improvement in outcomes in women at risk for preterm birth who are placed on activity restriction, including bed rest. There are multiple studies documenting untoward effects of routine activity restriction on the mother and family, including negative psychosocial effects. Therefore, activity restriction should not be routinely prescribed as a treatment to reduce preterm birth.

Don’t order serum aneuploidy screening after cfDNA aneuploidy screening has already been performed. Serum biochemistry and cell free DNA (cfDNA) are both screening tests for fetal aneuploidy. When low-risk results have been reported on either test, there is limited clinical value of also performing the other screen. While serum screening may identify some aneuploidies not detected by cfDNA, the yield is too low to justify this test if cfDNA screening has already been performed.

Don’t perform maternal serologic studies for cytomegalovirus and toxoplasma as part of routine prenatal laboratory studies.Routine serologic screening of pregnant women for CMV and toxoplasmosis is not recommended due to poor predictive value of these tests and potential for harm due to false positive results. Serologic screening during pregnancy for both diseases should be reserved for situations in which there is clinical or ultrasound suspicion of maternal or fetal infection.

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These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

Society for Maternal-Fetal Medicine

Fifteen Things Physicians and Patients Should Question

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Don’t recommend diagnostic testing following sonographic identification of an isolated echogenic intracardiac focus (EIF) or choroid plexus cyst (CPC) in women with low-risk aneuploidy screening results.The concept of using ultrasonographic soft markers for aneuploidy, such as EIF and CPC, was introduced in an era that predated screening for Down syndrome based on factors other than maternal age. Because the sensitivity of cell free (cfDNA) screening for Down syndrome approaches 99%, the residual risk for Down syndrome is very low in patients who have a negative cfDNA screening test result. Given the low a priori risk, the presence of an isolated EIF or CPC is unlikely to increase the detection rate for aneuploidy to any measurable degree. In addition, for a woman with an isolated EIF or CPC on a second-trimester ultrasound in the setting of any negative first- or second-trimester aneuploidy screening test result, a reasonable approach is to consider the presence of the isolated finding as a normal variant. Recent guidelines from the Society for Maternal-Fetal Medicine state that diagnostic testing should not be recommended to patients solely for the indication of an isolated EIF or CPC in the setting of a negative cfDNA screening test result or a negative first- or second-trimester screening test result.

Don’t perform serial cervical length measurement following cerclage placement.Although progressive cervical shortening after cerclage placement increases the risk of preterm birth, neither overall cervical length nor the length below the stitch correlates well with outcomes. Most importantly, there are currently no additional treatment options for a short cervix after cerclage (e.g., reinforcement suture does not improve outcomes). Although there may be theoretical psychological benefits to the patient and provider to visualize the stitch, there are insufficient data to suggest a clinical benefit of routine post-cerclage serial cervical length measurement.

Don’t test women for MTHFR mutations.MTHFR is responsible for the conversion of 5,10-methylenetetrahydrofolate to 5-methyltetrahydrofolate. Genetic variant C677T and A1286C have been associated with a mild decrease in enzymatic activity, which in the setting of reduced folate levels has been found to be a risk factor for hyperhomocysteinemia. Although hyperhomocysteinemia is a risk factor for cardiovascular disease and venous thrombosis, its cause is multifactorial and independent of the MTHFR genotype, even in homozygotic individuals. Despite earlier (mostly case control) studies that found an association between the MTHFR genotype and adverse outcomes, recent studies of more robust design have not replicated these findings. Due to the lack of evidence associating genotype independently with thrombosis, recurrent pregnancy loss, or other adverse pregnancy outcomes, MTHFR genotyping should not be ordered as part of a workup for thrombophilia.

