PMK Management Protocol in MFM 2007

••
•• Cfimca{ <Practice <]uicfe(ines
•• 2007
•• age ent Protocol
•• In
er a Fe a Medicine
•• * ********
••
••
•• a er a Fe al edicine Unit
•• Departmen of Obs etrics & Gynecology
Phramo g u tao Hospital
•• *** ************
••
••
CLINICAL PRACTICE GUIDELINES ••
••
IN
MATERNAL FETEAL MEDICINE
2007
••
Management of high risk pregnancy.•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••.1
NST/FAS, OCT guideline.••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• .2
••
Labor curve {Friedman's) ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••.4
Prolonged latent phase•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••.5
Protraction disorders.•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••.6
Arrest disorders •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• .?
Management of breech presentation •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••.8
Management of anemia & abnormal Hb in pregnancv. ..............................................9
••
••
Mar.agement of mild preedampsia.....................................................................10
Management of severe preedampsia••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• ,11
Management of pregnancy with diabetes.............................................................14
Management of preterm premature rupture of membrane.........................................17
Management of preterm labor.••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••.19
Management of IUGR. •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• .21
••
Management of intrauterine fetal death.••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• .22
Management of pregnancy GA;;,, 40 weeks•••••••••••••••••••••••••••••••••••••••••••••••••••••••••• .25
Management of third trimester bleeding with suspected placenta previa•••••••••••••••••••••••• .26
Management of third trimester bleeding with suspected placental abruption ••••••••••••••••••• .27
Management of postpartum hemorrhage•••••••••••••••••• :~ ••••••••••••••••••••••••••••••••••••••••.28
Management of Rh D negative•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• .30
••
Management of twin pregnancy.•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• ,32
Anti-HIV +ve in pregnancy ..............................................................................34
Management of rubella i~ pregnanc:y...................... :::-::.."'-••••••••••••••••••••••••••••••••••••••• .36
Management of herpes Simplex gemtahs m pregnancv. ••••• :;., ....................................38
Management of syphilis in pregnancy•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• .39
Management of STDs in pregnancy.••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••.41
••
Management of hyperthyroidism in pregnancy•••••••••••••••••••••••••••••••••••••••••••••••••••••• :42
Management of liver disease in pregnancy ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••.44
Management of heart disease in pregnancy..........................................................45
Anticoagulation management in pregnancy ••••••••••••••••••••••••••••••••••••••••••••••••••••••••• ;47
Antibiotic prophylaxis for perinatal group B streptococcal infection. ...............................49
Guideline for genetic counseling ......................................................................,SO
Department of Obstetrics & Gynecology

Phramongkutklao Hospital
••
••
••
•• CUNICAL PRACllCE GUIDEUNES
••
MANAGEMENT PROTOCOL IN
MATERNAL FETEAL MEDICNE 2007
•• SECOND EDITTON
••
Copy right © 2007 by Maternal Fetal Medicine Unit,
Department of Obstetrics & Gynecology,
Phramongkutklao Hospital & College of Medicine•
.AJI rights reserved. SO pages•
Price 100 Baht
•
•• ISBN 978-974-9752-24-1
••
••
Editor: Prisana Panichkul, MD.
Editorial staffs: Suphavit Muttamara, MD.

Otutawadi Vuthiwong, MD•
Peerapan Punpuckdeekoon
•• Maternal Fetal Medicine Unit

Phramongkutklao Hospitaf & College of Medicine
.,•,
315 Rajavithi Rd., Rajathevi
Bangkok 10400, Thailand
Phone: (+66) 2 354-7600 Ext. 94058, 94061
Fax: (+66) 2 354-7630
•• Printed by S. Sermmitr Pubishlng, Co. Ltd., Bangkok, Thailand
•
••
•• PREFACE
•• These dinical practice guidelines in maternal fetal medicine are developed by maternal
fetal medicine unit of Obstetrics and Gynecology Department, Phramongkutklao Hospital to
provide health professionals in Phramongkutklao Hospital with current, quality information on the
••
practice of high-risk management in obstetrics. These guidelines reflect emerging dinical and
scientific advances as of the date issued and are subject to change. The infonnation should not
be construed as dictating an exdusive course of treatment or procedure to be followed. Local
institutions can dictate amendments to these opinions. They may need to be adapted to meet
the special needs of a specific patient as detennined by the patient's provider.
•• Maternal Fetal Medicine Unit

