When LMP and Ultrasound Dates Don’t Match: When to Redate?
CLINICAL ACTIONS:
Historically, dating pregnancies and calculating due dates were left to weekly pregnancy calendars. However, ultrasound dating, in particular first trimester sonography, has greatly improved our ability to calculate the estimated due date (EDD). There will be times that dating based on LMP does not match the ultrasound date.
ACOG recommends redating as follows:
First trimester: based on CRL measurement
8w6d or less: redate if discrepancy is > 5d
9w0d – 13w6d: redate if discrepancy is > 7d
Second trimester: based on BPD, HC, AC and FL
14w0d – 15w6d: redate if discrepancy is > 7d
16w0d – 21w6d: redate if discrepancy is > 10d
22w0d – 27w6d: redate if discrepancy is > 14d
Third trimester: based on BPD, HC, AC and FL
28w0d and beyond: redate if discrepancy is > 21d
Use caution when redating in the 3rd trimester as discrepancy may reflect growth restriction
Management should not be based on ultrasound alone but rather comprehensive clinical assessment
SYNOPSIS:
Clinical determination of EDD, 280 days after the last menstrual period (LMP) still plays a role but may not always be accurate due to variability in length of an individual woman’s cycle length or timing of ovulation. Accurate dating is vital to pregnancy management, as certain interventions and management decisions may be based on such information including timing of delivery in the case of pregnancy complications.
KEY POINTS:
First trimester ultrasound is the most accurate time frame for pregnancy dating and can increase the accuracy of the EDD even if LMP is known
Consider a pregnancy without a dating ultrasound prior to 22 0/7 weeks ‘suboptimally dated’ (refer to Related ObG Topics below)
Mean sac diameter is not recommended for dating
In the setting of assisted reproductive technology (ART), the ART derived gestational age should be used for EDD using the age of the embryo and the transfer date
The age of the embryo is subtracted from the number of days between ovulation to delivery (280-14 = 266). For example, if the embryo is 3 days at transfer, the due date is 263 days from the date of transfer.
If the CRL is greater than 84 mm, biometric parameters should be used to date the pregnancy
Once the EDD has been established using the LMP and/or first accurate ultrasound measurement, it should be recorded in the medical record and discussed with the patient
Fetal Growth Restriction: Definition, Evaluation and Management
SUMMARY:
ACOG / SMFM released a guidance update on fetal growth restriction (FGR). While there is currently no clear consensus on the definition, evaluation, and management, FGR is associated with adverse perinatal outcomes. Therefore, timely diagnosis and management are key to optimizing long term benefit. Ultrasound and fundal height measurement are important physical exam diagnostic maneuvers. Early delivery and expectant management have similar outcomes thus creating deliberate birth plans should be discussed.
Key Terms and Definitions
FGR: EFW or AC <10th percentile for gestational age
Symmetric: Global growth restriction | Early insult
Asymmetric: Head-sparing with generally better outcomes
Small for gestational age (SGA): Newborn birthweight <10th percentile for gestational age
Risk Factors
Maternal Disease
Hypertensive disorders
Chronic hypertension
Gestational hypertension and preeclampsia
Kidney disease
Endocrine
Pregestational diabetes mellitus
Autoimmune
SLE
Antiphospholipid syndrome
Congenital heart disease (see ‘Learn More – Primary Sources’ for additional information)
Note: Nutrition, oxygenation, and cardiovascular adaptation to pregnancy (placental perfusion) are underlying maternal factor mechanisms that impact fetal growth
Fetal Factors
Multiple gestation
Teratogenic exposures
Medications (e.g. fetal hydantoin syndrome)
Substance abuse (modifiable risk) including alcohol, cocaine and smoking
Note: Placental implantation abnormalities (e.g. placental accreta spectrum, previa) not associated with FGR
Evaluation and Screening Methods
Fundal height measurements
Begin at 24 weeks gestation
Perform at each prenatal visit
3 cm discrepancy “proposed for identifying a fetus that may be growth restricted”
Limitations
Maternal obesity | Fibroids | Multiple gestation
Ultrasound
Preferred method of evaluation
Measurements include
BPD
HC
AC
FL
UA Doppler velocimetry
Reduces perinatal death when added to antepartum testing
Absent or reversed end-diastolic flow increases risk for perinatal mortality
