Category Archives: GUIDELINES

Consensus Document Establishes Levels of Maternal Care

Organizations representing women’s healthcare providers have released a consensus document establishing levels of care for perinatal and postnatal women. The proposed classification system for levels of maternal care pertains to birth centers, basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV).

Preeclampsia: Taking the Focus Off Proteinuria

Preeclampsia is a progressive multisystemic disease of pregnancy that affects the lining of the mother’s blood vessels causing high blood pressure, leaking of fluid from the blood vessels, and may also cause damage to multiple organs.

Last year, In recognition of the multisystemic nature of preeclampsia, the American College of Obstetricians and Gynecologists (ACOG) recommended that elevated blood pressure in addition to alternative systemic findings can fulfill the diagnosis of preeclampsia. Proteinuria does not need to be present to make the diagnosis of preeclampsia. Necessary interventions, such as control of blood pressure, should not be delayed because there is no protein in the urine [1,2].

Although the presence of significant* protein in the urine would indicate mulitsystemic involvement, the degree of proteinuria correlates poorly with short-term adverse outcomes and  long-term maternal renal prognosis [1-5]. There is no longer a recognized quantity of  urinary protein that would affect recommendations to deliver, thus eliminating  any degree of proteinuria as a  “severe feature” [1,2].

(*300 mg or more in a 24 hour urine timed collection  or  a protein/creatinine ratio of at least 0.3 (each measured as mg/dL) (≥ 30mg/mmol) . 1+ on dipstick may be used only if the above methods are unavailable [1,2,6])


The following findings are severe features of preeclampsia that indicate intervention including delivery may be indicated.

  • New-onset cerebral or visual disturbances .
  • Pulmonary edema (fluid in the lungs)
  • Low platelet count (less than 100,000 /microliter)
  • Elevated liver enzymes ( transaminases ) to  twice the normal concentration,  severe persistent pain in the right upper or middle upper abdomen that does not respond to medication and is not explained by another condition or both.
  • Renal insufficiency (serum creatinine greater than1.1 mg/dL) ,or a doubling of serum creatinine in the absence of other renal  disease
  • A systolic blood pressure (SBP) greater than or equal to 160 mm Hg OR a diastolic blood pressure (DBP) greater than or equal to 110 mm Hg measured on more than one occasion at least 4 hours apart while the patient is on bedrest (unless anti hypertensive therapy is initiated before this time)


Stroke is a major cause of death in women with  hypertensive disorders of pregnancy. As is  the case  in women who are not pregnant, control of the systolic blood pressure appears to be at least as important as control of the diastolic blood pressure [7, 8]. A review of  international clinical practice guidelines found that most authorities recommended  treatment during pregnancy for severe hypertension defined as a  blood pressure of   greater than or equal 160 / 110 mm Hg [9,12].

The American College of Obstetricians and Gynecologists (ACOG) recommends that systolic blood pressure greater than or equal to 160 mm Hg OR diastolic blood pressure greater than or equal to 110 mm Hg that persists greater than 15 minutes should be treated within 1 hour.  ACOG recommends intravenous labetalol or hydralazine, or nifedipine orally  for the  acute treatment of severe hypertension [1,2,11].

The Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) recommends antihypertensive treatment for all pregnant women with blood pressure greater than or equal to 160 mm Hg systolic OR 110 mm Hg diastolic. Severe hypertension requiring urgent treatment is defined as a systolic blood pressure greater than or equal to 170 mm Hg with or
without diastolic blood pressure greater than or equal to 110 mm Hg.  SOMANZ recommends intravenous labetalol , hydralazine , or diazoxide, or oral nifedipine for the  acute treatment of severe hypertension [13].