Phramongkutldao Hospital
•• December 2006
••
••
••
••
••
••
•• MFM Protocol 1
•• Patients who should be referred to high risk preanancy clinic
Patients who have medical complications
•• Multiple pregnancy
Fetal growth restriction
•• •
Management of high risk pregnancy
Hx taking, esp. medical complication-----<• Consult medicine
•• Reliable
•
•
•
Determine reliability of GA (LMP & EDC)
Physical examination
Proper lab. Ix for disease
for co-evaluate
patient's status
Unreliable
& Rx
•• !.------•"----U-/S_co_n-.~ ~-~
Matemal assessment Fetal assessment
• For early detection of • 20 wks: U/S screening for anomalies
•• Matematcomplication
T
complication
(Hx, Lab.)
Stable't:ondition
• 24-32 wks: Serial U/S q 4 wks
• 2: 32 wks:
Reassuring
fetal test
rial U/S q 2 wks
& assess fetal well-being
Non-reassuring
fetal test
••
t t
Rx alrdingly High lsk ANC Continue same Rx Delivery
until 38-40 weeks (After assess &
(Except OM Rx as protocol) counseling risk & benefit)
In doubt of maturity
•• . I
Positive
Amniintesis
For Shyke test
I I
Neg!tive
•• Spontaneous delivery,
induction, or C/S accordingly
Lwait
••
•• These gukjelines are designed for general use for most patients but may need to be adapted to meet the special needs of a specific patient
as de!EmWied by the patienrs p!Uvide!". (Last revised December 2006)
MfM f>rOO>ccl 2
••
NST/FAS. OCT guideline
NST/FAS
••
Reactive
o"t-
(patients oligohydramnios)
I
..
Non-reactive or
non-reassuring pattern
I
••
Repeat NST/FAS
weekly or more
t
Neoative
t
2:36 wks
Positive
I
t
Suspicious
or unsatisfactory
< 36 wks
••
t
••
as indicated
Delivery
BPP
Oligoh\tramnios
or score 0-2 T
Scof 4
I
.... .. Scoret8 -10
••
s36wk > 36 wk
-··. •t•• S361
Repeat BPP same day
,y·
or delivery Repeat BPP
(individualjudgmenf) in 24 hrs
I
~----Scores
Delivery
t
6
t
Score 8, ~o
Repeat NST/FAS weekly

or more as indicated
••
Remarks·
• Initiating test
• Indication for test :
: @GA 32-34 wks (if very high risk, begin@ 26-28 wks)
••
••
® Maternal indications ® Pregnancy related conditions
- Antiphospholipid syndrome - Decreased fetal movement
- Chronic renal disease - Intrauterine growth restriction
- Heart disease - Isoimmunization (moderate to severe)
- DiabeteS mellitus - Multiple gestation
- Hypertensive disorders - Oligo-Polyhydramnios
••
- Hyperthyroidism (poorly controlled) - Posttenn pregnancy
- SLE - Pregnancy-induced hypertension
- etc. - Previous fetal demise
(unexplained or recurrent)
- etc.
•Reactive: FHR acceleration l! 2 times that include all of the followings