Evaluation of the fetal ductus venosus has not been shown to improve perinatal outcomes (TRUFFLE study)
Note: No current evidenced based screening methods or preventative measures such as bed rest have demonstrated improved perinatal outcomes
KEY POINTS:
Management
Address modifiable risk factors, for example
Screen for fetal alcohol exposure
Discuss and encourage reduction in smoking and/or smoking cessation
Smoking is associated with 3.5 increased risk of SGA newborns
Genetic counseling
FGR alone may be associated with genetic syndromes and aneuploidy
Combined FGR and fetal structural abnormalizes increase aneuploidy risk and warrants genetic counseling referral
Depending on clinical scenario
Serial ultrasounds q3-4 weeks for growth and AFV
Do not measure fetal growth more often than every 2 weeks (measurements will be within error of the test)
Fetal assessment (NSTs or BPPs): “…should not begin before a gestational age when delivery would be considered for perinatal benefit”
Mode of delivery
Reserve cesarean section for obstetric/neonatal indications
Cesarean section and is not indicated for FGR in isolation
Timing of Delivery
Normal UA Doppler and EFW 3 to 10th percentile: 38w0d to 39w0d
EFW <3rd percentile (severe FGR): 37w0d
Decreased UA flow without absent end diastolic flow: 37w0d to 37w6d
Absent end diastolic flow: 33w0d to 34w0d
Reversed end diastolic flow: 30w0d to 32w0d
With oligohydramnios or concurrent conditions (e.g., preeclampsia, chronic hypertension): 34w0d to 37w6d
Note: If delivery planned <34 weeks, deliver at center with a NICU and consult MFM
When to Give Antepartum Corticosteroids
< 33w6d (anticipated delivery)
34w0d-36w6d (late preterm) if risk
No previous corticosteroids
Anticipate delivery within 7 days
Note: “Consider” magnesium sulfate (neuroprotection) if delivery <32w0d
Future Pregnancies
Counsel regarding 20% recurrence risk
Review history to identify modifiable factors and/or treat maternal disease
In subsequent pregnancies
…it may be reasonable to perform serial ultrasonography for growth assessment, although the optimal surveillance regimen has not been determined.
Maternal history of a prior SGA newborn with normal fetal growth in the current pregnancy is not an indication for antenatal fetal heart rate testing, biophysical profile testing, or umbilical artery Doppler velocimetry
Note: There is insufficient evidence to routinely administer aspirin to prevent SGA in this population
This study by Groom et al. (AJOG, 2017) aimed to determine if enoxaparin, a low molecular weight heparin blood thinner, can be used to prevent preeclampsia and small-for-gestational-age pregnancy in women who have a prior history of these conditions.
METHODS:
Randomized Clinical Trial (RCT)
RESULTS:
149 women with a history of preeclampsia or small-for gestational-age pregnancy were enrolled in the study. 77 received standard high-risk care, and 72 received high-risk care as well as a subQ injection of 40mg (4000 IU) enoxaparin daily from time of enrollment to delivery or 36 weeks’ gestation (whichever came first). Enoxaparin did not reduce the risk of preeclampsia and small-for-gestational-age neonates in women with a history of these complications.
Guidance on How to Manage the Suboptimally Dated Pregnancy
SUMMARY:
ACOG has reaffirmed a committee opinion defining ‘suboptimally dated’ pregnancies as those without an ultrasound before 22w0d to confirm or revise the EDC. (For guidelines on how to revise discrepant LMP and ultrasound, see the guideline summary in ‘Related ObG Topics’ below).
KEY POINTS:
Optimal time for dating remains the first trimester
No role for elective delivery in women with suboptimally dated pregnancies
Consider an ‘interval’ ultrasound scan for fetal weight and gestational age 3 to 4 weeks after the first scan
Fetal growth restriction may be identified
Consider antepartum fetal surveillance at 39-40 weeks
Amniocentesis for lung maturity is not part of routine management
Antenatal corticosteroid administration for anticipated preterm delivery:
24 weeks – 34 weeks
34 0/7 weeks – 36 6/7 weeks if delivery imminent within 7 days
Not recommended for presumed term delivery
The recommendation on timing of delivery states
Given concern that a full-term or late-term suboptimally dated pregnancy could actually be weeks further along than it is believed to be, late-term delivery is indicated at 41 weeks of gestation when gestational age is uncertain, using the best clinical estimate of gestational age.