1. Hypertension in pregnancy: executive summary. Obstet Gynecol. 2013 Nov;122(5):1122-31. doi:10.1097/01.AOG.0000437382.03963.88.PMID:24150027
2. The American College of Obstetricians and Gynecologists. Task Force on Hypertension in Pregnancy Hypertension in Pregnancy. Hypertension, Pregnancy Induced –Practice Guideline wq244 2013

3. Thangaratinam S, et. al., Estimation of proteinuria as a predictor of complications of pre-eclampsia: a systematic review. BMC Med. 2009 Mar 24;7:10. doi: 10.1186/1741-7015-7-10. PMID: 19317889

4.Payne B, et al.; PIERS Study Group. PIERS proteinuria: relationship with adverse maternal and perinatal outcome. J Obstet Gynaecol Can 2011;33:588–97.PMID: 21846448

5. Lampinen KH, Rönnback M, Groop PH, Kaaja RJ. Renal and vascular
function in women with previous preeclampsia: a comparison of lowand
high-degree proteinuria. Kidney Int 2006;70:1818–22 PMID: 17003812

6. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: executive summary. Magee LA, Pels A, Helewa M, Rey E, von Dadelszen P; Canadian Hypertensive Disorders of Pregnancy Working Group. J Obstet Gynaecol Can. 2014 May;36(5):416-41. English, French. PMID: 24927294

7. Martin JN, Jr., et al., Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure. Obstetrics & Gynecology. 2005;105(2):246-54. PMID: 15684147

8. Lindenstrøm E, et al., Influence of systolic and diastolic blood pressure on stroke risk: a prospective observational study. Am J Epidemiol. 1995 Dec 15;142(12):1279-90. PMID: 7503048

 9. Hypertensive disorders of pregnancy: a systematic review of international clinical practice guidelines. Gillon TE, Pels A, von Dadelszen P, MacDonell K, Magee LA. PLoS One. 2014 Dec 1;9(12):e113715. doi: 10.1371/journal.pone.0113715. eCollection 2014. PMID: 25436639

10. Adverse perinatal outcomes are significantly higher in severe gestational hypertension than in mild preeclampsia. Buchbinder A, Sibai BM, Caritis S, Macpherson C, Hauth J, Lindheimer MD, Klebanoff M, Vandorsten P, Landon M, Paul R, Miodovnik M, Meis P, Thurnau G; National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. Am J Obstet Gynecol. 2002 Jan;186(1):66-71. PMID: 11810087

11.Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Committee Opinion No. 623. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:521–5.PMID: 25611642

12. National Institute for Health and Care Excellence.Hypertension in pregnancy: The management of hypertensive disorders during pregnancyNICE clinical guideline 107
Issued: August 2010 last modified: January 2011
Avilable at: Accessed 12/29/2014.

13. Society of Obstetric Medicine of Australia and New Zealand. Guideline for the Management of Hypertensive Disorders of Pregnancy 2014
Available at:
Accessed 12/29/2014.

Copyright © 2014 by Focus Information Technology. All rights reserved

Defining Oligohydramnios

This year the American College of Obstetricians and Gynecologists (ACOG) restated their support for the use of the deepest vertical pocket (DVP)  of amniotic fluid volume of 2 cm or less to diagnose oligohydramnios (too little amniotic fluid) rather than an amniotic fluid index (AFI) of 5 cm or less [1,2]. The deepest vertical pocket (a.k.a. maximum vertical pocket) method for amniotic fluid assessment is preferred because  clinical trials have shown that defining oligohydramnios as a deepest vertical pocket of less than 2 cm or less will result in fewer obstetric interventions without a change  in adverse outcomes when compared with defining oligohydramnios as an AFI of less than or equal to 5 cm [3].

Deepest Vertical Pocket of Amniotic Fluid In addition , the DVP is a simpler method to use than the AFI method. The DVP is measured as the vertical measurement , in centimeters, of the single deepest pocket of amniotic fluid with a transverse measurement of 1 cm or more wide  without fetal small parts or umbilical cord  [4] . The AFI method uses the sum of measurements obtained for the deepest vertical pocket from four quadrants of the uterus, using the same criteria otherwise.

The DVP is already used more commonly in the evaluation of twin pregnancies [5-7] . However, the AFI is used by many antenatal testing centers as part of the the modified biophysical profile (BPP) [8,9]. The modified BPP consists of the nonstress test (NST) and an amniotic fluid volume assessment using the AFI method. The modified BPP is considered normal if both the NST is reactive and the AFI is greater than 5 cm [1]. The new recommendations would require only a single maximum vertical pocket of amniotic fluid greater than 2 cm for the amniotic fluid volume assessment component of the modified BPP to  be considered normal .