• peak at l! 15 bpm above baseline (need not all the time)
• each lasting l! 15 sec (from baseline to baseline)
• all occurring within 20 min of beginning the test
• with or without fetal movement be accepted
••
• Non-reactive: one that lacks sufficient FHR acceleration > 40 min peliod
(account for fetal sleep cycles)
These guidelines are designed for general use for most patients but may need to be adapted to meet the special needs of a specific patient
as determined by the patient's provider. (Last revised December 2006)
••
•• MFM Protocol 3
•• · ~~~~-!l~'l;1't~~
• Use of sound stimulation apply on maternal abdominal wall at fetal head site
in order to decrease NST test time and decrease false positive non-reactive NST.
•• • Negative no late or significant variable decelerations

• Positive : late decelerations following ?. 50% of contractions
- even if contractions frequency < 3 times in 10 min.
• Equivocal-suspicious : intermittent late decelerations or significant variable decelerations
•• • Equivocal-hyperstimulatory : deceleration that occurs when contractions more frequent

than every 2 min. or lasting longer than 90 sec.
• Unsatisfactory : contraction < 3 l:imes in 10 min. or uninterpretable tracing (poor quality)
Remarks:
••
Relative Contraindications for OCT
Increased risk of preterm labor or delivery
History of extensive uterine surgery or dassical qs
Placenta previa
PPROM
•• BPPScore
10
Interpretation
Normal, nonasphyxiated
Recommended Management
No fetal indication for intervention

Repeat test weekly, or more frequent as indicated
-,
•• 8
8
Nonnal fluid
Oligohydramnios
Normal, nonasphyxiated
Fetal asphyxia suspected

No fetal indication for intervention
Repeat te.ting per protocol
Deliver if ;,. 37 wk, otherwise repeat testing
•• 6
Equivocal test'
Possible fetal asphyxia
• If abnormal AF volume, deliver
• If normal Af' volume
}> GA > 36 wk, deliver
}> GA s 36 wk - repeat test
- s 6, .deliver
- > 6, observe & repeat per protocol
•• 4 Probable fetal asphyida

• If abnormal Af' volume, deliver
• If normal AF volume
}> GA > 36 wk, deliver
}> GAS36wk
- Repeat test same day; ifs 6, deliver'
e
••
- or Deliver intrapartum monitoring'
0-2 Almost certain fetal asphyxia Deriver due to fetal indications (usually qs)
••
Reference:
1. Cunningham FG, Levene KJ, Bloom SL, Hauth JC, Gilstrap III L, Wenstrom KD. Williams
Obstetrics. 22"" ed. USA: McGraw-Hill; 2005. p. 373-87.
2. Harman CR. Assessment of fetal health. In: Creasy RK, Resnik R, editors. Maternal-Fetal
Medicine: principles and practice. 5"' ed. Philadelphia: Saunders; 2004. p. 357-401.
3. American College of Obstetricians & Gynecologists. Antepartum fetal surveillance. ACOG Pract
••
Bull 1999;(9). .
as detel1Tlined by the patienrs provider. (Last revised December 2006)
••
••
MFM ProtOOll4
Labor curve (Friedman's)
••
10
E' 8
~
c
0
•
:;:;
l9
.!!l
'O 6
13
'1:
a 4
0
••
0 2 4 6 8
TIME (hr)
10 12 14 16
••
Labor disorders
••
Labor pattern Nulliparous Multiparous ••
••
Prolonged latent phase > 20 hrs > 14 hrs
Protracted active-phase dilatation < 1.2 cm/hr < 1.5 cm/hr
Protracted descent < 1.0 cm/hr < 2.0 cm/hr
Prolonged deceleration phase > 3 hrs > 1 hr
••
SecQndary arrest of dilatation Arrest> 2 hr
Arrest of descent Arrest> 1 hr
No deScent > 1 hr in deceleration phase
Failure of descent
or second stage of lcbor
••
••
•• MFM Protocol S
•• Diagnosis
Prolonged latent phase
••
• Prolonged latent phase
> 20 hrs in nulliparous
> 14 hrs in multiparous
Evaluation & Rx
.
Suspected prolonged latent phase
Rest ± Sedation (narcotics)
•• No cervical progression,
No contraction
Re-evaluate in 4-6 hrs
••
Results Out of labor Progress to active phase Unchanged
(false labor) (expected response) pattern
•
10% 85% 5%
Oxytocin iv.
Infusion
•• Outcome
l
Discharge
NormalANC
..-~~~~~~~--.
Normal progression to
vaginal delivery
Normal intrapartum care
Abnurmal
pJsession
•• Factors: Excessive sedation or epidural analgesia

