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The 10 recommendations
Aboubakr Elnashar
Benha university, Egypt
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
1. Don’t perform
maternal serologic screening for CMV and
Toxoplasmosis as part of routine ante natal
testing.
 1. Poor predictive value of these tests
2. Potential harm due to false positive results.
Serologic screening during pregnancy for both
should be reserved for:
Clinical or
Ultrasound suspicion of maternal or fetal
infection.
U/S: F toxoplasmosis
No findings: 80%
Specific findings:
1. Hydrops
2. Ventriculomegaly
3. Intracranial calcifications (periventricular)
Non specific findings:
1. Ascites
2. Hepatomegaly
3. liver calcification
4. Pericardial /pleural effusion
5. Oligohydramnios, IUGR, placental thickness
Severe ventriculomegaly
Ascites
Hepatic calcifications
 US F CMV:
1. Ascites and hydrops
2. Microcephaly
3. IUGR
4. Ventriculomegaly
5. Intracerebral calcification.
2. Don’t do
inherited thrombophilia evaluation for women
with histories of
 RM
 IUGR
 PET
 Abruption.
Scientific data supporting a causal association
are lacking.
Testing for antiphospholipid antibodies, when
clinically indicated, should be limited to
1. Lupus anticoagulant
2. Anticardiolipin antibodies
3. beta 2 glycoprotein antibodies.
Thrombophilia
 Predisposition to thrombosis
Causes:
I. Acquired:
antiphospholipid syndrome (APS).
II. Inherited
1. Factor V Leiden mutation (FVL) (homozygous or
heterozygous)
2. Prothrombin (FII) G20210A mutation
(Pm) (homozygous or heterozygous)
3. Deficiencies of the endogenous anticoagulants
Antithrombin (AT)
Protein C
Protein S.
4. Hyperhomocysteinemia (C677T) mutation
Methyl tetrahydrofolate reductase (MTHFR C677T)
 RCOG, 2011
Inherited Thrombophilia: 2nd TRM
1. Factor V Leiden mutation
2. Prothrombin gene mutation
3. Protein S deficiency
 Turkish Germany Association, 2016
Factor V Leiden, prothrombin G20210A mutation,
and protein S deficiency:
2nd TRM
Impact on other pregnancy complications:
conflicting.
No definite association between protein C and
antithrombin deficiency and adverse pregnancy
outcome, primarily due to their low prevalence.
The 10 recommendations of society of maternal fetal medicine 2016
Egyptian studies
Mohamed et al, 2012
The prevalence of thrombophilic mutations is higher
in cases of RM than control:
Factor V leiden
Prothrombin, and
Methylene tetra hydro folate reductase
Osman and Abulata, 2015
Methyl tetrahydrofolate reductase (MTHFR
C677T) polymorphism
FVL mutation
significantly higher in cases than controls in a
group of Egyptian women with un RM
3. Don’t screen for
IUGR with Doppler blood flow studies.
1. Inconsistent results.
2. No standards for the optimal definition of
Abnormal test
Best gest age for the performance of the test
Technique for its performance.
However, once the diagnosis of IUGR is
suspected:
antenatal fetal surveillance, including umbilical
artery Doppler flow studies, is beneficial.
 RCOG, 2013
Screening for IUGR
1. At booking for risk
factors
1 major risk factor:
At 26-28 W:
Serial US for
fetal size and
Um A D
3 minor risk factors:
At 20-24w:
Ut A D:
Abnormal [PI]
>95th centile:
At 26-28w: Serial US for
fetal size
Um A D
4. Don’t offer
noninvasive prenatal testing (NIPT) to
low-risk patients or
make irreversible decisions based on the
results of this screening test.
A scientific breakthrough came in 1997 with the
recognition of fetal cell-free DNA (cfDNA) contained
in maternal plasma.
1. Fetal sex determination.
2. Rhesus typing.
3. Screening for autosomal aneuploidies: trisomy
21, 18 and 13
4. Microdeletion syndromes.
5. Sex chromosome aneuploidy.
6. Single gene disorders.
7. Pregnancy complications.
1. NIPT has only been adequately evaluated in
singleton pregnancies at high risk for chromosomal
abnormalities:
•Maternal age >35
•Positive screening
•US suggestive of aneuploidy
•Translocation carrier at increased risk for trisomy 13, 18
or 21, or
•Prior pregnancy with a trisomy 13, 18 or 21.
2. Utility in low-risk pregnancies: unclear
3. False positive and false negative results,
particularly for trisomy 13 and 18.
4. Any positive NIPT result should be confirmed with
invasive diagnostic testing prior to a termination of
pregnancy.
Pretest counseling:
to explain the benefits and limitations.
5. Don’t order
serum aneuploidy screening after fetal cell
free DNA aneuploidy screening has already
been performed.
1. Both serum biochemistry and cell free DNA:
screening tests for fetal aneuploidy.
2. Low-risk results on either test: limited clinical
value of performing the other screen.
3. While serum screening may identify some
aneuploidies not detected by cell free DNA, the
yield is too low to justify this test if cell free DNA
screening has already been performed.
Serum biochemistry screening:
From 11 to 14 w and 14 to 20 w
–Integrated test
NT
Pregnancy-associated plasma protein A
PAPP-A +hCG,
AFP,
uE3,
inhibin A
–Serum integrated test
PAPP-A +hCG,
AFP,
uE3,
inhibin A
6. Don’t perform
routine cervical length screening for PTB risk
assessment in asymptomatic women before
16 w or beyond 24 w.
1. Before 16 w:
The predictive ability of cervical length
measurement: limited.
2. Beyond 24 w:
has not been proven to be effective.
It should be performed, when indicated, between
16 and 24 w.
Society for Maternal –Fetal
Medicine 2012
7. 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.
8. Don’t use
progestogens for PTB prevention in
uncomplicated multifetal gestations.
No reduction
9. 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
10. Don’t perform
antenatal testing on women with GDM who
are
well controlled by diet alone
without other indications for testing.
Risk of SB due to uteroplacental insufficiency is
not increased.
Antenatal testing
BPP
NST
The 10 recommendations
1.Don't perform maternal serologic studies for CMV
and toxoplasma as part of routine prenatal
laboratory studies.
2.Don’t do an inherited thrombophilia evaluation for
women with histories of pregnancy loss, IUGR,
preeclampsia and abruption.
3.Don’t screen for IUGR with Doppler
blood flow studies.
4. Don’t offer noninvasive prenatal testing to low-
risk patients or make irreversible decisions based
on the results of this screening test.
5. Don't order serum aneuploidy screening after cell
free DNA aneuploidy screening has already been
performed.
6. Don't perform routine cervical length screening
for PTB risk assessment in asymptomatic women
before 16 w or beyond 24 w of gestation.
7. Don’t place a cerclage in women with short cervix
who are pregnant with twins.
8. Don’t use progestogens for PTB prevention in
uncomplicated multifetal gestations.
9. Don't place women, even those at high-risk, on
activity restriction to prevent PTB.
10. Don't perform antenatal testing if GDM is well
controlled by diet alone and no other indications
for testing.

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The 10 recommendations of society of maternal fetal medicine 2016

  • 1. The 10 recommendations Aboubakr Elnashar Benha university, Egypt
  • 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
  • 3. 1. Don’t perform maternal serologic screening for CMV and Toxoplasmosis as part of routine ante natal testing.  1. Poor predictive value of these tests 2. Potential harm due to false positive results. Serologic screening during pregnancy for both should be reserved for: Clinical or Ultrasound suspicion of maternal or fetal infection.
  • 4. U/S: F toxoplasmosis No findings: 80% Specific findings: 1. Hydrops 2. Ventriculomegaly 3. Intracranial calcifications (periventricular) Non specific findings: 1. Ascites 2. Hepatomegaly 3. liver calcification 4. Pericardial /pleural effusion 5. Oligohydramnios, IUGR, placental thickness
  • 6.  US F CMV: 1. Ascites and hydrops 2. Microcephaly 3. IUGR 4. Ventriculomegaly 5. Intracerebral calcification.
  • 7. 2. Don’t do inherited thrombophilia evaluation for women with histories of  RM  IUGR  PET  Abruption.
  • 8. Scientific data supporting a causal association are lacking. Testing for antiphospholipid antibodies, when clinically indicated, should be limited to 1. Lupus anticoagulant 2. Anticardiolipin antibodies 3. beta 2 glycoprotein antibodies.
  • 9. Thrombophilia  Predisposition to thrombosis Causes: I. Acquired: antiphospholipid syndrome (APS). II. Inherited 1. Factor V Leiden mutation (FVL) (homozygous or heterozygous) 2. Prothrombin (FII) G20210A mutation (Pm) (homozygous or heterozygous) 3. Deficiencies of the endogenous anticoagulants Antithrombin (AT) Protein C Protein S. 4. Hyperhomocysteinemia (C677T) mutation Methyl tetrahydrofolate reductase (MTHFR C677T)
  • 10.  RCOG, 2011 Inherited Thrombophilia: 2nd TRM 1. Factor V Leiden mutation 2. Prothrombin gene mutation 3. Protein S deficiency
  • 11.  Turkish Germany Association, 2016 Factor V Leiden, prothrombin G20210A mutation, and protein S deficiency: 2nd TRM Impact on other pregnancy complications: conflicting. No definite association between protein C and antithrombin deficiency and adverse pregnancy outcome, primarily due to their low prevalence.