When to Introduce Aspirin to Reduce Risks of Preeclampsia?
PURPOSE:
This study by Roberge et al. (AJOG, 2017) surveyed previously performed randomized control trials (RCTs) to determine at what point during pregnancy aspirin should be introduced to reduce the risk of preeclampsia.
METHODS:
Systematic Review and Meta-Analysis
RESULTS:
This study analyzed 45 studies which included 20,909 women. Women received aspirin or a placebo starting at ≤ 16 weeks or > 16 weeks. Women who began taking aspirin ≤ 16 weeks displayed lower risk or preeclampsia and fetal growth restriction than those who began taking aspirin > 16 weeks. They also found that the greater the dose, the greater the decrease in risk.
Diagnosing Preeclampsia – Key Definitions and ACOG Guidelines
WHAT IS IT?
Preeclampsia is a pregnancy specific hypertensive disease with multi-system involvement. It usually occurs after 20 weeks of gestation and can be superimposed on another hypertensive disorder. While preeclampsia was historically defined by the new onset of hypertension in combination with proteinuria, some women will present with hypertension and multisystemic signs in the absence of proteinuria. The presence of multisystemic signs is an indication of disease severity.
SUMMARY:
Diagnostic Criteria
Blood Pressure Criteria
Hypertension – systolic BP > 140 mm hg or diastolic BP > 90 mm hg or both
On two occasions at least 4 hours apart after 20 weeks gestations with previously normal BP
Considered ‘mild’ until diastolic BP > 110mm hg or systolic BP ≥160 mm Hg
Severe Hypertension – systolic BP > 160 mm hg or diastolic BP > 110 mm hg or both
Can confirm using a short time interval (e.g., minutes) to facilitate timely antihypertensive therapy
Note: Gestational Hypertension
ACOG defines gestational hypertension as “hypertension without proteinuria or severe features develops after 20 weeks of gestation and blood pressure levels return to normal in the postpartum period”
Caution and close follow-up is warranted as up to a half of women with gestational hypertension will go on to manifest signs an symptoms consistent with preeclampsia
Women with severe gestational hypertension, even in the absence of proteinuria should be managed similar to women with severe preeclampsia
ACOG states
Women with gestational hypertension with severe range blood pressures (a systolic blood pressure of 160 mm Hg or higher, or diastolic blood pressure of 110 mm Hg or higher) should be diagnosed with preeclampsia with severe features.
Proteinuria Criteria
24 hour urine collection >300 mg protein or
Single voided urine protein/creatinine ratio ≥0.3
Dipstick reading of 2+ (use only if other quantitative methods not available)
Preeclampsia Definitions
Preeclampsia
Hypertension and proteinuria or
In absence of proteinuria, new-onset hypertension with the new onset of any of the following
Thrombocytopenia: Platelets <100 x 109/L
Renal insufficiency: serum creatinine >1.1 mg/dl or doubling of serum creatinine in the absence of other renal disease
Impaired liver function: Elevated blood concentrations of liver transaminases to twice normal concentration
Pulmonary edema
Neuro: Unexplained new-onset headache unresponsive to medication (without an alternative diagnosis) or visual symptoms
Preeclampsia with severe features
Preeclampsia diagnosis, above, with any of the following
Severe hypertension
On two occasions at least 4 hours apart while on bed rest (unless already on antihypertensive therapy)
Thrombocytopenia: Platelets <100 x 109/L
Impaired liver function (without an alternative diagnosis): Elevated liver transaminases greater than twice upper limit of normal or severe persistent right upper quadrant or epigastric pain not responsive to medications
Progressive renal insufficiency: serum creatinine >1.1 mg/dl or doubling of serum creatinine in the absence of other renal disease
Pulmonary edema
Neuro: Unexplained new-onset headache unresponsive to medication (without an alternative diagnosis) or visual symptoms
Note: The following are not diagnostic criteria for the diagnosis of preeclampsia or preeclampsia with severe features
Clinically evident edema
Rapid weight gain
Massive proteinuria
Does not qualify as a ‘severe feature’
Fetal growth restriction
ACOG states that while it is important to monitor fetal status, FGR in the setting of all other fetal assessment being within normal limits (e.g., AFV, Doppler), expectant management ‘may be reasonable’ if mother and fetus appear stable and no other clinical indication is present that would indicate the need for early delivery
Uric acid
Hyperuricemia in hypertensive pregnancy is not a diagnostic marker, but is an important finding as a risk factor for adverse maternal and fetal outcomes
Small for gestational age (SGA) infant
Prematurity
Risk for adverse maternal outcomes if include patients with preeclampsia and risks increase with increasing concentration of uric acid
May be warranted in the setting of ‘diagnostic dilemmas’ such as diagnosing superimposed preeclampsia in the setting of chronic hypertension
Aspirin Treatment for Women at Risk for Preeclampsia – ACOG, SMFM and USPSTF Recommendations
FINDINGS:
ACOG/SMFM have released guidance aligned with USPSTF regarding the use of low-dose aspirin during pregnancy to prevent preeclampsia. When indicated, low-dose aspirin should be started between 12 to 28 weeks and continued until delivery. Optimally, aspirin usage should begin <16 weeks.
Recommended (high risk)
Offer low-dose aspirin (81 mg/day) to women with ≥1 high risk factors
History of preeclampsia, especially if accompanied by an adverse outcome
Multifetal gestation
Chronic hypertension
Diabetes (Type 1 or Type 2)
Renal disease
Autoimmune disease (for example, systematic lupus erythematosus, antiphospholipid syndrome)
Moderate Risk Factors
Offer low-dose aspirin (81 mg/day) to women with ≥2 moderate risk factors
Nulliparity
Obesity (BMI >30)
Personal history
Low birthweight or SGA
Previous adverse pregnancy outcome
>10-year pregnancy interval
Family history of preeclampsia
Sister or mother
Social and demographic characteristics
Black race (as a proxy for underlying racism)
Lower income
Maternal age ≥35 years
IVF
Note: USPSTF does allow for consideration of aspirin prophylaxis if ≥1 moderate risk factor is present and states “Clinicians should use clinical judgment in assessing the risk for preeclampsia and discuss the benefits and harms of low-dose aspirin use with their patients”
Universal Implementation
Evidence supports a risk-based approach
ACOG/SMFM acknowledges that in some settings, a majority of patients will fall in to either high or moderate risk categories, and therefore
In these instances, universal implementation (eg, offering low-dose aspirin to all patients within such practices or institutions) may be medically reasonable
The USPSTF recommends the use of low-dose aspirin (81 mg/d) as preventive medication for preeclampsia after 12 weeks of gestation in persons who are at high risk for preeclampsia as per categories above (B recommendation – offer or provide this service)
Benefits
The most recent systematic evidence review (see ‘Learn More – Primary Sources) provided more precise estimate of the association between aspirin and the prevention of perinatal mortality (4% to 44% reduction in fetal and neonatal deaths)
Otherwise, benefits of low-dose aspirin for women at risk for preeclampsia were similar to previous reviews with lower risks for the following (moderate certainty)
Preeclampsia: Pooled relative risk (RR) 0.85 (95% CI, 0.75-0.95)
Perinatal mortality: Pooled RR 0.79 (95% CI, 0.66-0.96)
Preterm birth: Pooled RR 0.80 (95% CI, 0.67-0.95)
Intrauterine growth restriction: Pooled RR 0.82 (95% CI, 0.68-0.99)
Harms
No significant association was found for
PPH or other bleeding-related harms
Rare perinatal or longer-term harms
Long-term child developmental outcomes in offspring from in utero exposure to low-dose aspirin
Follow-up data from the Collaborative Low-dose Aspirin Study in Pregnancy (CLASP), found no differences in physical or developmental outcomes at 12 to 18 months
KEY POINTS:
Risk factors used for ACOG/SMFM recommendations only include factors obtained from the medical record
Uterine artery Doppler ultrasonography and biochemical markers are not included
ACOG/SMFM acknowledge that other studies, in particular the ASPRE trial (see ‘Related ObG Topics’ below), have incorporated ultrasound and maternal serum markers as well as doses >81 mg, but state
Further, the screening algorithm used includes first-trimester serum markers, including placental growth factor and pregnancy-associated plasma protein-A, as well as uterine artery dopplers, which limits the generalizability to a U.S. population. Therefore, a higher dose or doubling of the available 81-mg dose cannot be recommended at this time.