as OB indications
Unfavorable cervical condition - thick, uneffaced, or undilated
••
False labor
••
••
••
•• These guidelines are designed for general use for most patients but may need to be adapted to meet the special needs of a specific patient
as determ!ned by the patient's provider. (Last revised December 2006)
~
MFM Protocol 6
Protraction disorders ••
Diagnosis • Protracted active phase dilatation
( < 1.2 cm/hr in nulliparous, <1.5 cm/hr in multiparous)
• Protracted descent
(< 1.0 cm/hr in nulliparous, <2.0 cm/hr in multiparous)
••
Evaluation Power
Passage
i
: interval / duration / intensity of contraction
: full bladder/ mass / prominent ischial spine?
Passenger : malposition / EFW ?
!
••
Treatment • Expectant & SUpport
• Avoid excessive sedation
• Anesthesia
• Oxytocin if poor UC
••
••
• Amniotomy, etc.
Re-evaluate in 1-l hr(s)
••
Results Normal progression Abnormal progression
Outcome +
Vayinal delivery +
qs
as OB indications
••
••
••
••
••
•
as determined by the patienfs provider. (Last revised December 2006)
(
( MFM Protocol 7
( Arrest disorders
(
Diagnosis • Secondary arrest of dilafiJtion {arrest> 2 hrs)
•Arrest of descent {arrest> 1 hr)
( • Prolonged deceleration phase {> 3 hrs in nulliparous, > 1 hr in multiparous)
• Failure ofdescent {no descent> 1 hr in deceleration phase or second stage of labor)
(
Evaluation Power
i
: interval / duration I intensity of contraction
Passage : full bladder I mass/ prominent ischial spine?
( Passenger: malposition I EFW ?
( Treatment - Amniotomy if not done - Good contraction

- Oxytocin infusion if poor contraction - Spontaneous rupture of membrane
or amniotomy was done already
Re-evaluate in 1-2 hr(s)

(
...
( Results N o l progression Abnorm[I progression CPD
( Outcome Vaginal delivery qs

l-
qs
as OB indications
c Remarks:
( When regional·anesthesia is used,

- The 2"" stage will extend to 3 hrs (from 2 hrs) in nulliparas.
- The 2"" stage will extend to 2 hrs (from 1 hr) in multiparas.
(
( Reference:
1. Cunningham FG, Leveno Kl, Bloom SL, Hauth JC, Gilstrap III L, Wenstrom KO. Williams
Obstetrics. 22"" ed. USA: McGraw-Hill; 2005. p. 420-40, 495-505.
2. Bowes WA, Throp JM Jr. Oinical aspects of normal and abnormal labor. In: Creasy RK, Resnik R,
editors. Maternal-Fetal Medicine: principles and practice. s"' ed. Philadelphia: Saunders; 2004.
p. 671.-80.
( 3. American College of Obstetricians & Gynecologists. Dystocia and augmentation of labor. ACOG
Pract Bull 2003;(49).
(
(
( as determined by the patient's provider. (last revised December 2006)
{
( MFM Protocol 9
( Management of anemia & abnormal Hb in pregnancy
[Anemia = Hct< 33%; Hb < 11 g/dl]