Don’t screen asymptomatic pregnant women for subclinical hypothyroidism. Subclinical hypothyroidism (SCH) is defined as an elevated serum TSH level in the presence of a normal free T4 level and is found in 2% to 5% of otherwise healthy pregnant women. SCH is unlikely to progress to overt hypothyroidism during pregnancy. While some authorities and organizations have recommended routine screening for all pregnant women and subsequent treatment with levothyroxine, two recent, large (>100,000 women) prospective randomized clinical trials of screening and treatment for SCH demonstrated no effect of treatment on offspring IQ at age 5 years. Because treatment for SCH has not resulted in a beneficial effect on outcomes, routine screening for SCH is not currently recommended. Targeted screening for women at risk for overt hypothyroidism is still appropriate.

Don’t use amniotic fluid index to make a diagnosis of oligohydramnios (in the third trimester).Amniotic fluid volume can be measured using either the amniotic fluid index (AFI) or the deepest vertical pocket (DVP). Diagnosis of oligohydramnios based on an AFI of

Dizon-Townson D, Miller C, Sibai B, Spong CY, Thom E, Wendel G Jr, Wenstrom K, Samuels P, Cotroneo MA, Moawad A, Sorokin Y, Meis P, Miodovnik M, O’Sullivan MJ, Conway D, Wapner RJ, Gabbe SG; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network (NICHD MFMU). The relationship of the factor V Leiden mutation and pregnancy outcomes for mother and fetus. Obstet Gynecol. 2005 Sep;106(3):517–24.Silver RM, Zhao Y, Spong CY, Sibai B, Wendel G Jr, Wenstrom K, Samuels P, Caritis SN, Sorokin Y, Miodovnik M, O’Sullivan MJ, Conway D, Wapner RJ; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units (NICHD MFMU) Network. Prothrombin gene G20210A mutation and obstetric complications. Obstet Gynecol. 2010 Jan;115(1):14–20. Kupferminc MJ, Eldor A, Steinman N, Many A, Bar-Am A, Jaffa A, Fait G, Lessing JB. Increased frequency of genetic thrombophilia in women with complications of pregnancy. N Engl J Med. 1999 Jan;340(1):9–13. [published erratum appears in N Engl J Med 1999 Jul 29;341(5):384].

Durnwald CP, Momirova V, Rouse DJ, Caritis SN, Peaceman AM, Sciscione A, Varner MW, Malone FD, Mercer BM, Thorp JM Jr, Sorokin Y, Carpenter MW, Lo J, Ramin SM, Harper M, Spong CY; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network (NICHD MFMU). Second trimester cervical length and risk of preterm birth in women with twin gestations treated with 17-alpha hydroxyprogesterone caproate. J Matern Fetal Neonatal Med. 2010 Dec;23(12):1360–4. Berghella V, Odibo AO, To MS, Rust OA, Althuisius SM. Cerclage for short cervix on ultrasonography: meta-analysis of trials using individual patient-level data. Obstet Gynecol. 2005;106:181–9.

American College of Obstetricians and Gynecologists Committee on Genetics. Noninvasive prenatal testing for fetal aneuploidy. Committee Opinion No. 545. Obstet Gynecol. 2012 Dec;120(6):1532–4.

Society for Maternal-Fetal Medicine Publications Committee, Berkley E, Chauhan SP, Abuhamad A. Doppler assessment of the fetus with intrauterine growth restriction. Am J Obstet Gynecol. 2012 Apr;206(4):300–8.