Screening for Preeclampsia
USPSTF
Recommends that blood pressure measurements should be obtained during each prenatal care visit throughout pregnancy
Does not find evidence to support routine use of point-of-care urine protein tests for preeclampsia screening
Various studies have incorporated not only clinical risk factors but also biochemical markers and ultrasound to determine which women are at risk for early onset preeclampsia and may benefit from aspirin prevention (see ‘Related ObG Topics’)
ACOG/SMFM considers the supporting data for the use of such combined risk assessment algorithms to be limited and without more prospective clinical utility trials, states that
…biomarkers and ultrasonography cannot accurately predict preeclampsia and should remain investigational.
Deepest Pocket or AFI When Performing Prenatal Ultrasound?
FINDINGS:
There are two sonographic techniques that are used to measure amniotic fluid for the purpose of fetal assessment: (1) the amniotic fluid index (AFI) or (2) the single deepest vertical pocket (SDP). Oligohydramnios was defined as AFI ≤ 5 cm or the absence of a pocket measuring at least 2 × 1 cm. In a population of term pregnancies and using a multicenter randomized controlled trial design, the authors found:
In the AFI group, there were increased cases of oligohydramnios (9.8%) compared to SDP (2.2%) as well as increased induction of labor for this particular indication (P < 0.01)
There were significantly more abnormal fetal heart rate (FHR) tracings in the AFI group (32.3%) compared to the SDP group (26.2%), which was more pronounced in women who were otherwise low risk (P=0.03)
Neither test was better at predicting adverse pregnancy outcome, including NICU admissions, and cesarean section rates
The use of AFI resulted in more interventions for diagnoses of oligohydramnios with no benefit, thereby making SDP the preferable approach for assessing amniotic fluid, especially in low risk women
SYNOPSIS:
Measuring amniotic fluid volume remains an important part of fetal assessment. The SAFE trial (Ultrasound Obstet Gynecol, 2016), a multicentered randomized controlled trial (RCT), was designed to answer the question as to whether AFI or SDP technique is better in predicting pregnancy outcome. 1052 pregnant women at term with singleton pregnancies were included in this trial which included low risk as well as high risk indications, such as gestational diabetes (GDM), hypertensive disorder, fetal growth restriction, placental insufficiency or intrahepatic cholestasis of pregnancy.
KEY POINTS:
AFI was associated with more women being identified with oligohydramnios, but without any significant benefit in perinatal outcome
The SDP appears to be the favorable approach when estimating amniotic fluid volume in both high and low risk patients
Second Trimester Echogenic Bowel: Important Ultrasound Finding with Varied Causes and Some Serious Implications
CLINICAL ACTIONS:
Fetal bowel can sometimes appear bright on prenatal ultrasound depending on the transducer used and machine settings. However, echogenic bowel in the fetus is not a significant finding unless the bowel appears as bright as bone (the brightness of the iliac wing can be used a reference). If the ultrasound report does confirm echogenic fetal bowel, further management should include
Aneuploidy screening
No previous aneuploidy screening
NIPS or quad screening
Negative aneuploidy screening
No further aneuploidy evaluation
Further work-up
Offer cystic fibrosis screening if not yet performed in current or prior pregnancy
Evaluate for cytomegalovirus (CMV) infection with IgG and IgM titers
Follow-up fetal growth scan in the third trimester to evaluate for growth restriction
If aneuploidy screening is positive, offer confirmatory diagnostic testing, referral for high-risk OB consultation and genetic counseling
SYNOPSIS:
Fetal echogenic bowel is present in up to 1.8% of second trimester ultrasound exams. It can be due to congenital cytomegalovirus infection, cystic fibrosis, intra-amniotic bleeding, fetal growth restriction, aneuploidy or gastrointestinal obstruction. Therefore, further work-up is warranted.
KEY POINTS:
Echogenic bowel is associated with aneuploidy (3 to 5%), the most common is Down syndrome (Trisomy 21)
If all identifiable causes are ruled out, fetal growth should be evaluated, as there is an association with fetal growth restriction
When isolated, normal fetal outcomes are likely. Pediatrics should be informed of the prenatal findings and work-up
Short Femur on the Second Trimester Ultrasound Report: What to Include in the Management Plan?
CLINICAL ACTIONS:
A short femur is defined as a measurement below the 2.5 percentile for gestational age. This finding is typically identified on second trimester prenatal ultrasound, as femur measurements are part of the algorithm for pregnancy dating. While often there are no other abnormalities, the following should be included in the care plan:
Second trimester anatomical study to evaluate for short limb dysplasia
When short femur seen in isolation, with no other fetal abnormalities
If aneuploidy screening has not yet been done, then screening or diagnostic testing should be offered
If patient opts for aneuploidy testing and result is negative
Counsel patients that screening tests are not diagnostic and therefore there is still residual risk for chromosomal anomalies
ACOG guidance recommends offering prenatal screening for aneuploidy as an option for all pregnant women
Repeat sonogram in the 3rd trimester for growth
If aneuploidy screen result is positive, refer for genetic counseling and consideration of diagnostic testing options
If other anomalies are detected
Refer for genetic counseling and MFM assessment
ACOG guidance recommends offering invasive testing using microarray in the setting of fetal structural anomalies seen on prenatal ultrasound
SYNOPSIS:
The femur length should be measured with the bone perpendicular to the ultrasound beam and with epiphyseal cartilages visible, but not included in the measurement. The presence of a short femur may be associated with aneuploidy, intrauterine growth restriction and short limb dysplasia.
KEY POINTS:
The likelihood ratio for Down syndrome is 1.2 to 2.2, which indicates a minimal to small increase in the likelihood that the fetus will actually have this chromosomal abnormality
Evaluation of all the long bones is suggested to rule out limb dysplasia
ACOG guidance recommends offering
All patients the option of prenatal invasive testing or prenatal screening
Invasive testing using microarray in the setting of fetal structural anomalies seen on prenatal ultrasound
What are the Implications of a Short Fetal Humerus?
CLINICAL ACTIONS:
A short humerus is defined as a measurement below the 2.5 percentile for gestational age and may be identified during a prenatal ultrasound assessment. Consider the following next steps and referrals:
Second trimester anatomical study to evaluate for short limb dysplasia
If isolated finding
If aneuploidy screening has not yet been done, then screening or diagnostic testing should be offered
If patient opts for aneuploidy testing and result is negative, no further evaluation is required
Counsel patients that screening tests are not diagnostic and therefore there is still residual risk for chromosomal anomalies
ACOG guidance recommends offering prenatal screening for aneuploidy as an option for all pregnant women
If aneuploidy screen result is positive, refer for genetic counseling and consideration of diagnostic testing options
If other anomalies are detected
Refer for genetic counseling
ACOG guidance recommends offering invasive testing using microarray in the setting of fetal structural anomalies seen on prenatal ultrasound
SYNOPSIS:
The humerus should be measured with the bone perpendicular to the ultrasound beam and with the epiphyseal cartilages visible, but not included in the measurement. A short humerus is defined as a measurement below the 2.5 percentile for gestational age. The presence of short humerus can be associated with aneuploidy, intrauterine growth restriction and short limb dysplasia.
KEY POINTS:
Short humerus observed in the second trimester has a sensitivity of 9% in the prediction of Trisomy 21
If fetal aneuploidy screening test is ‘screen negative’ or a negative prenatal diagnostic test using amniocentesis or chorionic villus sampling indicates normal fetal chromosome complement, a short humerus should not be considered a risk factor for aneuploidy
ACOG guidance recommends offering
All patients the option of prenatal invasive testing or prenatal screening
Invasive testing using microarray in the setting of fetal structural anomalies seen on prenatal ultrasound
Evaluation of all the long bones using prenatal ultrasound is suggested to rule out limb dysplasia and other potential genetic syndromes
Third trimester ultrasound for growth is recommended
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