( 1" ANC lab - CBC, RBC indices (MCV, MCH) & DGP
f
Normal Hb & Hct
f
Normal Hb & Hct
•
Normal Hb & Hct Low Hb & Hct
f
LowHb&Hct
...
( MCV ;?_ 80 MCV ;?_ 80 MCV < 80 MCV < 80 MCV ;?_ 80
MCH ;?_ 27 MCH ;?_ 27 MCH < 27 MCH < 27 MCH ;?_ 27
• •
DOP - ve DCIP +ve DCIP - ve i +ve DCIP - ve/+ve DCIP-ve
( I I
*
Normal • Consult hematologist
No work up t t
( Hb typing Hb tyPing & PCR for a.__-th_a_1-_1_ _ _ _ _~
I
f ... f ~ f f ...
( Normal Hb E trait or Hb trait CS or ·Abnormal Hb AE Bart' s Hb H Normal
~. Hb CS
T.,
Hb typing Homo. Hb E fl globin Disease Disease Hb typing
+
Normal
,==.,~~" ... • Counseling
l
ANC
• Ferrous supplemen
( ANC high risk) • Counseling if no Iron overtoad
• Counseling • Ferrous
• Ferrous supplemert
( supplement (except fl-thal major, ~ent Normal
(
~ ~· - - - f lgive
1 _-_tha_l'.._Hb_E_;_....,
Follc a 5 mg/d) r - i1
n - 1 trait
Partner's Hb typirg :~;:1~~ an~~ia Ane~a
r!
.~-~I~... Work up for
Low Normal other causes
t of anemia :
Partner's (Stool exam
PCR for a-thal-1 ±Serum ferritin)
( Normal Abnormal f ' t f T
Hb typing (E, etc.) or
pr~lte
Hb typing Partner Normal
& Hb A2 Hb A2 level> 3.5 % a-thal-1 trait '----+-----' Nonnlal
( I .__I~___.I • Fe supplement
+
• Counseling
+
• Counseling
•Normal ANC
(Except disease
Rx.
postpartum
( & normal ANC - Risk of Thalassemia in fetus ANC high risk) +
(Except disease - Option for prenatal diagnosis Fe supplement
(
ANC high risk)
+
Repeat Hct & reticulocyte count
in 2-4,wks
f ...
(
•
Still abnormal
• Consult hematologist •
•
Normal
Normal ANC
+ Fe supplement
Notes : Homo. Hb E = Homozygous Hemoglobin E Homo. Hb CS = Homozygous Hemoglobin CS
Reference:
1. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap III L, Wenstrom KO. Williams
Obstetrics. 22"" ed. USA: McGraw-Hill; 2005. p.1144-56.
( 2. Kilpatrick SJ, Laros RK Jr. Maternal hematologic disorders. In: Creasy RK, Resnik R, editors.
Maternal-Fetal Medicine: principles and practice. 5"' ed. Philadelphia: Saunders; 2004. p.975-88.
3. American College of Obstetricians & Gynecologists. Hemoglobinopathies in pregnancy. ACOG
z Pract Bull 2005;(64).
(
(
MFM Protocol B
Management of breech presentation (
Breech presentation (
+
U/S detection fetal anomalies, parameters, placenta & AF
(
Lethal fetal condition.--------~.._--+ Normal or non-lethal fetal condition
...
Optional : {Individual judgment) (
[After counseling risk & benefit]
External cephalic version (ECV)-----+---Elective C/S @ 38-40 wk (

@ GA ~ 36 completed wk (except frank breech)
If - Active labor (
- Indication for delivery
Assess
• EFW 2,000-3,500 g • Not frank breech • Preterm EFW < 1,500 g

c frank breech • Severe IUGR or GA < 32 wks
Vaginal delivery
except
• EFW > 3,500 g (
• When delivery is indicated in
maternal indicat" the abseni:e of spontaneous labor Inron!usive
• ?revious perinatal death or
c
previous children birth trauma
whether C/S or
vaginal delivery
(
• Healthy & viable preterm fetus ?more benefits
(EFW 1,500-2,000 g)
• A request for sterilization
(
• Lack of an experienced operator
X-ray pelvimetry & fetogram

