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JukkaUotila

Antenatal Clinics and Specialist Care: Consultations, Referrals, Treatment Guidelines

Essentials

  • Familiarize yourself with the referral criteria submitted by your local maternity hospital.
  • In unclear cases, consult an appropriate specialist (physician/midwife) either by telephone or in writing.
  • If possible avoid an emergency referral, and make an appointment for the patient. This will ensure that adequate hospital staff and equipment will be available, and the hospital staff will have time to consult the appropriate literature should it be necessary.
  • Send the patient as an emergency if the state of the mother or foetus requires immediate assessment or treatment. The problems of an emergency referral are many: waiting times at the hospital might be long, investigations and treatment may be carried out in haste, the referral may cause unnecessary worry for the patient and the credibility of the antenatal clinic might even be questioned.
  • See also Antenatal Clinics: Care and Examinations.

Referral at the pregnancy pre-planning stage

  • Pre-planning the pregnancy together with specialist teams might be necessary if the patient has
    • a chronic illness which is classified as serious or the prognosis of which is unclear Chronic Diseases and Pregnancy
    • a history of a serious complication during a previous pregnancy the character of which was inadequately evaluated during postnatal examination
    • a family history of a hereditary illness and she is not aware of the incidence rate or the availability of screening.
  • If required, the patient will be invited to attend an obstetrics clinic, a genetics clinic or another specialist clinic. Treatment guidelines will be drawn up by the primary care team and the hospital together.
  • See also Chronic Diseases and Pregnancy.

Diabetes mellitus Different Intensities of Glycaemic Control for Pregnant Women with Pre-Existing Diabetes, Continuous Subcutaneous Insulin Infusion for Pregnant Women with Diabetes

  • It is important that diabetes is well controlled at conception as well as during early pregnancy in order to reduce the risk of malformations.
  • The mother should discuss pregnancy plans with her own doctor. Medication is modified to be suitable for pregnancy.
  • If the patient's diabetes is already complicated (nephropathy, renal impairment, severe retinopathy, coronary disease) the additional risks of pregnancy should be considered and specialist consultation sought when required.

Other chronic illnesses

  • Illnesses warranting pregnancy risk assessment and pre-planning of pregnancy include significant heart disease, severe hypertension or renal disease, thromboembolic illness or severe autoimmune illness.
  • Investigations at the pre-planning stage might also be warranted for some very rare illnesses.

Hereditary illnesses

  • A referral to genetic counselling (or obstetrician) should be considered if the patient is not fully aware of the character of the hereditary illness or if carrier status studies of the genetic defect have not been performed.