Society for Maternal-Fetal Medicine Publications Committee, Berghella V. Progesterone and preterm birth prevention: translating clinical trials data into clinical practice. Am J Obstet Gynecol 2012 May;206(5):376–86.Combs CA, Garite T, Maurel K, Das A, Porto M; Obstetrix Collaborative Research Network. 17-hydroxyprogesterone caproate for twin pregnancy: a double-blind, randomized clinical trial. Am J Obstet Gynecol. 2011 Mar;204(3):221.e1–8.Combs CA, Garite T, Maurel K, Das A, Porto M; Obstetrix Collaboration Research Network. Failure of 17-hydroxyprogesterone to reduce neonatal morbidity or prolong triplet pregnancy: a double-blind, randomized clinical trial. Am J Obstet Gynecol. 2010 Sep;203(3):248.e1–9.Caritis SN, Rouse DJ, Peaceman AM, Sciscione A, Momirova V, Spong CY, Iams JD, Wapner RJ, Varner M, Carpenter M, Lo J, Thorp J, Mercer BM, Sorokin Y, Harper M, Ramin S, Anderson G; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network (NICHD MFMU). Prevention of preterm birth in triplets using 17 alpha-hydroxyprogesterone caproate: a randomized controlled trial. Obstet Gynecol. 2009 Feb;113(2 Pt 1):285–92.

Iams JD, Goldenberg RL, Meis PJ, Mercer BM, Moawad A, Das A, Thom E, McNellis D, Copper RL, Johnson F, Roberts JM. The length of the cervix and the risk of spontaneous premature delivery. National Institute of Child Health and Human Development Maternal Fetal Medicine Unit Network. N Engl J Med. 1996 Feb 29;334(9):567-72.Conoscenti G, Meir YJ, D’Ottavio G, Rustico MA, Pinzano R, Fischer-Tamaro L, Stampalija T, Natale R, Maso G, Mandruzzato G. Does cervical length at 13–15 weeks’ gestation predict preterm delivery in an unselected population? Ultrasound Obstet Gynecol. 2003 Feb;21(2):128-34.Ozdemir I, Demirci F, Yucel O, Erkorkmaz U. Ultrasonographic cervical length measurement at 10-14 and 20-24 weeks gestation and the risk of preterm delivery. Eur J Obstet Gynecol Reprod Biol. 2007 Feb;130(2):176-9. Berghella V, Talucci M, Desai A. Does transvaginal sonographic measurement of cervical length before 14 weeks predict preterm delivery in high-risk pregnancies? Ultrasound Obstet Gynecol. 2003 Feb;21(2):140-4.

Rosenstein MG, Cheng YW, Snowden JM, Nicholson JM, Doss AE, Caughey AB. The risk of stillbirth and infant death stratified by gestational age in women with gestational diabetes. Am J Obstet Gynecol. 2012;206:309.e1-7.

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How This List Was CreatedAs a national medical specialty society, the Society for Maternal-Fetal Medicine relies on the input of any number of its committees in the development of various documents. In the case of the items included in this list, the Publications Committee reviewed the literature and evidence from SMFM’s published documents for possible topics. For SMFM’s first set of five recommendations a sub-group of the Committee initially developed a list of 10 items that the Committee then ranked for the top five with input and suggestions by the Society’s Executive Committee. For SMFM’s second set of recommendations, the sub-group of the Committee developed a list of 12 items that the Committee then ranked for the top five, again soliciting input and suggestions by the Society’s Executive Committee. For SMFM’s third set of five recommendations, the sub-group of the Publications Committee developed a list of 10 items that the Committee ranked for the top five, again soliciting input and suggestions by the Society’s Executive Committee. The final lists have been reviewed and approved by the Society’s Document Review Committee and Executive Committee.

SMFM’s disclosure and conflict of interest policy can be found at www.smfm.org.

Sources

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The mission of the ABIM Foundation is to advance medical professionalism to improve the health care system. We achieve this by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice.

The Society for Maternal-Fetal Medicine (SMFM) is a society of physicians and scientists who are dedicated to the optimization of pregnancy and perinatal outcomes. SMFM was established in 1977 and is the membership organization for obstetricians/gynecologists who have additional formal education and training in maternal-fetal medicine. There are currently about 2,000 active members of SMFM. The Society hosts an annual scientific meeting in which new ideas and research in the area of maternal-fetal medicine are presented. The Society is also an advocate for improving public policy and expanding research funding and opportunities in the area of maternal-fetal medicine.

For more information about SMFM, visit www.smfm.org.