(
or dinical pelvimetry & U/f fetal head condit" (attitude)
Favoralie pelvis Unfavortble pelvis

(
·& no hyperextended head (interspinous 0 < 10 cm
I or shape*) (
+ or hyperextended fetal head \
Plan vaginal delivery
- Continuous intrapartum FHR monitoring
- Try to keep membrane intact
- Notify pediatrician & anesthetist
I
t + (
Successful Uterine dysfunction
vaginal delivery OR
Other OB indications (
C/S
Remark: * Unfavorable pelvic shape: platypelloid & android pelves c
Reference:
1. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap Ill L, Wenstrom KO. Williams
(
2. Bowes WA Jr, Throp JM Jr. ainical aspects of abnormal and normal labor. In: Creasy RK, Resnik
R, editors. Maternal-Fetal Medicine: principles and practice. 5"' ed. Philadelphia: Saunders; 2004.
(
p. 684-6.
3. American College of Obstetricians & Gynecologists. External cephalic version. ACOG Pract Bull
2000;{13).
4. American College of Obstetricians & Gynecologists. Mode of term singleton breech delivery.
ACOG Committee Opinion 2006;{340) .
as determined by the patient's provider. (Last revised December 2006) (
(
MFM Protocol 10
(
Management of mild preeclampsia (
Diagnosis: • BP ;z 140/90 mmHg in previous normotensive patient (

• with proteinuria ;z 300 mg in 24 hrs or<!: 1' !Tom Dipstick of random urine
t
(
•
• Asses:.~ maternal status
Oinical of SPE
I •
Admit
Assess fetal status
NST/FAS
(
DxSPE
r lx: CBC, pit, coagulogram,_BUN, Cr, _L'.f
24-hr urine for protein & creatirnne
GA<37wks
I
+
U/S for fetal growth, AF, placenta-,.
I
GA,,37wks
Non-reassuring
fetal test
+ (
+
• Serial maternal assessment
+
Terminate pregnancy+
Consider delivery
Symptoms & signs of SPE I depend on GA (
Daily BW, DTR & protei!l)uria T T t
BP qid, urine output f Ripe or wait Unripe other
4
• Serial fetal assessment
Oinical - fundal height, FHS
cervix if dinical stable cervix OB indicat"
t (GA 5 40 wks) t (
Daily FMC Oxytocin Serial induct"
NST/FAS ± U/S IV drip c FGE2 (
- Beware of SPE • Intrapartum
- Steroid for GA < 34 wks - Continued assess mother
- Beware of SPE
(
Not response Response - Continuous etal monitoring
• Maternal:develop SPEtc stable maternal
(dinical or lab Ix) & fetal condit" Response Failed
(
t
• Fetal compromise If
any - Monitor until
conditions GA " 37 wks
(may be OPD case)
i
Vaginal
delivery
induction
s (
-ANCweekly
l
(dinical, BP,
proteinuria)
- NST/FAS weekly
-± U/S q 2 wks
• SPE management -t _
(if develop SPE) Stable patient
Terminate Pregnancy Terminate Pregnancy (
Remarks: (
- If MPE diagnosed in LR: baseline lab Ix
~ blood for CBC, platelet count, coagulogram, BUN & Cr, LFT and repeat urine protein q void (
(
(
(
(
(
as determined by the patient's provider. (Last revi~ December 2006) (
(
(
MFM Protocol 11
( Management of severe preeclampsia
Diagnosis : BP systolic 2: 160 mmHg OR diastolic 2: 110 mmHg

( Proteinwia 2: 2 g in 24 hrs or persistent 2: 2' from Dipstick
Oliguria s 500 ml in 24 hrs
Cerebral or visual disturbances or epfgastric pain
( Pulmonary edema
Other lab Ix abnormalities - coagulopathy, thrombocytvpenia,
l
creatinine > 1.2 mg/di
( (unless known tv be previously elevated},
impaired LFT, IUGR
Ad'Vit LR
( f t
• Assess maternal status • Assess fetal status
Ix: ·cac,platelet cou,-it, coagulogram Oinical: - fundal height, FHS
BUN, Cr, ITT, U/A NST±BPP
24-hr urine for protein & creatinine U/S - EFW, growth, AF volume, placenta
(If still not done) - presentation, R/O hydrops fetalis, twins
• Nftuid: LRS
• Record VS q 1 hr, retain Foley catheter
( • Record l/O & urine sp. gr. q 4 hrs
• Beware of edampsia
• No diuretics unless pulmonary edema is developed
(
•
• Continuous fetal monitoring
• Prevention of convulsion (1" line = MgSO.)

( • Antihypertensive Rx if diastolic > 105 mmHg or systolic > 160 mmHg*
GA 124 wks GA 241< 32 wks GAT32wks

( H
•Termination of pregnancy • Optional expectant Rx •Termination of pregnancy
(Only selected case"* (delivery within 24 hr.:
( after counseling risk & benefit) of onset of symptoms)
f I 't
Favorable Other
( Corticosteroid
Continued anticonvulsant for 48 hrs cef!X
. OB indicat"
Closed monitor maternal & fetal status T or
Daily Ix: CBC, pit, coagulogram Oxytocin unfavorable
(
R!po~ ~cemx
LFT, BUN, Cr
drip Fated
(
Termination of pregnancy I induction
If 1. GA <: 32 wks -f
( or 2. worsening maternal Vaginal C/S
or fetal condition deli,very I
( ...
• Continue anticonvulsant
until 24 hrs postpartum
• Control BP, keep diastolic 90 - 105 mmHg
( (antihypertensive drug may be oral fonn)
NOTES:
* NHBPEP (2000) recommendation
( **Expectant Rx is NOT considered in 2: 1 of the followings:
1. uncontrolled severe HT
(systolic BP > 160 mmHg or diastolic BP > 105 mmHg despite max. recommended dose of antiHT)
2. edampsia
· 3. platelet count < 100,000/µI
4. AST/ ALT >2X upper normal limit with epigastric/RUQ pain
( 5. pulmonary edema
\
(continue next page)
(
as detennined by the patient's provider. (last revised December 2006)
\
I
\
( MFM Protocol 13
( Reference:
1. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap III L, Wenstrom KD. Williams
Obstetrics. 22"" ed. USA: McGraw-Hill; 2005. p. 761-87, 1210-20.
( 2. Roberts JM. Pregnancy-related hypertension. In: Creasy RK, Resnik R, editors. Maternal-Fetal
Medicine: principles and practice. s"' ed. Philadelphia: Saunders; 2004. p. 859-93.
3. American College of Obstetricians & Gynecologists. Diagnosis and management of preedampsia
( and eclampsia. ACOG Pract Bull 2002;(33).
4. American College of Obstetricians & Gynecologists. Ouonic hypertension in pregnancy. ACOG
( 5. Oin Obstet Gynecol 1999;42(3):470-8.
6. Oin Obstet Gyna""OI 2004;47:118-273.
7. Gregg AR. Hype1tension in pregnancy. Obstet Gynecol Ciin N Am 2004;31:223-41.
(
(
(
'
(
(
(
(
(
(
(
(
(
(
(
MFM Protorol 12
**Expectant Rx is NOT considered in ;,_ 1 of the followings: (continued)