The  normal the range for the deepest vertical pocket is about 2 cm  to 8 cm in singleton and twin gestations [4, 10-12] , or about one third the values for  the normal range of the AFI.  

Depth of largest visible

 Qualitative Description

 < 1 cm
 severe oligohydramnios
> 1 and
< 2  cm
 mild oligohydramnios
 > 2  and  < 8 cm  normal
> 8
and < 12 cm
>12 cm and <
 moderate polyhydramnios
> 16 cm  severe polyhydramnios

Some causes of oligohydramnios [13,14]

  • Ruptured membranes
  • Congenital abnormalities
    • Bilateral renal agenesis or cystic dyplasia
    • Obstruction of the urinary tract
    • Meckel-Gruber syndrome
    • VACTERL (vertebral, anal, cardiac, tracheo-esophageal, renal, limb) association
    • Sirenomelia
    • Sacral agenesis
  • Growth restriction (placental insufficiency)
  • Postterm pregnancy
  • Drugs
    • Angiotensin-converting enzyme inhibitors
    • Prostaglandin synthase inhibitors
  • Twin- to -twin transfusion
  • TRAP (twin reverse arterial perfusion sequence)
  • Fetal demise
  • Idiopathic

1. Antepartum fetal surveillance. Practice Bulletin No. 145. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;124:182–92PMID:24945455
2. Reddy UM, et al.Fetal Imaging: Executive Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop Obstet Gynecol. 2014 May;123(5):1070-82. doi: 10.1097/AOG.0000000000000245. PMID: 24785860
3. Nabhan AF, Abdelmoula YA.Amniotic fluid index versus single deepest vertical pocket as a screening test for preventing adverse pregnancy outcome. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006593. doi: 10.1002/14651858.CD006593.pub2. PMID: 18646160
4. Chamberlain PF, Manning FA, Morrison I, Harman CR, Lange IR. Ultrasound evaluation of amniotic fluid volume. I. The relationship of marginal and decreased amniotic fluid volume to perinatal outcome. Am J Obstet Gynecol 1984;150:245–9.PMID:6385713
5.Magann EF, et al. The ultrasound estimation of amniotic fluid volume in diamniotic twin pregnancies and prediction of peripartum outcomes. Am J Obstet Gynecol. 2007 Jun;196(6):570.e1-6; discussion 570.e6-8. PMID: 17547899
6.Royal College of Obstetricians and Gynaecologists .Monochorionic Twin Pregnancy, Management Green-top Guideline No. 51December 2008
7. WAPM Consensus Group on Twin-to-Twin Transfusion, Baschat A, et. al. Twin-to-twin transfusion syndrome (TTTS). J Perinat Med. 2011 Mar;39(2):107-12. Epub 2010 Dec 13. PMID:21142846
8. Nageotte MP, et. al. Perinatal outcome with the modified biophysical profile. Am J Obstet Gynecol. 1994 Jun;170(6):1672-6. PMID:8203424
9.Miller DA, et. al., The modified biophysical profile: antepartum testing in the 1990s.Am J Obstet Gynecol. 1996 Mar;174(3):812-7. PMID:863364
10.Chamberlain PF, Ultrasound evaluation of amniotic fluid volume. II. The relationship of increased amniotic fluid volume to perinatal outcome. Am J Obstet Gynecol. 1984 Oct 1;150(3):250-4.PMID:6385714
11.Hill LM, et al. Polyhydramnios: ultrasonically detected prevalence and neonatal outcome.Obstet Gynecol. 1987 Jan;69(1):21-5.PMID:3540761
12. Magann EF,et al The ultrasound estimation of amniotic fluid volume in diamniotic twin pregnancies and prediction of peripartum outcomes. Am J Obstet Gynecol. 2007;196(6):570.PMID:17547899
13. Peipert JF, Donnenfeld AE, Oligohydramnios: a review.Obstet Gynecol Surv. 1991 Jun;46(6):325-39. PMID:2067755
14. McCurdy CM Jr, Seeds JW. Oligohydramnios: problems and treatment. Semin Perinatol. 1993 Jun;17(3):183-96. PMID:7690990

Copyright © 2014 by Focus Information Technology. All rights reserved

The FDA is concerned about over-the-counter sale of fetal ultrasound heartbeat monitors

The FDA issues consumer update regarding  over-the-counter sale of prescription fetal ultrasound heartbeat monitors (also called doptones).