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About the ABIM Foundation About the Society for Maternal-Fetal Medicine

For more information or to see other lists of Things Physicians and Patients Should Question, visit www.choosingwisely.org.

To learn more about the ABIM Foundation, visit www.abimfoundation.org.

Society for Maternal-Fetal Medicine (SMFM), Habeber E, Sciscione A. SMFM Consult Activity Restriction in Pregnancy. Contemp Ob Gyn. 2014.

Society for Maternal-Fetal Medicine (SMFM) Publications Committee. Society for Maternal-Fetal Medicine Consult Series #36: Prenatal aneuploidy screening using cell-free DNA. Am J Obstet Gynecol. 2015 Jun;212(6):711-6.

Committee Opinion No. 640: Cell-Free DNA Screening For Fetal Aneuploidy. Obstet Gynecol. 2015;126(3):e31-7.

Society for Maternal-Fetal Medicine (SMFM), Hughes BL, Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine Consult Series #39: Diagnosis and antenatal management of congential cytomegalovirus (CMV) infection. Am J Obsts Gynecol. 2016 (in press).

American College of Obstetricians and Gynecologists. Practice Bulletin #151: Cytomegalovirus, Parvovirus B19, varicella zoster, and toxoplasmosis in pregnancy. Obstet Gynecol. 2015 Jun;125(6):1510-25.

Society for Maternal-Fetal Medicine (SMFM). Norton ME, Biggio JR, Kuller JA, Blackwell SC. The role of ultrasound in women who undergo cell-free DNA screening. Am J Obstet Gynecol. 2017 Mar;216(3):B2-B7.Benn P, Cuckle H, Pergament E. Non-invasive prenatal testing for aneuploidy: current status and future prospects. Ultrasound Obstet Gynecol 2013;42:15-33.

Society for Maternal-Fetal Medicine (SMFM). McIntosh J, Feltovich H, Berghella V, Manuck T. The role of routine cervical length screening in selected high- and low-risk women for preterm birth prevention. Am J Obstet Gynecol. 2016 Sep;215(3):B2-7.

Baxter JK, Airoldi J, Berghella V. Short cervical length after history indicated cerclage: I s a reinforcing cerclage beneficial? Am J Obstet Gynecol 2005;193:1204-7.

Inherited thrombophilias in pregnancy. ACOG Practice Bulletin No. 197. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132:e18—34.

Hickey SE, Curry CJ, Toriello HV. ACMG Practice Guideline: lack of evidence for MTHFR polymorphism testing. Genet Med. 2013 Feb;15(2):153-6.

Baglin T, Gray E, Greaves M, et al. Clinical guidelines for testing for heritable thrombophilia. Br J Haematol 2010;149:209–220.

Thyroid disease in pregnancy. Practice Bulletin No. 148. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015; 125:996–1005.

Lazarus JH, Bestwick JP, Channon S, Paradice R, Maina A, Rees R, et al. Antenatal thyroid screening and childhood cognitive function [published erratum appears in N Engl J Med 2012;366:1650]. N Engl J Med 2012;366:493–501.

Society for Maternal-Fetal Medicine. Screening for thyroid disease during pregnancy. Contemporary OB/GYN; August 2012. https://www.smfm.org/publications/88-screening-for-thyroid-disease-in-pregnancy

Kehl S, Schelkle A, Thomas A, Puhl A, Meqdad K, Tuschy B, et al. Single deepest vertical pocket or amniotic fluid index as evaluation test for predicting adverse pregnancy outcome (SAFE trial): a multicenter,open-label, randomized controlled trial. Ultrasound Obstet Gynecol. 2016;47(6):674-9.

Ultrasound in pregnancy. Practice Bulletin No. 175. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;128:e241–56.

Antepartum fetal surveillance. Practice Bulletin No. 145. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;124:182–92.

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gonzalez hot topics in maternal-fetal medicine...the membranes, no ultrasound examination in the...

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