Referral during early pregnancy - based on medical history

Mother's chronic illness

  • See also Chronic Diseases and Pregnancy.
  • The timing of the referral depends on the severity of the illness and on the extent to which relevant treatment guidelines and the effect of the pregnancy are known.
  • Type 1 or 2 diabetes
    • Refer already in early pregnancy.
    • The aim is to maintain good control before conception as well as during early pregnancy.
  • Thromboembolic predisposition or a history of venous thrombosis
    • The timing and method of thrombosis prophylaxis depends on the following factors: in what situation and location was the previous venous thrombosis and how severe is the thrombotic predisposition, whether congenital or acquired, according to laboratory findings.
    • Thrombosis prophylaxis in low-risk patients may be carried out in primary health care, as agreed upon locally.
  • Congenital or acquired cardiac disease
    • Illnesses which are poorly tolerated during pregnancy are cardiac defects with NYHA class III-IV symptoms, Marfan's syndrome with dilatation at the aortic root, Eisenmenger's syndrome and other pulmonary hypertension.
    • During the pregnancy the cardiological status should be monitored as well as the mother's functional capacity. A birth plan is drawn up and prophylactic medication should be decided upon, e.g. anticoagulation, antiarrhythmic agents and cover against endocarditis.
    • The treating obstetrician should be made aware of the pregnancy, and an appropriate referral should be made in early or mid pregnancy.
  • Rheumatoid and collagen diseases
    • The course of the illness or its treatment (medication) might alter during pregnancy.
    • The illness may affect the pregnancy, particularly in the presence of phospholipid or ENA antibodies.
    • The mother should usually be referred to the care of an obstetric team in early pregnancy unless the illness is particularly mild, well investigated and problem free.
  • Chronic hypertension Elevated Blood Pressure in Pregnancy (Gestational Hypertension, Pre-Eclampsia)
    • If hypertension is severe and complicated consideration should be given to referring the patient in early pregnancy.
    • In chronic hypertension three routine antenatal appointments are warranted: early/mid pregnancy, weeks 28-32 and late pregnancy.
    • The patient should, however, be referred to an obstetrician if her blood pressure shows significant increase or other complications arise.
    • If the diagnosis of chronic hypertension has not been established, but the blood pressure is mildly elevated in measurements during the early pregnancy, the situation may be monitored in primary care. A referral to specialist clinic is made if blood pressure level substantially increases or if proteinuria is detected. Blood pressure medication should not be started in primary care.
  • Chronic renal disease
    • A well controlled renal disease does not require more than regular check-ups at early, mid and late pregnancy. The potential risks involved include the development of associated pre-eclampsia, worsening of the renal disease and disturbances in the foetal growth.
  • Bleeding disorder
    • The most common bleeding disorder is von Willebrand's disease. Specialist consultation is required to ascertain the severity of the condition and to obtain information regarding the birth.
  • Epilepsy or other neurological disease
    • Due to the increased risk of malformations, an accurate anomaly screening should be carried out, and medication and treatment plans should be drawn up for the pregnancy and delivery. Folic acid supplementation, see Antenatal Clinics: Care and Examinations.
  • Chronic intestinal illness
    • The patient should first be referred to the treating physician. If the illness is severe, symptomatic or newly diagnosed the patient should also be referred to an obstetrician. Long-term medication may need to be instigated during pregnancy. An active intestinal illness increases the risk of preterm birth.
  • Lung disease, e.g. brittle asthma
    • The patient should first be referred to the treating physician. During pregnancy, medication should be adequate to maintain optimal lung function.
    • Asthma medication has not been shown to be harmful during pregnancy.
  • Treated malignant tumour
    • A structural ultrasound examination should be carried out by the specialist team, particularly if the principles regarding the monitoring of the pregnancy and the tumour remain unclear.
  • Thyroid dysfunction
    • The need for thyroxin increases by 25-50 µg per day. The dose is increased immediately after the onset of pregnancy by 25 µg per day or according to plasma TSH concentration so that during pregnancy TSH remains below 2.5 mU/l in the first trimester and below 3 mU/l in the second and third trimesters.
    • Untreated hyperthyroidism may be dangerous both to the mother and the foetus.
    • A history of previously treated hyperthyroidism (e.g. Graves' [Basedow's] disease treated with radio-iodine) also warrants referral to monitoring in specialized care if serum concentration of TSH receptor antibodies is increased.
  • Psychiatric illness
    • If the pregnant mother has a significant psychiatric illness, a multidisciplinary approach must be adopted, including a psychiatrist, the treating physician and an obstetrician.
    • These patients often need a great deal of input during their pregnancy and appointments with an obstetrician might be beneficial even when the pregnancy progresses without actual problems.
    • See also Mental Disorders during Pregnancy.
  • Chronic infections, see "Maternal infectious diseases" below.

Genital malformation and uterine myomas

  • Potential risks include increased likelihood of miscarriage, slowed foetal growth, preterm birth, obstruction to delivery or prolonged parturition.

Previous pregnancies with complications

  • The patient should be referred to an obstetrician during early pregnancy if she previously to the present pregnancy has had
    • 3 or more consecutive miscarriages
    • very preterm births (before 30 weeks of pregnancy)
    • foetal death or severe foetal developmental problems
    • early and severe pre-eclampsia.
  • The patient should be referred at a later stage, as considered necessary, if she has a history of
    • abnormal delivery with problematic labour, e.g. emergency caesarean section, difficult vacuum extraction, heavy blood loss, inadequate pain relief or problems with the newborn.
    • other problems of late pregnancy.

Increased risk of foetal malformation or hereditary illness

  • See Screening for Fetal Chromosomal Abnormalities.
  • If the results of screening or other investigations suggest that the risk of foetal abnormality is increased the mother should be referred for a specialist consultation should she so wish.

