CLINICAL PRACTICE

GUIDELINES ON MEDICAL
COMPLICATIONS IN
PREGNANCY
 CARDIAC
COMPLICATIONS
RHEUMATIC HEART DISEASE IN
PREGNANCY
 Rheumatic heart disease (RHD)
◦ constitutes 40-50% of all cardiac diseases during
pregnancy
◦ divided into stenotic and regurgitant lesions
 Mitral stenosis (MS)
 Aortic Valve Stenosis (AoS)
 Aortic and Mitral Regurgitation
 RHEUMATIC HEART DISEASE IN
PREGNANCY
 Does pregnancy affect valvular heart
disease (VHD)?
◦ Mitral stenosis (MS)
 increase in maternal heart rate shortens diastole
 reduced left ventricular filling
 reduced cardiac output
 increased left atrial pressure and overt cardiac failure
 shortness of breath with exertion (2nd trimester)
 orthopnea and paroxysmal nocturnal dyspnea (pregnancy
advances)
 RHEUMATIC HEART DISEASE IN
PREGNANCY
 Does pregnancy affect valvular heart
disease (VHD)?
◦ Mitral stenosis (MS)
 Maternal outcomes
 favorable with mild MS
 high rate of morbidity with moderate to severe
stenotic lesion
 Predictors of adverse maternal outcome include the
severity of MS (valve area of < 1.5 cm) and New
York Heart Association (NYHA) Functional class
(FC).
 RHEUMATIC HEART DISEASE
IN PREGNANCY
 Does pregnancy affect valvular heart
disease (VHD)?
◦ Aortic Valve Stenosis (AoS)
 increase in stroke volume and fall in systemic
vascular resistance  increase in the gradient
across the aortic valve  symptoms develop
 Moderate to severe AoS  associated with
significant maternal morbidity (heart failure,
arrhythmia and syncope)
 RHEUMATIC HEART DISEASE IN
PREGNANCY
 Does pregnancy affect valvular heart
disease (VHD)?
◦ Aortic and Mitral Regurgitation
 Pregnancy is usually well tolerated in women with
chronic left sided valve regurgitation without left
ventricular dysfunction
 During labor, delivery and early postpartum period,
symptoms (dyspnea on exertion, orthopnea and
paroxysmal nocturnal dyspnea) may occur with
severe lesions.
 RHEUMATIC HEART DISEASE IN
PREGNANCY
 Does VHD affect pregnancy?
◦ Mitral stenosis
 Moderate and severe MS
 increased incidence of preterm delivery
 intrauterine growth restriction
 Birth weight was significantly decreased
 Fetal mortality of 30% has been reported with
NYHA class IV disease in the mother.
 RHEUMATIC HEART DISEASE IN
PREGNANCY
 Does VHD affect pregnancy?
 Aortic Stenosis
◦ Severe AoS
 Has higher incidence of:
 preterm delivery (44%)
 IUGR (22%)
 low birth weight (2650g vs. 3391g)
 RHEUMATIC HEART DISEASE IN
PREGNANCY - MANAGEMENT
 Pre-pregnancy Evaluation
◦ All patients with severe valve stenosis/
regurgitation (Stages C and D) * should undergo
pre-pregnancy counseling by a cardiologist
with expertise in managing patients with VHD
during pregnancy. (Level I, Grade C)
◦ All patients with suspected valve
stenosis/regurgitation should undergo a clinical
evaluation and transthoracic esophageal
echocardiography before pregnancy. (Level I,
Grade C)
 RHEUMATIC HEART DISEASE IN
PREGNANCY - MANAGEMENT
 Pre-pregnancy Intervention
◦ Mitral Stenosis
 Patients with severe MS should undergo
intervention before pregnancy. (Level I,
Grade C)
 Valve intervention is recommended
before pregnancy for symptomatic
patients with severe MS (mitral area <
1.5cm, stage D).
 RHD IN PREGNANCY -
MANAGEMENT
 Pre-pregnancy Intervention
 Aortic Stenosis
◦ Patients with severe AoS should undergo intervention pre-
pregnancy if:
 They are symptomatic (Level I, Grade B)
 Or dysfunction (LVEF 50%) is present (Level I, Grade C)
 Aortic velocity > 4.0 m/second or mean pressure gradient
> 40 mmHg, stage C) (Level II-1, Grade C)
◦ Asymptomatic patients with severe AoS should undergo
intervention pre-pregnancy when they develop symptoms
during exercise testing. (Level I, Grade C)
◦ Asymptomatic patients with severe AoS should be
considered for intervention pre-pregnancy when a fall in
blood pressure below the baseline during exercise testing
occurs. (Level II-1, Grade C)
 RHD IN PREGNANCY -
MANAGEMENT
 Pre-pregnancy Intervention
 Mitral and Aortic Regurgitation
◦ Patients with severe aortic and mitral
regurgitation and symptoms of impaired
ventricular function or ventricular dilation
should be treated surgically pre-pregnancy.
(Level I, Grade C)
◦ Valve repair or replacement is
recommended before pregnancy for
symptomatic women with severe valve
regurgitation (stage D). (Level II, Grade C)
 RHD IN PREGNANCY -
MANAGEMENT
 During pregnancy
 Signs and symptoms
◦ severe progressive dyspnea, orthopnea,
paroxysmal nocturnal dyspnea,
hemoptysis, chest pain and syncope
◦ Symptoms of cardiac
 severe systolic murmur (> grade 3/6) with
palpable thrill, diastolic murmur, parasternal
heave, cyanosis and clubbing and persistent
jugular venous distention
 RHD IN PREGNANCY -
MANAGEMENT
 Duringpregnancy
◦ Antenatal Visits
 mild disease every month
 moderate and severe disease:
every 2 weeks for until 28 weeks
then weekly thereafter until
delivery
 RHD IN PREGNANCY -
MANAGEMENT
 During pregnancy
 Antepartum Evaluation
◦ Maternal
 Vital signs and signs and symptoms of
cardiac failure should be monitored
closely.
 Screening for asymptomatic bacteriuria
and prevention of anemia are a must.
 RHD IN PREGNANCY -
MANAGEMENT
 During pregnancy
 Antepartum Evaluation
◦ Fetal
 Accurate dating of pregnancy: for possible early
termination
 Optimum time for screening for congenital malformations:
18-22 weeks.
 Fetal surveillance for growth usually starts at 28 weeks
 fetal biophysical profile testing: risk for fetal compromise
due to maternal cardiac complications.
 Doppler velocimetry: for fetuses with poor fetal growth due
to maternal hypoxia.
 RHD IN PREGNANCY -
COMPLICATIONS
 Heart failure
◦ All patients with heart failure during pregnancy
should be admitted for bed rest.
◦ Medical treatment
 salt and fluid restriction,
 diuretics to limit volume load
 antihypertensive therapy to reduce afterload reduction.
Angiotensin converting enzyme (ACE)
inhibitors are contraindicated during
pregnancy.
 RHD IN PREGNANCY -
COMPLICATIONS
 Heart failure
◦ Mitral Stenosis
 In patients with symptoms of pulmonary
hypertension, restricted activities and 1
selective blockers are recommended. (Level
I, Grade B)
 Use of -blockers as required for rate control
is reasonable for pregnant patients with MS
in the absence of contraindication if
tolerated. (Level II-1, Grade C)
 RHD IN PREGNANCY -
COMPLICATIONS
 Heart failure
◦ Mitral Stenosis
 Diuretics are recommended when congestive
symptoms persist despite -blockers. (Level
1, Grade B)
 Use of diuretics may be reasonable for
pregnant with MS and heart failure
symptoms (stage D). (Level II-2, Grade C)
 ACE inhibitors and angiotensin receptor
blockers (ARBs) should not be given to
pregnant patients with valve
stenosis/regurgitation.
 RHD IN PREGNANCY -
COMPLICATIONS
 Arrhythmias
◦ Therapeutic anticoagulation is
recommended in the case of atrial
fibrillation, left atrial thrombus or prior
embolism. (Level I, Grade C)
◦ Anticoagulation should be given to
pregnant patients with MS and atrial
fibrillation unless contraindicated. (Class
I, Grade B)
◦ Medical therapy is recommended in
pregnant women with regurgitant lesions
when symptoms occur. (Level I, Grade C)
 RHD IN PREGNANCY -
INTERVENTION
 Mitral Stenosis
◦ Percutaneous mitral balloon
commisurotomy should be considered
in pregnant patients with severe
symptoms or systolic pulmonary artery
pressure > 50mmHg despite medical
therapy. (Level II-1, Grade B)
 RHD IN PREGNANCY -
INTERVENTION
 Mitral Stenosis
◦ Percutaneous mitral balloon
commisurotomy is reasonable for
pregnant patients with severe MS
(mitral valve < 1.5 cm2, stage D) with
valve morphology favorable for
percutaneous mitral balloon
commisurotomy who remain
asymptomatic with NYHA class III to IV
heart failure symptoms despite medical
therapy. (Level II-1, Grade B)
 RHD IN PREGNANCY – During
pregnancy
 Vaginal delivery is the preferred
mode of delivery with adequate pain
relief with epidural anesthesia.
 Primary cesarean section should be
considered for patients on oral
anticoagulation in preterm labor
with acute intractable heart failure,
aortic root diameter > 45 mm and
patients with acute or chronic aortic
dissection.
 RHD IN PREGNANCY – During
pregnancy
 Routine endocarditis antibiotic
prophylaxis is not recommended.
◦ They recommend antibiotic
prophylaxis for high-risk patients with
prosthetic heart valves, previous
history of endocarditis, complex CHD
or surgically corrected systemic-
pulmonary conduit.
 RHD IN PREGNANCY – Post
Partum Period
 Control IV volume by close monitoring for
postpartum IV overload after placental
delivery
 Controlled IV infusion of oxytocin is more
appropriate than IV bolus of oxytocin in the
3rd stage of labor, as it might cause a sudden
fall in cardiac output.
 Close monitoring for signs of heart failure is
recommended.
 Elastic support stockings and early
ambulation are important to reduce the risk of
thromboembolism.
 RHD IN PREGNANCY –
Contraception
 Monthly injectables that contain medroxyprogesterone
acetate (MPA) are inappropriate for patients with heart
failure because of the tendency for fluid retention
 Low dose oral contraceptive pills containing 20 ug of
estradiol are safe in women with low thrombogenic
potential but not in women with complex VHD
 Progestin only contraceptives are recommended for
patients with contraindications to estrogen
 Barrier methods and the levonorgestrel-containing
intrauterine device (IUD) are the safest and most effective
options for women with cardiomyopathy and reduced
systolic ventricular function and those with advanced
pulmonary hypertension.
 Vasectomy for the male partner is another efficacious
option
 CONGENITAL HEART
DISEASE IN PREGNANCY
 CONGENITAL HEART DISEASE IN
PREGNANCY
 Most common types of birth defects responsible for nearly 1/3 of all
major congenital anomalies
 most common CHD worldwide:
 ACYANOTIC
◦ ASD
◦ VSD
◦ PDA
◦ CoArc
◦ Marfan Syndrome
◦ AoS
◦ PVS
◦ Congenitally corrected TGA
◦ Single Ventricle repaired
◦ Ebstein Anomaly
◦ Eisenmeger Syndrome
CYANOTIC
 TOF
 Single ventricle unrepaired
 TVA
 EUROPEAN SOCIETY OF
CARDIOLOGY GUIDELINES FOR
MANAGEMENT OF
CARDIOVASCULAR DISEASE
DURING PREGNANCY
Class I

 are associated with no detectable

increased risk of maternal mortality
and/no mild increase in morbidity
1. Uncomplicated small PDA
2. Mild PS
3. MVP
4. Successfully repaired simple
lesions(ASD, VSD, PDA or anomalous
pulmonary venous drainage)
5. Isolated atrial or ventricular ectopic
beats
Class II
 Are associated with small increased
risk of maternal mortality or moderate
increase in morbidity
1. Unrepaired ASD or small VSD with
normal pulmonary artery pressure
2. Repaired TOF
3. Most arrhythmias
Class II to III
1. Mild left ventricular impairment
2. Hypertrophic cardiomyopathy
3. Native or tissue valvular heart disease
(VHD) not considered WHO I or IV
4. Repaired CoA
5. Marfan syndrome with aortic dimension
<40mm without aortic dissection
6. Bicuspid aortic valve with ascending
aorta diameter <45mm
Class III
 Are associated with significantly increased
risk of maternal mortality or severe morbidity
1. Mechanical valve
2. Systemic right ventricle
3. Fontan circulation
4. Unrepaired cyanotic heart disease
5. Other complex CHD
6. Bicuspid aortic valve with ascending aortic
diameter of 45-50mm
7. Marfan syndrome with aortic diameter of 40-
45mm
Class IV
 are associated with extremely high risk of maternal
mortality or severe morbidity, pregnancy is
contraindicated
1. Severe mitral stenosis
2. Symptomatic sevee AoS
3. Bicuspid aortic valve with ascending aorta diameter
>50mm
4. Marfan syndrome with aorta dilated >45mm
5. Severe systemic ventricular systolic dysfunction (left
ventricular ejection fraction (<30% NYHA FC III-IV)
6. Unrepaired severe CoA
7. Significant pulmonary arterial hypertension of any
cause (indiopathic or Eisenmenger Syndrome)
 INDIVIDUAL RISK FACTOR:
PULMONARY ARTERIAL
HYPERTENSION
 Limits the appropriate adaptive response to
circulatory changes of pregnancy and to the
volatile changes in labor, delivery and
postpartum
 Eisenmenger syndrome risk of maternal
cyanosis and thromboembolic phenomenon
 Preterm delivery and fetal growth restriction
occur in at least (50%) of cases
 INDIVIDUAL RISK FACTOR:
CYANOSIS
 Most important predictors of fetal movement
and maternal outcomes arterial oxygen
saturation
 Resting arterial oxygen saturation below 85%,
the likelihood of a live birth was much lower
 Mothers with cyanotic lesions had significant
postpartum cardiac complication
 Secondary erythrocytosis occur, unless
hematocrit is > 65% with hyperviscoscity
symptoms (headache, loss of concentration,
fatigue and myalgias)
 INDIVIDUAL RISK FACTOR
 POOR MATERNAL NYHA FC
◦ NYHA FC III or IV: most at risk for poor
maternal and fetal outcome
 NATRIURETIC PEPTIDE LEVELS
◦ Independent risk factor for
cardiovascular events during pregnancy
◦ Elevated level (>128pg/mL) at 20 weeks
of gestation
CHD: PRECONCEPTION CARE
 Inform the patient about the risk as far as one
can anticipate them
 Assess the functional ability with
echocardiography and exercise testing before
pregnancy
 Carefully consider the potential risk of
maternal medications to the fetus
 In form the patient about recurrent risks of
CHD
 Detect risk factors for main obstetric
complications(preeclampsia, early preterm
delivery, fetal death in-utero)
CHD: During Pregnancy
 Transvaginal fetal 2D-echocardiography:
as early as 14-16 weeks to detect
moderate to severe congenital heart
lesions
 Transabdominal fetal echocardiography:
anytime from 19th to 22nd week of
pregnancy with transabdominal fetal
echocardiography
CHD: Prenatal Visits
 Class I: cardiology follow up during pregnancy may be
limited to one or two visits
 Class II: follow up every trimester
 Class II-III: cardiology follow up ranges from every
trimester to monthly
 Class III: at least monthly or bi monthly cardiology
follow up during pregnancy. Intensive specialist cardiac
and obstetric monitoring are needed throughout
pregnancy, childbirth and the puerperium
 Class IV: pregnancy is contraindicated. If pregnancy
continues, at a minimum, care as for Class III
 CHD: During pregnancy
 Regular echocardiographic evaluations
are indicated in patients with dilatation of
aorta, left heart obstruction, AoS and MS,
impaired ventricular function, clinical
deterioration or new onset heart murmur
 Required to use anticoagulant. (Heparin)
 Refrain from prescribing iron supplements
 CHD: During pregnancy
Cardiac Drugs
 Relatively safe  NOT safe
 Adenosine
◦ ACE inhibitors
 Amiloride
◦ Angiotensin II
 Beta blockers
receptor antagonist
 Ca+ channel blockers
◦ Warfarin
 Digoxin
◦ Amiodarone
 Flecainide
 Heparin ◦ Phenytoin
 Lidocaine ◦ Spironolactone
 Mexiletine
 Procainamide
 Quinidine
 CHD: Management of Labor,
Delivery and the Postpartum
 The goal is to manage the stress of labor in a manner
by which it will not exceed the woman’s capacity to
cope with it.
 Vaginal delivery:
◦ lower risk of complications for both the mother and fetus
◦ Hazardous with regard to cardiovascular status is if there
is a risk or aortic rupture (Marfan syndrome, bicuspid
aortic valve or operated aortic isthmus stenosis)
 Position of choice: left lateral decubitus
 Antibiotic prophylaxis may be considered prior to
vaginal delivery or at time of rupture for selected high
risk patients
 PROSTHETIC HEART
VALVES IN PREGNANCY
 PROSTHETIC HEART VALVES IN
PREGNANCY
 BIOPROTHETIC VALVES
◦ Pregnancy is well tolerated
 MECHANICAL VALVES
 Well functioning mechanical valves
tolerate pregnancy hemodynamically
well
 High risk of maternal thromboembolism
and death with inadequate
anticoagulation
 Recommends use of anticoagulant
Anticoagulant regimen: 1st trimester
 Continuation of oral anticoagulants should
be considered during 1st trimester, if the
warfarin dose required for therapeutic
anticoagulation is less than 5mg/day, after
patient information and consent.
 Continuation of warfarin during the first
trimester is reasonable for pregnant
women with a mechanical prosthesis if the
dose of warfarin to achieve a therapeutic
INR is 5mg/day or less after full discussion
with the patient about risks and benefits.
 Anticoagulant regimen: 1st
trimester
 Discontinuation of oral anticoagulants between
weeks 6 and 12 and replacement by
unfractionated heparin (UFH) and low
molecular weight heparin (LMWH) under strict
dose control may be considered on an
individual basis in patients with warfarin dose
required for therapeutic anticoagulation of
<5mg/day.
 Dose-adjusted LMWH at least twice daily or
continuous infusion of UFH during the 1st
trimester is reasonable for pregnant patients
with a mechanical prosthesis if the dose of
warfarin is 5mg/day or less to achieve a
therapeutic INR.
Anticoagulant regimen: 1st trimester
 In pregnant women managed with LMWH, the post
dose anti-Xa level should be assessed weekly
 LMWH should be avoided, unless anti-Xa is
monitored
 LMWH should not be administered to pregnant
patients with mechanical prosthesis unless anti-Xa
levels are monitored 4-6 hours after administration
 The American College of Chest (ACC) Physician
2012 guidelines recommended the continuation of
warfarin throughout pregnancy in high-risk patients,
including those with older generation prosthesis, a
mitral prosthesis or a history of thromboembolism,
atrial fibrillation or left ventricular dysfunction.
Anticoagulant regimen: 2nd and 3rd
trimester
 Oral anticoagulant are recommended during
2nd and 3rd trimester until 36th week
 Warfarin is recommended in pregnant
patients with a mechanical prosthesis to
achieve a therapeutic INR in the 2nd and 3rd
trimester
 Low-dose aspirin (75-100mg) once daily is
recommended for pregnant patients in the
2nd and 3rd trimester with either a
mechanical prosthesis or bioprosthesis
 Anticoagulant regimen: guidelines
for patients after 36 Gestational
Weeks
 Oral anticoagulant should be discontinued and
dose-adjusted UFH or adjusted-dose LMWH
started at the 36th week of gestation
 LMWH should be replaced by IV UFH at least 36
hours before planned delivery. UFH should be
continued until 4-6 hours before planned delivery
and restarted 4-6 hours after delivery if there are
no bleeding complications
 Discontinuation of warfarin with initiation of IV
UFH (with an activated aPTT >2 times control) is
recommended before planned vaginal delivery in
pregnant patients with a mechanical prosthesis
Anticoagulant regimen: guidelines
for patients after 36 Gestational
Weeks
 Change of anticoagulation during pregnancy
should be implemented in hospital
 If delivery starts while on oral anticoagulant,
cesarean delivery is indicated
 Routine antibiotic prophylaxis is routinely given
to patients with prosthetic heart valves
 Immediate echocardiography is indicated in
women with mechanical valves presenting with
dyspnea and/or embolic event
 PROSTHETIC HEART VALVES IN
PREGNANCY:
Delivery
 Planned vaginal delivery is usually
preferred with prior switch to heparin
 Cesarean section may be considered an
alternative for high risk valve thrombosis in
order to keep the time without oral
anticoagulant
 PULMONARY
COMPLICATIONS
 PNEUMONIA:
RISK FACTOR
 Pre-existing chronic maternal
disease such as asthma and
anemia
 Smoking
 Use antenatal corticosteroids to
enhance fetal lung maturity
 Use of tocolytic agents to control
preterm labor
 PNEUMONIA:
Diagnosis
 Is physical examination superior
to clinical history as regards to
the diagnosis of CAP?

◦ Physical examination, combined with

clinical history remains one of the
cornerstones in the diagnosis of
pneumonia
 PNEUMONIA:
Diagnosis
 What is the gold standard to
confirm the diagnosis of
pneumonia?

 Chest X-ray
◦ Presence of an infiltrate with single
lobar involvement that is not due to
any other cause (such as pulmonary
edema or infarction) with or without
the associated microbiologic results
 PNEUMONIA:
Diagnosis
 When should a chest chest X-ray be
performed for patients presenting with
suspected CAP?

 All patients admitted to the hospital

with suspected CAP should have a
chest radiograph performed as soon
as possible to confirm or refute the
diagnosis.
 PNEUMONIA:
Diagnosis

 Should all patients with CAP be

evaluated by microbiological studies for
specific pathogens?
 OPTIONAL or not routinely offered to
patients with LOW-RISK CAP
 ALL patients with MODERATE to
SEVERE CAP should be evaluated by
appropriate microbiological studies,
preferably prior to the start of antibiotic
therapy
 PNEUMONIA:
Diagnosis
 MINOR Criteria for severe CAP:
◦ Confusion/disorientation
◦ Uremia (BUN level > 20mg/dL)
◦ PaO2/ FiO2 ratio < 250
◦ Multilobar infiltrates on chest X-ray
◦ Leukopenia (WBC count < 4000 cells/mm3)
◦ Thrombocytopenia (Plt count < 100000
cells/mm3)
◦ Hypothermia (core temp <36 C)
◦ Hypotension requiring aggressive fluid
resuscitation
PNEUMONIA:
Diagnosis
 MAJOR Criteria for severe CAP:
◦ Invasive mechanical ventilation
◦ Septic shock with the need for vasopressors
 Other Criteria to consider:
◦ Hypoglycemia (in non-diabetic patients)
◦ Acute alcoholism/ alcoholic withdrawal
◦ Hyponatremia
◦ Unexplained metabolic acidosis or elevated
lactate level
◦ Cirrhosis
◦ Asplenia
PNEUMONIA:
Diagnosis
DIAGNOSTIC TEST
 Chest X-ray with abdominal shield to establish
diagnosis of pneumonia
 Complete blood count
 Electrolytes [Na, K, Cl] and serum BUN to assess
severity of CAP
 Assessment of oxygenation by either pulse oximeter
or ABG’s, if needed
 Blood culture, if suspect sepsis
 Gram stain of sputum, to aid in choosing initial
antibiotic coverage of moderate to high-risk patients;
because in low-risk patients gram stain of sputum
usually produces a low yield
 MEDICATIONS - ANTIBIOTICS
 When should empiric antibiotic treatment
be initiated in pregnant women with CAP?

 The empiric treatment of CAP with IV

antibiotics in pregnant women admitted
to the hospital should be initiated as
soon as the diagnosis is considered
likely of confirmed by chest X-ray even
without microbiological evidence of the
etiologic agent
 PNEUMONIA:
MEDICATIONS - Antibiotics
 ANTIBIOTICS (Out-patient):
◦ Mild or low severity CAP in a healthy pregnant
women with no history of antibiotic use with no
history of antibiotic use within the previous 3
months
 No risk factors for drug-resistant S. pneumoniae (DRSP)
infection, single antibiotic therapy is recommended
 Oral macrolide
 Standard: AZITHROMYCIN
 Alternative: CLARITHROMYCIN
 At risk for DRSP
 Oral macrolide (Azithromycin) PLUS high-dose beta lactam
(Amoxicillin 3g/day) or cephalosporin (Cefuroxime 500mg
BID)
 MEDICATIONS - Antibiotics
 ANTIBIOTICS (Out-patient):
◦ Mild CAP but with presence of stable co-
morbidities or antibiotic use within the previous
3 months
 No risk factors for DRSP infection
 Combination of beta lactam (high-dose oral Amoxicillin) PLUS
Oral macrolide or respiratory Fluoroquinolone (Levofloxacin)
 At risk for DRSP
 Combination of beta lactam (Penicillin or Cephalosporin with
beta lactamase inhibitor OR
 2nd generation Cephalosporin with or without extended
Macrolides
 MEDICATIONS - Antibiotics

 ANTIBIOTICS (In-patient):
◦ Uncomplicated pneumonia
 No risk factors for DRSP infection
 IV Macrolide (Azithromycin 500mg IV daily or Erythromycin
500mg IV QID
 At risk for DRSP
 IV macrolide plus beta lactam (Ceftriaxone or Cefotaxime
Ampicillin) OR
 Monotherapy with a respiratory Fluoroquinolone
 MEDICATIONS - Antibiotics
 ANTIBIOTICS (In-patient):
◦ Severe CAP, needing ICU admission
 No risk factors for pseudomonal infection
 Anti-pneumococcal Beta lactam (Cefotaxime, Ceftriaxone
or Ampicillin-Sulbactam) PLUS either a Macrolide
(Azithromycin or Erythromycin) or Respiratory
Fluoroquinolone (Levofloxacin)
 For penicillin-allergic patients: respiratory
Fluoroquinolone AND Aztreonam
 With risk factors for pseudomonas infection
 Anti-pneumococcal, anti-pseudomonal beta-lactam
(Imipenem, Meropenem, Piperacillin-Tazobactam) PLUS
either Ciprofloxacin or Levofloxacin (750mg) OR
 Beta-lactam PLUS an Aminoglycoside (Amikacin,
Gentamicin, Tobramycin) and Macrolide (Azithromycin or
Erythromycin)
 PNEUMONIA:
MEDICATIONS - Antibiotics
 The duration of treatment for low risk uncomplicated
bacterial pneumonia should for minimum of 5 days.
Discontinuation of antibiotics is considered if patient is
afebrile for 48-72 hours and with no more than 1
CAP-associated sign of clinical instability. Antibiotic
treatment may be prolonged to 14-21 days for
moderate to high-risk CAP.
 For hospitalized CAP patients, IV antibiotics are
shifted to oral antibiotics once the patient is afebrile
for at least 48-72 hours and clinically stable and
have a normal functioning gastrointestinal tract to be
able to ingest oral antibiotics without danger of
aspiration.
 Consider discharge as soon as the patient is clinically
stable, have no other active medical problems, and have
a safe environment for continued care.
 MEDICATIONS – Anti-viral
 Recommended dosage and duration for patients
with confirmed or suspected influenza A or B
◦ Treatment
 Oseltamivir 75mg/cap, 1 cap BID x 5 days
 Zanamivir 10mg (two 5mg inhalations) BID x 5 days
 For severely ill patients: longer treatment course is
recommended
◦ Chemoprophylaxis (after last known exposure)
 Oseltamivir 75mg/cap, 1 cap OD x 7 days
 Zanamivir 10mg (two 5mg inhalations) OD x 7 days
◦ Use of M2 inhibitors or amantadanes
 Active for Influenza A ONLY
 Amantadine or Rimatidine 100mg PO Q12
 MEDICATIONS – Anti-retroviral
 Pneumocytis Pneumonia in HIV-infected
pregnant women
◦ Treatment of choice Trimethoprim-
sulfamethoxazole
 For mild to moderate symptoms:
 Oral dose is 2 double-strength tablets every 8 hours
 IV doses may be used in patients that have difficulty in
tolerating oral medications
◦ For patients who can not tolerate TMP-SMX
 Pentamidine less effective in treatment of PCP
 MEDICATIONS - STEROIDS
 Should giving of antenatal steroids
for fetal lung maturity be offered
routinely in pregnant women with
CAP who are not in labor?
 The prophylactic giving of antenatal
steroid for fetal lung maturity to
pregnant women with CAP but who
are not in labor has not been
evaluated; thus, is currently not
recommended.
 MEDICATIONS – LABOR & DELIVERY
 Will elective delivery of pregnant
patients who are in respiratory failure
due to pneumonia but who are not in
labor improve their respiratory status?

 Elective delivery of these pregnant patients

is not recommended as there are no
definitive evidence to support that elective
delivery will improve the respiratory status
in these women. Delivery should be
reserved only for obstetrical indications.
 MEDICATIONS – LABOR & DELIVERY
 Will delivery through labor induction in
women with respiratory failure as a
result of severe CAP improve maternal
outcomes?

 Delivery through labor induction should

be reserved for those women with
imminent maternal death as delivery
does not improve maternal condition in
respiratory failure.
BRONCHIAL ASTHMA
 GENERAL TRENDS
 ASTHMA was generally less severe during the
last 4 weeks of pregnancy
 In women who improved, the improvement was
gradual as pregnancy progressed.
 In women whose asthma worsened, the increase
in symptoms was most prominent between 29 to
36 weeks of gestation
 Substantial asthma symptoms were uncommon
during labor and delivery
 The course of asthma in successive pregnancies
in an individual patient tended to be similar
 Severe asthma is more likely to worsen during
pregnancy, than mild asthma
 MANAGEMENT
 Four important components of effective
asthma therapy during pregnancy are:
◦ Objective monitoring of lung function and
fetal well being as a guide to therapy
◦ Proper control of environmental and other
triggers for asthma
◦ Patient education
◦ Pharmacologic therapy
 MANAGEMENT
◦ Monitoring maternal lung function
 MANAGEMENT
◦ Monitoring of fetal well-being
 Fetal surveillance: Serial ultrasound examination
for growth evaluation
 IUGRantenatal fetal testing should be performed
 Patient Education
 Proper control of environmental and other
triggers for asthma
◦ Devised plan to enable to reduce the exposure:
 Complete avoidance of the trigger
 Limit exposure to the trigger if it cannot be
completely avoided
 Take an extra dose of bronchodilator and an
antihistamine before trigger exposure
Management
 Pharmacologic therapy
Management
 Pharmacologic therapy
 Peripartum Care
 Short acting beta agonist is given to manage
bronchoconstriction that may ensue due to
hyperventilation during labor
 Women with asthma may safely use all forms of
usual labor analgesia
 Oxytocin appears to be safe in pregnant patient
with asthma
 Prostaglandin F2alpha is recommended than
prostaglandin E1 or E2. This is based on the risk of
bronchoconstriction associated with the latter
agent.
 Maintain O2 saturation of 94-98% to prevent
maternal and fetal hypoxia
 HEMATOLOGIC
COMPLICATIONS
 THALASSEMIA
Screening
 All pregnant women from an ethnic
background at increased risk pf thalassemia
should be screened by CBC, which should
include the MCV and MCH, hemoglobin
electrophoresis or high performance liquid
chromatograhy
 Any abnormality in a woman’s initial screening
requires prompt screening of the partner,
which includes CBC, hemoglobin
electrophoresis, and HbA2 and HbF
quantitation
 THALASSEMIA:
Prenatal Diagnosis
 There are certain clinical situations arising from screening
that will require molecular (DNA) testing to explain the
carrier status and constantly the risk of having an affected
child, and/or to provide the information required for prenatal
diagnosis. Therefore, a referral to a clinical genetics until
should be expedited
 THALASSEMIA:
Prenatal Diagnosis
 All pregnant carrier woman and her partner at risk of having a
child with a clinically significant thalassemia should be offered
prenatal diagnosis by DNA analysis of amniocytes and it
should only be performed with the informed consent of the
woman or couple
 For those who do not want an invasive testing and are at risk
of Hemoglobin Bart’s hydrops fetalis (four gene deletion
alpha-thalssemia), serial detailed fetal ultrasound for
assessment of the fetal cardiothroracic ratio should be done
for early identification of an affected fetus
 The finding of hydrops fetalis on UTZ in the 2nd or 3rd trimester
in pregnant women with an increased risk of thalassemia
should prompt immediate investigation of the pregnant patient
and her partner to determine their carrier status for
thalassemia
 Preconception Care
 Aggressive chelation in the preconception stage ca reduce
and optimize body iron burden and reduce end-organ
damage
 Iron chelators should be reviewed, and defarasirox and
deferiprone ideally discontinued 3 months before conception
 Thalassemic women with DM should be referred to
diabetologist and good glycemic control should be achieved
pregnancy. Serum fructosamine is preferred for monitoring in
women with thalassemia
 Thyroid function should be determined in women with
thalassemia. They should be biotechnically and clinically
euthyroid prior to conception
 Preconception care
 All women should be assessed by cardiologist prior
to embarking on a pregnancy with an
echocardiogram and an electrocardiogram (ECG)
as well as T2* cardiac MRI
 All women with thalassemia should be offered
bone density scan to document pre-existing
osteoporosis and if necessary, serum vitamin D
concentrations should be optimized
 Folic acid (5mg) is recommended preconceptually
to all women to prevent neural tube defect
 Antepartum Care
 Pregnant women with thalassemia should be
seen by a multidisciplinary team that should
provide routine as well as specialist antenatal
care.
 The recommended schedule for ultrasound in pregnant
women with thalassemia should include early scan at 7-9
weeks of gestation, a routine first trimester scan (11-14
weeks of gestation), detailed anomaly scan at 18-22 weeks
of gestation, and serial fetal biometry scans every 4 weeks
from 24 weeks of gestation.
 All women with ß-thalassemia major should be receiving
blood transfusions on a regular basis aiming for a pre-
transfusion hemoglobin of 10 g/dL. For symptomatic
patients or those with growth restriction patients with B-
thalassemia intermedia, transfusion should be started to
achieve hemoglobin of 12 g/dL.
 Antepartum Care
 Women with myocardial iron loading should undergo
regular cardiology review during the pregnancy as
signs of cardiac decompensation are the primary
indications for intervention with chelation therapy.
 Women with thalassemia major or intermedia have an
increase risk for venous thromboembolism (VTE) due
to the presence of abnormal red cell fragments,
especially if they have undergone splenectomy. These
red cell fragments combined with a high platelet count
further increases the risk and would require antenatal
thromboprophylaxis.
 INTRAPARTUM CARE
 The timing of delivery should be individualized
depending on the patients' underlying complications of
thalassemia, e.g. women with diabetes mellitus or
gestational diabetes mellitus should be managed
according to the standard protocols for diabetic women
in labor. In cases where pregnancy is uncomplicated,
delivery can be planned according to local guidelines
 Thalassemia itself is not an indication for abdominal
delivery.
 In women with thalassemia major intravenous (IV)
Deferoxamine 2 g over 24 hours should be administered
for the duration of labor.
 INTRAPARTUM CARE
 For patients with thalassemia major, the timing of the
most recent transfusion will determine if transfusion
is required during labor and delivery. A crossmatch
sample is advised on admission, with 2 units
requested to be available if hemoglobin is < 10 g/dL2
 For patients with thalassemia intermedia, if
hemoglobin is > 8 g/diL at 36 weeks then transfusion
can be avoided prior to delivery and the patient
transfused if needed only during postpartum.
 Active management of the third stage of labor should
be done to minimize blood loss.
 POSTPARTUM CARE
 Women with thalassemia are considered at
high risk for VTE postpartum and should be
given prophylaxis for 7 days post discharge in
the case of uncomplicated vaginal delivery,
and for 6 weeks following cesarean section
IDIOPATHIC THROMBOCYTOPENIC
PURPURA
 Diagnosis
 As in non-pregnant patients, the diagnosis
of ITP is one of exclusion of other causes
of thrombocytopenia in pregnancy
 Diagnosis
 All women with platelet counts <100 x 10/L
should be screened for clinical or
laboratory evidence of preeclampsia,
coagulopathy or autoimmune disease.
Bone marrow aspiration is unnecessary
unless there is suspicion of leukemia.
IDIOPATHIC THROMBOCYTOPENIC
PURPURA: Diagnosis
 The routine measurement of platelet-associated
IgG or platelet antibodies is not recommended
 Predictors of Neonatal Thrombocytopenia
◦ Maternal platelet count, maternal platelet antibody
levels, or a history of splenectomy cannot reliably
predict fetal or neonatal count.
◦ Risk of neonatal thrombocytopenia is increased if
there was a previously affected pregnancy or low
platelet count at birth of first or second sibling.
◦ There is no evidence that cordocentesis at 38-39
weeks and fetal scalp blood sampling in labor are
justified. Both are not recommended as they carry
more risks than potential clinical benefits.
MANAGEMENT
 Management
 Prenatal:
◦ Asymptomatic women with platelet counts >30 x10/L do not need
treatment until delivery is imminent
◦ Platelet counts >50 x 10/L safe for normal vaginal delivery
◦ Platelet counts >80 x 10°/L  safe for cesarean section, spinal or
treatment until delivery is imminent. (Level II, Grade C) patients with
otherwise normal coagulation. (Level il1, Grade C) epidural anesthesia
in patients with otherwise normal coagulation. (Level III Grade C)
◦ In women who need treatment, both oral corticosteroids and IVig have
a similar response rate with the use of these agents in the non-
pregnant patient.
◦ There are no convincing data on the effect (beneficial or otherwise of
corticosteroids IVlg on the fetal/neonatal platelet count. (Level III,
Grade C)
◦ Severe refractory ITP may respond to high dose IV methyl
azathioprine. If essential, splenectomy may prednisolone : IVig or be
performed (ideally in the second trimester) and the laparoscopic route
may have clinical advantages similar to those seen in non- pregnant
patients.
 MANAGEMENT
 Labor and Deliver
◦ Plan delivery in a center with appropriate multidisciplinary
expertise.
◦ Cesarean section is performed entirely for obstetric
indications. No evidence shows that any fetal/neonatal
hemorrhage risk is lessened by elective cesarean section.
◦ Platelet counts >50 x 10/L are safe for normal vaginal delivery
if coagulation is otherwise normal.
◦ Maternal platelet transfusion is needed to cover delivery if the
platelet count is <50 x 10/L
◦ Platelet counts >80 x 10/L are safe for spinal/epidural
anesthesia or cesarean section if coagulation is otherwise
normal.
◦ Episiotomy should be avoided if possible with low maternal
platelet counts
 Management
 Post-delivery
◦ Nonsteroidal anti-inflammatory drugs
(NSAIDs) should be avoided for postpartum
or post-operative analgesia in women with
platelet counts <100 x 109/L.
◦ Breastfeeding is not contraindicated
◦ Cord platelet counts should be measured in
all neonates of mothers with ITP and those
with subnormal levels monitored clinically and
with daily counts until after the nadir which
usually occurs on days 2-5 after delivery.
DENGUE
 RECOMMENDATIONS
 Dengue in the Philippines is an all year round disease. Most
dengue cases (approximately 60%) occur during the rainy
season from July to August and every area of the country is
affected
 Dengue fever and the more severe form, dengue hemorrhagic
fever (DHF), are caused by any of the four serotypes of
dengue (types 1,2, 3, and 4) based on the laboratory
confirmed dengue cases in the Philippines, in which all four
dengue virus (DENV) serotypes were present
 The predominant serotype is DENV-1 followed by DENV-2,
mostly occurring in the National Capital Region (NCR) region.
 Infection with one serotype of DENV confers lifelong immunity
to the serotype and short-term immunity (typically 2-3 months)
to the other DENV serotypes
 RECOMMENDATIONS
 The incubation period of the disease is normally
3-8 days. The virus is detectable in human
subjects 6-18 hours
 Detection of dengue-specific immunoglobulin M
(lgM) is a suitable method for ascertaining acute
or recent infection because it is present early in
infection and can persist for up to 6 months
 The IgM immunoassay (MAC-ELISA or
equivalent) is the most commonly used for rapid
confirmation of the diagnosis
 The presentation and clinical course of dengue
in pregnant women is similar to non-pregnant
 RECOMMENDATIONS
 The presentation and clinical course of dengue in
pregnant is similar to non-pregnant
 The developing fetus may be susceptible to DENV
infections, especially during the critical period of
organogenesis (congenital dengue), or late in the
pregnancy, even though the primary infection may not
manifest overt symptoms in the mother
 Early onset or late onset in pregnancy appeared to
have a bad prognosis
 Most pregnant women developed uneventful recovery
from dengue virus infection but infection in the first
trimester has been reported to increase the risk of
abortion. The main complication reported during
peripartum period was bleeding
 RECOMMENDATIONS
 A history of fever and hypertension that
predates pregnancy may be helpful for
arriving at a provisional diagnosis while the
definite diagnosis of dengue infection should
be confirmed serologically
 Signs and symptoms of dengue ever might
easily be confused with those of other
pregnancy complications such as toxemia or
its variant, HELLP syndrome (hemolysis,
elevated liver enzymes low platelets)
DENGUE
 RECOMMENDATIONS
 Treatment is supportive with fever reduction
measures, analgesics and careful
maintenance of fluid and electrolyte
 The majority opinion would be for
conservative management unless there is
some other obstetrical reason to intervene
ENDOCRINOLOGIC
COMPLICATIONS
 Thyroid Disorder

 Serum thyroid stimulating hormone (TSH) and free

T4 (FT4)  preferred tests to diagnose thyroid
dysfunction in pregnancy and interpretation should
be based on the laboratory established trimester
specific reference ranges for pregnant women.
THYROID DISORDER:
 How should hypothyroidism during
pregnancy be managed?
 Pregnancy should be avoided among overtly
hypothyroid women since maternal overt
hypothyroidism is known to have serious adverse
effects on the fetus. If overt hypothyroidism is
diagnosed during pregnancy thyroid function tests
should be normalized as rapidly as possible with L-
T4. Less than 2.5 mIU/L serum TSH in the 1st
trimester (or 3 mlU/L in 2nd and 3 trimesters) or to
trimester-specific TSH ranges should be reached and
maintained. Preemptively increasing the L-T4 dose at
the time of the positive pregnancy test is
recommended
 Thyroid function tests should be re-measured every
4-6 weeks because the LT4 dose usually needs to be
incremented every 4-6 weeks of gestation.
 How should hypothyroidism during pregnancy be managed?

 Pregnant women should be given once daily

prenatal vitamins containing 150-200 ug
iodine in the form of potassium iodide or
iodate, to ensure that all pregnant women
taking prenatal vitamins are protected from
iodine deficiency. Utilizing iodized salt during
pregnancy is also recommended.
 How is thyroid storm diagnosed
and treated in pregnancy?
 If thyroid storm is suspected, serum FT4,
FT3 and TSH levels should be evaluated
to help confirm the diagnosis, but therapy
should not be withheld pending the results.
 Therapy for thyroid storm consists of a
standard series of drugs. Each drug has a
specific role in the suppression of thyroid
function.
How is thyroid storm diagnosed and
treated in pregnancy?
 Treatment Protocol of Thyroid Storm in
Pregnant Women
◦ PTU 600-800 mg orally, stat, then 150-200 mg
orally every 4-6 hours If oral administration is
not possible, use MMI rectal suppositories if
available locally.
◦ Starting 1-2 hours after PTU administration,
saturated solution of potassium iodide (SSKI)
2-5 drops orally every 8 hours, or sodium
iodide 0 5-1.0g intravenously (IV) every 8
hours, or Lugol's solution 8 drops every 6
hours, or lithium carbonate 300 mg orally every
6 hours.
How is thyroid storm diagnosed and
treated in pregnancy?
 Treatment Protocol of Thyroid Storm in
Pregnant Women :
◦ Dexamethasone 2 mg IV or intramuscularly
(IM) every 6 hours for four doses
◦ Propranolol 20-80 mg orally every 4-6 hours,
or propranolol, 1-2 mg IV every 5 minutes for
a total of 6 mg, then 1-10 mg IV every 4 hours
If the patient has a history of severe reserpine
1-5 mg IM every 4-6 hours, diltiazem 60 mg
orally every 6-8 hours.
◦ Phenobarbital 30-60 mg orally every 6-8 hours
as needed for extreme restlessness.
ANTENATAL AND INTRAPARTUM
FETAL SURVEILLANCE IN HIGH
RISK PREGNANCIES
 What fetal surveillance tools
are available?
 Fetal kick counting  Intrapartal electronic
 Biometry fetal monitoring
 Biophysical profile  Intermittent auscultation
 Modified BPP  Fetal electrocardiogram
 NST  Fetal oximetry
 Contraction stress test  Scalp pH
 Doppler studies
 RECOMMENDATIONS on
Antenatal Fetal Assessment
 FETAL MOVEMENT COUNTING
◦ Dally monitoring of fetal movements starting at 26
to 32 weeks should be done in all pregnancies wilth
risk factors for adverse perinatal outcome
◦ Healthy pregnant women without risk factors for
adverse perinatal outcomes should be made aware
of the significance of fetal movements in the 3rd
trimester and asked to perform a fetal movement
count if they perceive decreased movements.
◦ Women who do not perceive 6 movements in an
interval of 2 hours require further antenatal testing
and should contact their caregivers or hospital as
soon as possible.
Antenatal Fetal Assessment
 FETAL MOVEMENT COUNTING
◦ Women who report decreased fetal movements (< 6 distinct
movements within 2 hours) should have a complete
evaluation of maternal and fetal status, including NST and/or
BPP Prior to considering an intervention for fetal well-being,
an anatomical scan to rule out a fetal malformation should be
done, if one has not already done management should be
based upon the following:
 NST is normal and there are no risk factors the woman should
continue with daily fetal movement counting.
 NST is normal and risk factors or clinical suspicion of IUGR/
oligohydramnios is identified an ultrasound for either full BPP or
AFV assessment within 24 hours. The woman should continue
with daily fetal movement counting.
 NST is atypical/abnormal: further testing with BPP and/or CST
and assessment of AFV) should be performed as soon as
possible.
 Antenatal Fetal Assessment
 NONSTRESS TEST
◦ Antepartum NST may be considered when risk factors for
adverse perinatal outcome are present.
◦ Women at high risk for stillbirth should undergo antepartum
fetal surveillance using the NST, CST, BPP or modified BPP.
◦ Initiation of testing at 32 to 34 weeks of gestation is
appropriate for most pregnancy that are at increased risk of
stillbirth. In pregnancies with multiple or particularly
worrisome high-risk initiated as early as 26 to 28 weeks of
gestation.
◦ When the clinical condition that prompted testing persists, a
reassuring test should be repeated weekly or, depending on
the test used and the presence of certain high-risk
conditions, twice weekly until delivery. Any significant
deterioration in fetal activity requires fetal re-evaluation,
regardless of the amount of time that has elapsed since the
last test.
 Antenatal Fetal Assessment
 NONSTRESS TEST
◦ An abnormal NST or modified BPP usually should be further
evaluated by a CST or a full BPP. Subsequent management
should then be predicated on the results of the CST or BPP,
the gestational age, the degree of oligohydramios (if
assessed) and the maternal condition.
◦ In the presence of a normal NST, usual fetal movement
patterns, and absence of suspected oligohydramnios, it is
not necessary to conduct a BPP or CST
◦ A normal NST should be classified and documented by an
appropriately trained and designated individual as soon as
possible, (ideally within 24 hours). For atypical or abnormal
NST, the nurse should inform the attending physician (or
primary care provider) at the time that the classification is
apparent. An abnormal NST should be viewed by the
attending physician (or primary care provider) and
documented immediately.
 Antenatal Fetal Assessment

 CONTRACTION STRESS TEST

◦ The CST should be considered in the presence of an
atypical NST as a proxy for the adequacy of intrapartum
uteroplacental function and together with the clinical
circumstances, will aid in decision making about timing and
mode of delivery
◦ The CST should not be performed when vaginal delivery is
contraindicated.
◦ The CST should be performed in a setting where
emergency section is available.
 Antenatal Fetal Assessment
 BIOPHYSICAL PROFILE
◦ In pregnancies at increased risk for adverse
perinatal outcome and where facilities and
expertise exist, BPP is recommended for
evaluation of fetal well-being.
◦ When an abnormal BPP is obtained, the
responsible physician or delegate should be
informed immediately. Further management will be
determined by the overall clinical situation.
 Antenatal Fetal Assessment
 UTERINE ARTERY DOPPLER
◦ Where facilities and expertise exist, uterine
artery Doppler may be performed at the time of
the 17 to 22 weeks gestation detailed anatomical
ultrasound scan in women with the following
factors for adverse perinatal outcome.
 Previous obstetrical history
 Previous early onset gestational
hypertension
 Placental abruption
 IUGR
 Stillbirth
Antenatal Fetal Assessment
 UTERINE ARTERY DOPPLER
◦ Where facilities and expertise exist, uterine artery Doppler
may be performed at the time of the 17 to 22 weeks'
gestation detailed anatomical ultrasound scan in women
with the following factors for adverse perinatal outcome.
 Risk factors in current pregnancy
 Pre-existing hypertension
 Gestational hypertension
 Pre-existing renal disease
 Long-standing type I diabetes mellitus with vascular
complications, nephropathy, retinopathy
 Abnormal maternal serum screening (human chorionic
gonadotropin (hCG] or alpha fetoprotein [AFPI> 2.0 MoM)
 Low PAPP-A (consult provincial laboratories for moms)
Antenatal Fetal Assessment
 UTERINE ARTERY DOPPLER
◦ Women with a positive uterine Doppler screen
should have the following:
 A double marker screen (for AFP and p-hCG) if at or
before 18 weeks gestation
 A second uterine artery Doppler at 24 to 26 weeks If
the uterine artery Doppler is positive at the second
scan, the woman should be referred to a maternal-
fetal medicine specialist for management
 Antenatal Fetal Assessment
 UMBILICAL ARTERY DOPPLER
◦ Umbilical artery Doppler should not be used as a screening tool in
healthy pregnancies, as it has not been shown to be of value in this
group
◦ Umbilical artery Doppler should be available for assessment of the
fetal placental circulation in pregnant women with suspected
placental pathology Fetal umbilical artery Doppler assessment
should be considered (1) at time of referral for suspected growth
restriction, or (2) during follow-up for suspected placental
pathology
◦ Depending on other clinical factor reduced, absent, or reversed
umbilical artery end-diastolic flow is an indication for enhanced
fetal surveillance or delivery. If delivery is delayed to improve fetal
lung maturity with maternal administration of glucocorticoids,
intensive fetal surveillance until delivery is suggested for those
fetuses with reversed end-diastolic flow
◦ Fetal and umbilical ultrasound among women with high risk may
help reduce the number of babies who died, fewer cesarean
sections and operative deliveries, but the quality of the studies was
not high and there remains some uncertainty here
 Intrapartum Fetal Assessment
 LABOR SUPPORT DURING ACTIVE
LABOR
◦ Women in active labor should receive continuous
close support from an appropriately trained
person
 Recommendation 8: PROFESSIONAL
ONE-TO ONE CARE AND INTRAPARTUM
FETAL SURVEILLANCE
◦ Intensive fetal surveillance by intermittent
auscultation or EFM requires the continuous
presence of nursing or midwifery staff. One-to-one
care of the woman is recommended, recognizing
that the nurse/midwife is really caring for 2
patients, the woman and her unborn baby
 Intrapartum Fetal Assessment
 INTERMITTENT AUSCULTATION IN LABOR
◦ Intrapartum fetai surveillance for healthy term women in
spontaneous labor in the absence of risk factors for
adverse perinatal outcome: Intermittent auscultation
following an established protocol of surveillance and
response is the recommended method of fetal surveillance
compared with EFM; it has lower intervention rates without
evidence of compromising neonatal outcome
◦ Epidural analgesia and intermittent auscultation:
Intermittent auscultation may be ased to monitor the fetus
when epidural analgesa is used during labor, provided that
a protocol is in place for intermittent auscultation
assessment (eg. every 5 minutes for 30 mins after
epidural initiation and after bolus top-ups as long as
maternal vital signs are normal
 RECOMMENDATIONS:
Intrapartum Fetal Assessment
 Recommendation 10: ADMISSION FETAL
HEART TEST
◦ Admission fetal heart tracings are not
recommended for healthy women at term in labor
in the absence of risk factors for adverse
perinatal outcome, as there is no evident benefit
◦ Admission fetal heart tracings are recommended
for women with risk factors for adverse perinatal
outcome
◦ In high risk pregnancies, recent, normal
antepartum fetal test results should not preclude
the use of intrapartum fetal monitoring
 Intrapartum Fetal Assessment
 INTRAPARTUM FETAL SURVEILLANCE FOR WOMEN
WITH RISK FACTORS FOR ADVERSE PERINATAL
OUTCOMES
◦ EFM is recommended for pregnancies at risk of adverse
perinatal outcome
◦ Normal EFM tracings during the first stage of labor. When a
normal tracing is identified, it may be appropriate to interrupt
the EFM tracing for up to 30 minutes to facilitate periods of
ambulation, bathing, or position change, providing that
 (1) the maternal-fetal condition is stable, and
(2) if oxytocin is being administered, the infusion rate is not
increased
◦ In the absence of obstetric contraindications, delivery of the
fetus with an abnormal test result often may be attempted by
induction of labor with continuous monitoring of the FHR and
contractions. If repetitive late decelerations are observed,
cesareen delivery generally is indicated
 Intrapartum Fetal Assessment
 DIGITAL FETAL SCALP STIMULATION
◦ Digital fetal scalp stimulation is recommended in
response to atypical electronic fetal heart tracings
◦ In the absence of a positive acceleratory response
with digital fetal scalp stimulation:
 Digital fetal scalp stimulation is recommendation in
response to atypical electronic fetal heart tracings
 If the absence of a positive acceleratory response
with digit fetal scalp stimulation:
 fetal scalp blood sampling is recommended when
available
 If fetal scalp blood be sampling is not available,
consideration should be given to prompt delivery,
depending upon the overall cincal situation
THANK YOU!