  • 13. Egyptian studies Mohamed et al, 2012 The prevalence of thrombophilic mutations is higher in cases of RM than control: Factor V leiden Prothrombin, and Methylene tetra hydro folate reductase Osman and Abulata, 2015 Methyl tetrahydrofolate reductase (MTHFR C677T) polymorphism FVL mutation significantly higher in cases than controls in a group of Egyptian women with un RM
  • 14. 3. Don’t screen for IUGR with Doppler blood flow studies. 1. Inconsistent results. 2. No standards for the optimal definition of Abnormal test Best gest age for the performance of the test Technique for its performance.
  • 15. However, once the diagnosis of IUGR is suspected: antenatal fetal surveillance, including umbilical artery Doppler flow studies, is beneficial.
  • 16.  RCOG, 2013 Screening for IUGR 1. At booking for risk factors 1 major risk factor: At 26-28 W: Serial US for fetal size and Um A D
  • 17. 3 minor risk factors: At 20-24w: Ut A D: Abnormal [PI] >95th centile: At 26-28w: Serial US for fetal size Um A D
  • 18. 4. Don’t offer noninvasive prenatal testing (NIPT) to low-risk patients or make irreversible decisions based on the results of this screening test. A scientific breakthrough came in 1997 with the recognition of fetal cell-free DNA (cfDNA) contained in maternal plasma.
  • 19. 1. Fetal sex determination. 2. Rhesus typing. 3. Screening for autosomal aneuploidies: trisomy 21, 18 and 13 4. Microdeletion syndromes. 5. Sex chromosome aneuploidy. 6. Single gene disorders. 7. Pregnancy complications.
  • 20. 1. NIPT has only been adequately evaluated in singleton pregnancies at high risk for chromosomal abnormalities: •Maternal age >35 •Positive screening •US suggestive of aneuploidy •Translocation carrier at increased risk for trisomy 13, 18 or 21, or •Prior pregnancy with a trisomy 13, 18 or 21. 2. Utility in low-risk pregnancies: unclear
  • 21. 3. False positive and false negative results, particularly for trisomy 13 and 18. 4. Any positive NIPT result should be confirmed with invasive diagnostic testing prior to a termination of pregnancy. Pretest counseling: to explain the benefits and limitations.
  • 22. 5. Don’t order serum aneuploidy screening after fetal cell free DNA aneuploidy screening has already been performed. 1. Both serum biochemistry and cell free DNA: screening tests for fetal aneuploidy. 2. Low-risk results on either test: limited clinical value of performing the other screen. 3. While serum screening may identify some aneuploidies not detected by cell free DNA, the yield is too low to justify this test if cell free DNA screening has already been performed.
  • 23. Serum biochemistry screening: From 11 to 14 w and 14 to 20 w –Integrated test NT Pregnancy-associated plasma protein A PAPP-A +hCG, AFP, uE3, inhibin A –Serum integrated test PAPP-A +hCG, AFP, uE3, inhibin A
  • 24. 6. Don’t perform routine cervical length screening for PTB risk assessment in asymptomatic women before 16 w or beyond 24 w. 1. Before 16 w: The predictive ability of cervical length measurement: limited. 2. Beyond 24 w: has not been proven to be effective. It should be performed, when indicated, between 16 and 24 w.
  • 25. Society for Maternal –Fetal Medicine 2012
  • 26. 7. 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.
  • 27. 8. Don’t use progestogens for PTB prevention in uncomplicated multifetal gestations. No reduction
  • 28. 9. 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
  • 29. 10. Don’t perform antenatal testing on women with GDM who are well controlled by diet alone without other indications for testing. Risk of SB due to uteroplacental insufficiency is not increased. Antenatal testing BPP NST
  • 30. The 10 recommendations 1.Don't perform maternal serologic studies for CMV and toxoplasma as part of routine prenatal laboratory studies. 2.Don’t do an inherited thrombophilia evaluation for women with histories of pregnancy loss, IUGR, preeclampsia and abruption. 3.Don’t screen for IUGR with Doppler blood flow studies.
  • 31. 4. Don’t offer noninvasive prenatal testing to low- risk patients or make irreversible decisions based on the results of this screening test. 5. Don't order serum aneuploidy screening after cell free DNA aneuploidy screening has already been performed.
  • 32. 6. Don't perform routine cervical length screening for PTB risk assessment in asymptomatic women before 16 w or beyond 24 w of gestation. 7. Don’t place a cerclage in women with short cervix who are pregnant with twins. 8. Don’t use progestogens for PTB prevention in uncomplicated multifetal gestations. 9. Don't place women, even those at high-risk, on activity restriction to prevent PTB. 10. Don't perform antenatal testing if GDM is well controlled by diet alone and no other indications for testing.