“When the product is purchased over the counter and used without consultation with a health care professional taking care of the pregnant woman, there is no oversight of how the device is used. Also, there is little or no medical benefit expected from the exposure,” Vaezy says. “Furthermore, the number of sessions or the length of a session in scanning a fetus is uncontrolled, and that increases the potential for harm to the fetus and eventually the mother.”

See more at:

Joint panel, NICHD, SMFM, ACOG, ACR, SPR and SR, issues an executive summary on fetal imaging

In an executive summary a panel of experts recommended Elimination of the terms partial and marginal previa and retaining  only the terms placenta previa and low-lying placenta

  • If the placental edge is less than 2 cm from the internal os but not covering the internal os, the placenta should be labeled as low-lying, and follow-up ultrasonography is recommended at 32 weeks of gestation.
  • “If the placental edge covers the internal cervical os, the placenta should be labeled as placenta previa, and follow-up ultrasonography is recommended at 32 weeks of gestation. “

The panel also issued opinions on soft markers used to evaluate the risk for Down syndrome in fetuses.

  • Isolated soft markers that are of no importance in the absence of an elevated a priori risk for fetal aneuploidy are choroid plexus cyst and echogenic intracardiac foci.

There is no need for ultrasonographic follow-up in fetuses with isolated choroid plexus cysts, because the cysts almost always resolve.

  • When mild pyelectasis is identified, a targeted ultrasound study to rule out other structural abnormalities and correlation with aneuploidy screening results should be done. Follow-up ultrasonography at 32 weeks of gestation to rule out persistent pyelectasis should be performed. If the renal pelvis measures 7 mm or greater at the 32-week examination, postnatal follow-up is suggested because of correlation with postnatal renal disease.

Other important recommendations given by the panel may be found in the article available at:

REFERENCE: Reddy UM, etr al. Fetal imaging: Executive Summary of a joint Eunice Kennedy Shriver National institute of child health and human development,  society for maternal-fetal medicine, american institute of ultrasound in medicine, american college of obstetricians and gynecologists, american college of radiology, society for pediatric radiology, and society of radiologists in ultrasound fetal imaging workshop. J Ultrasound Med. 2014 May;33(5):745-57.  PMID:24764329

Pregnant women at risk for developing preeclampsia should take low-dose aspirin

Pregnant women  at risk for developing preeclampsia should take low-dose aspirin daily to reduce their chance of developing the disorder according to new recommendations by the U.S. Preventive Services Task Force (USPSTF).

The USPSTF recommends low-dose aspirin (81 mg/day) preventive medication after 12 weeks’ gestation in women who are at high risk for preeclampsia.

Women at high risk include:

  • Prior preeclampsia, especially when accompanied by an adverse outcome
  • Multiple gestation pregnancy
  • Chronic hypertension
  • Type 1 or 2 diabetes
  • Renal disease
  • Autoimmune disease (i.e., systemic lupus erythematous, antiphospholipid syndrome)

In addition The U.S. Preventive Services Task Force (USPSTF)  recommends women with more than one moderate risk factor for pre-eclampsia should to take 81 mg of aspirin daily after 12 weeks of gestation

Moderate risk factors include:

  • Nulliparity (first pregnancy)
  • Obesity (i.e., body mass index >30 kg/m2)
  • Family history of preeclampsia (i.e., mother, sister)
  • Sociodemographic characteristics (i.e., African American race, low socioeconomic status)
  • Age ≥35 years
  • Personal history factors (e.g., low birth weight or small for gestational age, previous adverse pregnancy outcome, >10-year pregnancy interval)

The USPSTF recommendations are similar to recommendation given by the National Institute for Health and Clinical Excellence (NICE) in previous years.

The USPSTF Draft Recommendation Statement is available at: