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ISUOG Recommendations: Fetal Ultrasound Follow-Up for Women with Established Preeclampsia

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Recall the ISUOG recommendations for the role of ultrasound in the monitoring of patients who have a diagnosis of preeclampsia
2. Discuss the impact of common medications used to treat preeclampsia on Doppler indices

Estimated time to complete activity: 0.25 hours

Faculty:

Ashley Comfort, MD, FACOG is the Director of Medical Content, ObG Project.

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Ashley Comfort, MD, has a financial interest in Pfizer and has no other conflicts of interest to disclose.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 3 2018 through Jan 25 2023, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

SUMMARY:

The ISUOG Clinical Standards Committee has released practice guidelines reviewing the latest evidence and provides recommendations regarding the role of ultrasound in follow-up for women diagnosed with preeclampsia.

KEY POINTS:

Close fetal surveillance is warranted as deteriorating fetal status may be an indication for earlier delivery
Sonographic follow up of PE should include
- Fetal growth
- Biophysical profile
- Fetal Doppler assessments
Frequency and impact of sonographic follow up has yet to be determined by large-scale clinical trials

Role of B-mode Ultrasound

Ultrasound assessment should include

Fetal growth
- Rule out impaired growth
Biophysical profile
- BPP of >8: Normal – manifestation of fetal wellbeing
- BPP of 6: Inconclusive – repeat test
- BPP of ≤4: Non-reassuring – consider delivery
Amniotic fluid volume
- Ensure presence of MVP >2 cm and/or AFI >5 cm
- Evidence that MVP may result in fewer interventions (see ‘Related ObG Topics’ below)
Placentation
- Thickness | Echogenicity | Uteroplacental interface
- Severe PE may be associated with
  - Placental edema and diffuse echogenicity due to edema
  - Thick placenta and reduced vascularization
  - Cystic regions (infarctions/ hematomas)
- Abruption (poor sensitivity with 50 to 75% missed on ultrasound
  - Hematoma (preplacental and retroperitoneal) | Subchorionic and marginal blood | Increased placental thickness and echogenicity

Role of Doppler Studies

4 major Doppler exams
- Umbilical artery (UA)
- Fetal middle cerebral artery (MCA)
- Fetal ductus venosus
- Uterine arteries

Especially in the presence of maternal headache, abdominal pain, bleeding and/or reduced fetal movements consider

*UA
- absent or reversed end-diastolic flow is strongly associated with poor perinatal outcomes
- Increased resistance in the uterine arteries is not a useful indicator for timing of delivery
*Fetal MCA PI
- Reduced MCA-PI <10th percentile (cephalization) may precede abnormal UA indices, and warrants close fetal surveillance
*Cerebroplacental ratio (CPR)
- CPR: MCA PI / UA PI
- CPR<10th percentile may represent hemodynamic redistribution
- Warrants close fetal surveillance
Fetal ductus venosus
- Unlike the above 3 indices (marked with *), ductus venosus is not included in ultrasound recommendation list (‘Good Practice Points’) for preeclampsia follow up
- However, the guideline does point out that a reversed a-wave is strongly association with fetal cardiac deterioration

Note: ISUOG states that the above tests should also “be considered for women admitted for PE or with suspected PE, as well as for those with severe PE or HELLP syndrome” as a ‘Good Practice Point’.

Impact of Medications on Ultrasound Indices

Antihypertensives
- Not associated with changes in maternal and fetal Doppler indices
Antenatal steroids
- Associated with a transient decrease in vascular resistance in the UA and ductus venosus
Magnesium sulfate
- Unclear

Learn More – Primary Sources:

ISUOG Practice Guidelines: role of ultrasound in screening for and follow up of pre-eclampsia

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