Substance abuse Psychological and/or Educational Interventions for Alcohol or Drug Consumption in Pregnancy, Psychosocial Interventions for Supporting Women to Stop Smoking in Pregnancy

  • See Pregnant Substance Abuser.
  • If it is noted or suspected during antenatal appointments and guidance that the mother suffers from substance addiction (alcohol, illegal drugs or use of medicinal products for a non-therapeutic effect Pregnant Substance Abuser) she should be referred to the care of a specialist team because
    • the treatment of the addiction and the mother's motivation is likely to be enhanced by the referral
    • substance abuse is associated with multidisciplinary problems
    • the hospital team will prepare themselves for problems associated with the delivery and puerperium, both for the mother and newborn.
  • Definitions
    • Experimentation: trial of drugs at some stage of life; assessment for possible substance dependence is indicated in such cases
    • Drug addiction: use of drugs more than 10 times
    • Current substance addiction: less than 12 months from stopping regular use or continuation of use on an irregular basis
    • Excessive alcohol consumption (criteria for pregnancy): the consumption of more than 8 units of alcohol per week or binge drinking of more than 4 units at a time.

Consultation in case of disorder or abnormality

Hyperemesis gravidarum (intractable vomiting) Acupressure and Acupuncture for Treating Nausea and Vomiting in Early Pregnancy, Interventions for Nausea and Vomiting in Early Pregnancy

  • It is sometimes difficult to tell the difference between mild and severe vomiting during pregnancy. The mother should be referred to hospital or alternatively, if feasible, admitted to a primary care ward for fluid therapy at least in case of ketosis, weight loss (5%, > 2 kg/week) or dehydration. The mother should also be sent to hospital if the condition becomes prolonged or is intolerable for her. In the hospital, intravenous fluids are usually administered to restore normal fluid balance.
  • Treatment of nausea at the antenatal clinic, see Antenatal Clinics: Care and Examinations.

Maternal blood loss

  • Bleeding will usually originate from the uterine cavity, but may also be caused by inflammation, ulceration or tumour of the vagina or cervix.
  • Maternal blood loss in early pregnancy (before week 22) Bleeding during First and Second Trimesters of Pregnancy signifies impending miscarriage. No effective treatment is available. Rest can be considered. If emergency referral is not required due to the extent of blood loss or pain, an ultrasound examination Ultrasound Scanning during Pregnancy should be carried out on the following working day to determine the character of the pregnancy.
  • Maternal blood loss can originate from
    • a normal intrauterine pregnancy
    • intrauterine pregnancy where the embryo or foetus has died (missed abortion)
    • intrauterine pregnancy where the embryo fails to develop (blighted ovum, "anembryonic pregnancy")
    • inevitable miscarriage where the cervix opens and the uterine contents are expelled. It is likely that at the time of the examination only fragments of the pregnancy tissue remain in the uterus.
    • extrauterine pregnancy
  • Maternal blood loss in late pregnancy (after week 22) might originate from
    • the uterine mucous membranes as the cervix ripens, the uterus contracts or labour begins
    • placenta praevia or (partial) placental abruption.
  • The blood is usually maternal but could also partly be foetal.
  • Because blood loss may be indicative of a serious danger to the foetus, and rapid measures might be needed to save the foetus, the mother must be sent to a maternity hospital urgently.

Increased blood pressure or pre-eclampsia Altered Dietary Salt for Preventing Pre-Eclampsia, Maternal Obesity and Infant Outcomes, Planned Early Delivery Versus Expectant Management for Hypertensive Disorders from 34 Weeks Gestation to Term

  • See also Elevated Blood Pressure in Pregnancy (Gestational Hypertension, Pre-Eclampsia) and Chronic Diseases and Pregnancy.
  • Low-dose aspirin at 100 mg in the evening is started at gestational week 12+0 (-16) for those with pre-eclampsia risk factors (see table T1) and continued until gestational week 36+0 .
  • Blood pressure at rest is considered to be abnormally high if repeated measurements show
    • systolic pressure ≥140 mmHg
    • diastolic pressure ≥90 mmHg
    • systolic pressure increased more than 30 mmHg from baseline
    • diastolic pressure increased more than 15 mmHg from baseline
  • Proteinuria is considered significant if the concentration is over 0.3 g/l in a 24-hour urine sample (strip test + or ++).
  • Other symptoms associated with pre-eclampsia include: oedema, upper abdominal pain, nausea, headache, visual disturbances and other neurological symptoms.
  • A non-urgent referral for an obstetric consultation should be made for an asymptomatic patient with elevated blood pressure or with significant proteinuria. The patient should receive an appointment within a week of the arrival of the referral.
  • A symptomatic patient or a patient who presents with proteinuria and acutely increased blood pressure might warrant an urgent referral to a maternity hospital.
  • Acute upper abdominal pain associated with a rise in blood pressure, however small, and/or the presence of proteinuria may be indicative of the HELLP syndrome (haemolysis, elevated liver enzymes, low platelet count). In this case the mother must be sent to hospital urgently.

Starting low-dose aspirin at an antenatal clinic*

If even one of the following is present:OR if 2 or more of the following are present:
Chronic hypertensionPrimigravida
SLE or positive antiphospholipid antibodiesAge > 40 years
Chronic kidney diseaseBMI > 30
Type 1 or 2 diabetesHistory of pre-eclampsia in the patient's mother or sister
History of:Pregnancy with donated eggs
Pre-eclampsiaInterval between pregnancies > 10 years
Placental insufficiency with fetal growth abnormalityMultiple pregnancy
Intrauterine fetal death due to placental causePAPP-A MoM < 0.4 in first trimester screening
* Modified from: [Gestational hypertension and pre-eclampsia]. A Current Care Guideline. Working group appointed by the Finnish Medical Society Duodecim and the Finnish Society of Obstetrics and Gynaecology. Helsinki: the Finnish Medical Society Duodecim, 2021. [in Finnish] http://www.kaypahoito.fi/hoi50128

Gestational diabetes (GDM) Lifestyle Interventions for the Treatment of Women with Gestational Diabetes, Insulin Versus Oral Anti-Diabetic Pharmacological Therapies for Gestational Diabetes, Gestational Diabetes Mellitus and Pregnancy Outcomes, Diet and/or Exercise for Pregnant Women for Preventing Gestational Diabetes Mellitus, Treatments for Gestational Diabetes, Dietary Advice in Pregnancy for Preventing Gestational Diabetes Mellitus, Abnormal Screening Glucose Challenge Test in Pregnancy and Future Risk of Diabetes, Gestational Diabetes Mellitus and Future Risk of Diabetes, Metformin for Gestational Diabetes, Maternal Obesity and Infant Outcomes, Maternal Obesity as a Risk Factor for Complications in Pregnancy, Interventions for Preventing Excessive Weight Gain during Pregnancy, Energy and Protein Intake in Pregnancy,

  • See also Gestational Diabetes Mellitus (Gdm).
  • Screening at the antenatal clinic is based on risk factors and a glucose tolerance test (GTT).
  • A GTT should be carried out in almost all pregnant women between weeks 24 and 28.
  • There is no need of a GTT in
    • a nulliparous woman aged < 25 years with a BMI < 25 kg/m² and no type 2 diabetes in near relatives
    • a woman who has previously given birth aged < 40 years (with a BMI < 25 kg/m² and no previous delivery of a macrosomic child.
  • A GTT should be carried out already between weeks 12 and 16 if the patient has
    • a history of gestational diabetes during earlier pregnancies
    • BMI > 35 kg/m²
    • glucosuria in early pregnancy
    • near relatives with type 2 diabetes
    • ongoing oral glucocorticoid medication.
  • The test should be repeated between weeks 26 and 28 if the earlier test is normal.
  • The mother has gestational diabetes if one or more of the results of an oral 75 g glucose challenge (2 hours) is abnormal, see table T1.
  • If the GTT is abnormal, diet counselling is provided and home monitoring of blood glucose is started. Referral for specialist care is made on the basis of blood glucose levels in home monitoring.
  • Foetal macrosomia must, however, be always detected and appropriate delivery plans put into action.

GTT upper limits for normal glucose values (mmol/l)

Sample0 hr1 hr2 hrs
Capillary whole blood or venous plasma5.310.08.6

Cholestasis of pregnancy (hepatosis) Interventions for Treating Cholestasis in Pregnancy

  • Cholestasis of pregnancy in most cases occurs during the third trimester and its typical symptoms include pruritus in palms of the hands and soles of the feet. In mothers with such pruritus, blood concentrations of ALT and bile acids are determined. If one of these values is elevated the mother is referred to an obstetrician.
  • If the pruritus is severe and intolerable the patient must be sent to hospital urgently, without waiting for the laboratory results. Likewise, if a patient with hepatosis complains of an acutely worsening pruritus she must be sent to hospital urgently.

Anaemia Daily Oral Iron Supplementation during Pregnancy, Treatments for Iron-Deficiency Anaemia in Pregnancy, Intermittent Oral Iron Supplementation during Pregnancy, Effects and Safety of Periconceptional Folate Supplementation for Preventing Birth Defects, Folic Acid Supplementation during Pregnancy for Pregnancy Outcomes other Than Neural Tube Defects

Premature contractions or impending preterm birth Magnesium Sulphate for Preterm Labour, Home Uterine Activity Monitoring for Detection of Preterm Labour, Bed Rest for Preventing Preterm Birth, Prenatal Administration of Progesterone for Preventing Preterm Birth, Magnesium Sulphate for Women at Risk of Preterm Birth for Neuroprotection of the Foetus, Cervical Stitch (Cerclage) for Preventing Preterm Birth in Singleton Pregnancy, Antenatal Corticosteroids for Fetal Lung Maturation for Women at Risk of Preterm Birth, Subclinical Hypothyroidism and Pregnancy, Cervical Stitch (Cerclage) for Preventing Preterm Birth in Multiple Pregnancy, Planned Early Delivery Versus Expectant Management of the Term Suspected Compromised Baby

  • See also Threatened Premature Labour.
  • Premature contractions are very common. The majority of women who suffer from premature contractions will go on to deliver full term.
  • The cervix is assessed either manually or measured with an ultrasound to assess the risk of preterm birth. See also Bishop score Antenatal Clinics: Care and Examinations.
  • Send the mother to hospital urgently if
    • the contractions are painful and regular (lasting for more than 2 hours and occurring < 10 minutes)
    • contractions are accompanied by bloody, mucous or watery discharge
    • contractions are associated with significant pain or feeling of pressure
    • frequent contractions occur together with a significantly ripe cervix, considering the weeks of gestation.
  • A non-urgent referral may be considered if the risk of preterm delivery is not imminent but specialist consultation is required to clarify treatment guidelines; for example, the mother's need for tocolytic medication, glucocorticoids for foetal lung development Antenatal Corticosteroids for Fetal Lung Maturation for Women at Risk of Preterm Birth or the mother's need for hospitalisation.
  • After the mother completes 35 full weeks of pregnancy no other active measures except rest are offered; the benefit of such measures has not been established. The closer the mother is to completing the full 35 weeks the less urgency there is to send her for a specialist consultation.
  • A non-urgent referral should be considered if
    • contractions remain frequent despite primary care interventions (sickness leave, rest, treating of infections)
    • considering the weeks of gestation, the cervix appears markedly ripe.

Rupture of the membranes

  • Suspected or confirmed rupture of the membranes requires an urgent referral to hospital.
  • Rupture of the membranes often leads to the onset of labour. It might also signify an existing infection or lead to an infection.
  • As the membranes rupture the placental circulation usually alters and the umbilical cord may become compressed.
  • If the mother describes a very small and uncertain loss of fluid and if, based on speculum examination and the history, rupture of the membranes does not appear likely it is safe to wait and observe.

Formation of antibodies

  • In many countries the blood of the mother is tested for antibodies against the foetal red cells at a national transfusion laboratory. The laboratory will advise the antenatal clinic staff regarding the necessity for repeat samples.
  • The presence of antibodies is reported both to the antenatal clinic and to the appropriate maternity hospital. The hospital will arrange any necessary follow-up studies and instigate appropriate treatment guidelines.
    • The maternity hospital staff must prepare themselves for the correct monitoring of the newborn and the possibility of blood transfusions.
    • Some of the more severe antibody formations against red cells or thrombocytes might require specialist procedures which need to be carried out during the pregnancy.
  • The majority of the antibody formations, however, are mild and require no intervention during the pregnancy.

Abnormal uterine growth or abnormal amount of amniotic fluid

  • Uterine growth is measured using the symphysis-fundal height (SFH).
  • Usually the growth of the uterus coincides with a given reference curve. The growth of the uterus of a particularly small- or large-sized woman might obviously deviate from the reference curve.
  • An ultrasound examination Ultrasound Scanning during Pregnancy is warranted if
    • the SFH deviates over 2 cm from the reference curve
    • the SFH deviates over 2 cm from the patient's own curve.
  • A referral for an obstetrician should be considered if
    • the amount of amniotic fluid is particularly large (single deepest amniotic fluid pocket measurement over 8 cm)
    • the amount of amniotic fluid is particularly low (largest amniotic fluid pocket measurement less than 3 cm)
    • the foetus is exceptionally small or large (see later "Foetal reasons for referral").

Method of delivery

  • If the method of delivery has not been decided upon, this should be done during the last pregnancy month by the treating obstetric team. By this time realistic assessments can be made regarding the predicted size of the foetus, its presentation, the ripening of the cervix and other relevant factors.
  • If the patient is highly anxious or very worried about the birth, an earlier consultation could be considered, see below.
  • A referral in order to draw up a birth plan should be considered if
    • the patient has a history of a complicated delivery
    • the uterus has been operated on
      • If only one section has been performed because of a reason that is not estimated to occur again and if all other preconditions for a vaginal delivery seem to be well in place, a referral to specialized care is not necessarily needed.
    • a narrow pelvis is suspected
    • a disproportionately large foetus is suspected.

Post-term pregnancy

  • The first assessment appointment is usually made with the maternity hospital 10-12 days after the expected date of delivery has passed, unless there are other indications to refer the mother earlier.
  • Pregnant women who are older than 40 years or who have gestational diabetes with abnormal sugar balance are referred to a maternity outpatient clinic already after the gestational week 40 has passed.
  • The mother should be informed that the appointment is merely for the assessment of the maternal and foetal condition and not necessarily for the purposes of inducing labour.
  • The term "overdue" should not be used until week 42 has been completed.

Fear of childbirth Interventions for Fear of Childbirth

  • The antenatal staff should discuss the most common reasons behind any fears. It is important for the success of the future delivery that all fears are recognised and addressed. Special questionnaires may be used to recognise any fears.
  • A mother who is particularly afraid of the birth should be referred to the care of the maternity hospital by week 28, at the latest, so that any relevant issues can be discussed.

Multiple pregnancy Hospitalization and Bed Rest for Multiple Pregnancy

  • There is regional variability regarding the referral system and the workload division between primary care and the maternity hospital.
    • After a twin pregnancy is diagnosed, the possibility of a monoamniotic or monochorionic pregnancy should also be assessed already during the early pregnancy (the presence and thickness of inter-twin membrane, whether there is membrane attachment to the placenta like a lambda sign, suggesting a dichorionic twin pregnancy Ultrasound Scanning during Pregnancy).
    • As soon as a monoamniotic or monochorionic twin pregnancy is diagnosed the mother should be referred to the care of an obstetric team.
    • In a monochorionic twin pregnancy the uterine growth might be fast during the second trimester, causing stretching of the uterus. Should the mother present with such symptoms an urgent referral should be made in order to diagnose and treat a possible twin-to-twin transfusion syndrome.
    • In all twin pregnancies, the state of the cervix and the growth of the foetuses should be monitored at regular intervals. Preterm birth and developmental problems of one or both foetuses are common in twin pregnancies. The monitoring of twin pregnancies is usually carried out by an obstetrician.
    • As soon as a triplet pregnancy is diagnosed the mother should be referred to the care of an obstetric team.

Abnormally large foetus

  • The assessment of the size of the foetus should always take the size of the mother into account.
  • If the foetus is assessed to be large Ultrasound Scanning during Pregnancy (weight assessment or abdominal circumference > 75-90 percentile, see Ultrasound Scanning during Pregnancy) and there is a suspicion of foeto-pelvic disproportion, the mother should be referred early enough, preferable by weeks 37-38, for the drawing up of a birth plan.
  • Glucose metabolism investigation should be considered if the foetus is not symmetrically macrosomic, particularly if the body is prominent.
  • An asymmetrically macrosomic foetus is more likely to require obstetric intervention than a symmetrically macrosomic foetus.

Delayed foetal growth Biochemical Placental Function Tests for Foetal Assessment, Biochemical Tests of Placental Function Versus Ultrasound Assessment of Fetal Size for Stillbirth and Smallforgestationalage Infants, Symphysial Fundal Height (Sfh) Measurement in Pregnancy for Detecting Abnormal Fetal Growth

  • A low SFH measurement Symphysial Fundal Height (Sfh) Measurement in Pregnancy for Detecting Abnormal Fetal Growth, or a measurement which falls below its own curve, may be indicative of delayed foetal growth. Likewise, an ultrasound examination carried out in primary care Ultrasound Scanning during Pregnancy might reveal a small-for-gestational-age foetus.
  • An abnormal growth of the foetus may be indicative of structural or functional abnormality. A foetus whose development is delayed is also more prone to either acute or chronic asphyxia.
  • Delayed foetal growth (weight assessment or abdominal circumference < 10-25 percentile) is an indication for further investigations (the possibility of infectious aetiology, chromosome and structural abnormalities or an insufficiency of the placenta) and monitoring by an obstetrician.

Abnormal presentation External Cephalic Version for Breech Presentation at Term, External Cephalic Version for Breech Presentation Before Term

Suspected or confirmed foetal structural abnormality

  • The mother should be referred for confirmation and further management of the situation.
  • The mother should be given an appointment as soon as possible when the necessary expertise and relevant diagnostic investigations are available at the hospital.

Abnormal foetal heart rate

  • Persistent bradycardia (heart rate < 110/min) or tachycardia (heart rate > 160-180/min) might be indicative of foetal arrhythmias or other complications of the pregnancy.
  • A persistent abnormal rhythm might have haemodynamically serious consequences and such patients should be sent to hospital urgently, even if the possibility to carry out further investigations were not immediately available.
  • A short-term (lasting for a few minutes) bradycardia or tachycardia might indicate a predisposition to arrhythmias. Usually, however, an arrhythmia of this type is merely a healthy indication of foetal activity or mother's supine position. If necessary, an appointment could be considered for further investigations of the structure and functioning of the foetal heart.
  • Occasional foetal ectopic beats are normal, and occur in all foetuses. Should ectopic beats occur in abundance and repeatedly a non-urgent referral should be considered in order to have the structure and functioning of the foetal heart further investigated.
  • If an abnormal foetal heart beat is associated with other problems, e.g. abnormally few foetal movements, delayed foetal growth or a known maternal risk, contact the on-call obstetric team.

Slowing down of foetal movements

  • If the mother counts less than 10 foetal movements for one hour, including the particularly active times of the day, foetal distress should be considered Fetal Movement Counting for Assessment of Fetal Wellbeing.
  • Foetal movements should be recounted and if there is no change the mother should be sent urgently to the maternity hospital for the evaluation of the state of the foetus.

Foetal death

  • A suspected or confirmed foetal death must be referred to the maternity hospital urgently.

Maternal infectious diseases Antenatal Lower Genital Tract Infection Screening and Treatment Programs for Preventing Preterm Delivery, Intrapartum Antibiotics for Known Maternal Group B Streptococcal Colonization

Herpes simplex

  • See Genital Herpes.
  • The incidence of neonatal herpes simplex is approximately 2 per 10000 births. Maternal primary infection during pregnancy is more than one hundred times as likely to infect the foetus than a recurrent infection. Antibodies of a recurring herpes infection offer protection to the foetus.
  • Herpesvirus nucleic acid testing is used to diagnose primary herpes infection.
  • Acyclovir (200 mg 5 times daily for 5 days) or valacyclovir (500 mg twice daily for 5 days) can be used particularly in primary infection, but also in recurrent infection, to alleviate the mother's symptoms and to provide the foetus with potential protection. Prophylactic treatment, or the introduction of acyclovir on symptom onset, should be considered in late pregnancy. The aim is to reduce the activity of genital herpes during labour.
  • When the mother is admitted for her delivery she should inform the hospital staff of the occurrence of genital herpes during pregnancy.
  • If primary herpes is suspected, or recurrent infection is particulalrly problematic, a referral is made for an obstetric consultation.

Chickenpox

  • See Chickenpox.
  • The risk of varicella embryopathy between the pregnancy weeks 12 and 24 is 2-3%, and very small at the other stages of pregnancy.
  • In practice there is no risk if the mother herself has had chickenpox, antibodies are demonstrable or the illness is herpes zoster (shingles).
  • If a seronegative mother comes into contact with chickenpox before pregnancy week 24, acyclovir medication (800 mg, five times daily for 7 days) should be considered 7-9 days post contact.
  • If the mother is diagnosed with chickenpox before week 24, a foetal anomaly investigation may be considered after the illness, and, in some cases, foetal infection can be determined with nucleic acid testing of amniotic fluid.
  • Chickenpox can be a serious illness for a pregnant woman. If hospitalisation is required the mother should be treated on a medical ward.
  • If the mother contracts chickenpox 5 days prior to or 2 days after the delivery, the newborn baby has a high risk of contracting the infection and special measures are required. Consult with the specialized care.

Parvovirus infection

  • See Erythema Infectiosum.
  • Should the foetus become infected, hepatitis and myelosuppression are possible which, in turn, may be fatal for the foetus.
  • Antibody assays are used to diagnose a parvovirus infection.
  • Once the disease is detected by antibodies, a referral should be made to a maternity outpatient clinic where appropriate monitoring to determine foetal infection status and to detect possible signs of anaemia will be organized.
  • Contracting the infection in pregnancy week 24 or later does usually not cause any significant problems to the foetus.

Toxoplasmosis

  • An acute toxoplasma infection is diagnosed with antibody assays, see Toxoplasmosis.
  • If the antibody assay is positive (IgM antibodies positive, low avidity IgG antibodies) a referral should be made for a specialist team who will organise further investigations to determine foetal infection status and organise treatment for mother and foetus.

Hepatitis and HIV

  • See Viral Hepatitis and HIV Infection.
  • Newly diagnosed hepatitis or HIV require a referral for specialist care.
  • Drug treatment in HIV is particularly important to prevent mother-to-child transmission.
  • Chronic hepatitis: HBV nucleic acid testing is performed on HBsAg positive mothers. If the result is > 200 000 IU/ml, the mother is referred to specialized care for consideration of hepatitis treatment.

Listeriosis suspicion

  • See Listeriosis.
  • A possible exposure to Listeria monocytogenes does not warrant a referral for specialist care.
  • A clinically significant listeriosis in a pregnant woman manifests itself as a septic febrile disease or severe enteritis.
  • Listeriosis, and its consequences, is the most serious septic illness for a pregnant woman, but other bacteria are also capable of infecting the foetus and foetal membranes, leading to an early induction of labour.
  • If the mother's pyrexia is of unknown origin the mother should be sent urgently to hospital for a specialist consultation regarding the diagnosis, treatment and the foetal status.

Group B streptococcus (GBS), Streptococcus agalactiae

Indications for emergency referral

  • Suspicion of deteriorating foetal status
    • Decreased foetal movements (less than 10 movements per hour whilst the foetus is at its most active)
    • Persistent bradycardia or tachycardia
    • Suspected or confirmed foetal death
  • Impending (preterm) birth
    • Maternal blood loss after week 22
    • Suspected rupture of the membranes
    • Regular contractions
    • Severe abdominal pain
  • Blood pressure complications
    • Increased blood pressure together with abnormal headache, visual disturbances, dyspnoea, upper abdominal pain
    • Increased blood pressure together with decreased or weak foetal movements
    • Acutely high blood pressure (> 160/105 mmHg)
    • Increased blood pressure together with marked proteinuria
    • Suspected HELLP syndrome: upper abdominal pain and malaise with an increase in blood pressure, however small
  • Severe, intensive pruritus
  • Severe nausea
  • Suspected venous thrombosis or pulmonary embolus
  • High-grade pyrexia
  • Any other condition where emergency measures are considered appropriate.

References

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  • Julkunen H. Pregnancy and lupus nephritis. Scand J Urol Nephrol 2001 Sep;35(4):319-27. [PubMed]
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  • Haddow JE, Palomaki GE, Allan WC, et al. Maternal thyroid deficiency during pregnancy and subsequent neuropsychological development of the child. N Engl J Med 1999 Aug 19;341(8):549-55. [PubMed]
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  • Schmidt MI, Duncan BB, Reichelt AJ, Branchtein L, Matos MC, Costa e Forti A, Spichler ER, Pousada JM, Teixeira MM, Yamashita T, Brazilian Gestational Diabetes Study Group. Gestational diabetes mellitus diagnosed with a 2-h 75-g oral glucose tolerance test and adverse pregnancy outcomes. Diabetes Care 2001 Jul;24(7):1151-5. [PubMed]
  • American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2007;30(Suppl 1):S42-7.
  • World Health Organization. Definition and diagnosis of diabetes mellitus and intermediate hyperglycemia: report of a WHO/IDF consultation. WHO 2006 http://www.who.int/publications/i/item/definition-and-diagnosis-of-diabetes-mellitus-and-intermediate-hyperglycaemia
  • Dommergues M. Prenatal diagnosis for multiple pregnancies. Curr Opin Obstet Gynecol 2002 Apr;14(2):169-75. [PubMed]
  • Tanel RE, Rhodes LA. Fetal and neonatal arrhythmias. Clin Perinatol 2001 Mar;28(1):187-207, vii. [PubMed]
  • Stagnaro-Green A, Abalovich M, Alexander E et al. Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and postpartum. Thyroid 2011;21(10):1081-125. [PubMed]
  • Garber JR, Cobin RH, Gharib H et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract 2012;18(6):988-1028. [PubMed]
  • Snowden JM, Tilden EL, Snyder J et al. Planned Out-of-Hospital Birth and Birth Outcomes. N Engl J Med 2015;373(27):2642-53. [PubMed]

Evidence Summaries ⬆