6. compromised renal function (rise in serum creatinine of 1 mg/di over baseline level)
7. abruptio placentae
8. persistent severe headache or visual changes (
9. worsening fetal conc!ition
10. HELLP syndrome
11. significant hematological, cerebral or liver abnormalities due to preeclampsia (
- If severe preeclampsia develops before GA 34 wks, antiphospholipid syndrome should be investigated.
- If eclampsia develops, delivery should oa:ur within 12 hrs of the onset of convu!sions. (
Maintenance Recurrent
(
Drug Initial dose Antidote Monitor
dose convulsion
a. patellar reflex = present
4g 20 g of 50 % MgSO. 10%caldum b. urine output ;,_ 100 ml/4 hr Repeat 2 g of
HgS04 (10% MgS04) in 5% D/W 500 ml gluconate c. RR;,_ 16/min 10% Mgso. iv.
(1" line) iv. rate iv. drip 25-50 ml/hr 10 ml iv. d. Mg" level @ 1 hr later,
then q 4 hr until reach
& recheck
Mg2+ level
(
:5 1 g/min (1-2 g/hr} over 3 min
therapeutic level x 2 times
Phenytoin
1000 mg dose
250-500 mg oral
(
Infused over - therapeutic level 10-25 µg/ml -
(2"" line) or iv. 10 hr later
1-hr period
Remarks
- If next dose of Mg504 cannot be given, reassess a., b. and c. q 30 mins. and retreat when a., b. and c.
meet the above aiteria.
- If ronvulsion develops during giving maintemnce dose of MgSO.,, phenytoin 125 mg. iv. (dose up to
(
250 mg iv. over 3-5 min.) or <flilZepam 5 mg iv. may be considered.
- Therapeutic level ofMf/' = 4.8- 8.4 mg/di
(
Preparation: 2 mg/2 ml ampoule
Treatment dose : I. Iv. bolus: 2 mg/2 ml ampoule + saline 2 ml. (0.5 mg/ml)
(
0.5 mg (1 ml) iv. over 1-2 min monitor BP q 5 min for 15 min
• If no effect (BP not J, ): repeat dose q l:S min.
• If optimal effect - not repeat dose until diastolic BP ;,_ 110 mmHg
,.,. if patient's BW > 80 kg, initial start dose @ 1 mg (2 ml) ««
II. Iv. drip: 10 mg in 5% D/W 100 ml. (0.1 mg/ml) start at 2 mg./hr (20 µd/min)
• If no optimal effect (BP not J, ): t 2 mg/hr (20 µd/min) dose q 15 min (
Maximum dose: 10 mg/hr
Neoreso{fDihvdralazinel (
Preparation: 25mg/2ml.
Test dose: 1 mg iv. over 1.min, monitor BP q 5 min (to avoid idiosyncratic hypotensive effect)
Treatment dose: 5 - 10 mg iv. over 2 - 4 min monitor BP q 5 min for 20 min later (
• If no effect (BP not J, ): repeat dose.
• If optimal effect - not repeat dose until diastolic BP ;,_ 110 mmHg
Maximum dose: Total 30 mg - if can not control BP, then switch to another regimen (
NifetJ.pine..Jt/!.:!!!2~~~-'K;;>;o'X i5~U'"WHDS.llo'-~~,m------
Preparation: 10, 20 mg/capsule
_;Ji
(
Treatment dose: 10 mg oral monitor BP q 5 min for 15 min later
repeat dose in 30 min if necessary
»» Beware ofsynergistic interaction with MgSO, that causes severe hypotension.
(
Use only after stop HgSO, for at least 6 hrs. «« ·
Maximum dose: 120 mg/d
(
These guldelines are designed for general use for most patients but may need to be adapted to meet the special needs of a specific patient
as detennined by the patient's provider. (Last revised December 2006) (
(
MFM Protocol 14
Management of pregnancy with diabetes (
Risk assessment for GDM should be done at 1" prenatal visit

(
Low Risk No aiteria for high or low risk
----.
High Risk
• Age < 25' years AND OR member of high prevalence • Obesity(> 90 kg) OR
• BMI :S 25 (normal weight) AND of type 2 DM ethnic group* • Age 2 25 years OR
• No Hx of abnormal • Previous GDM OR
glucose metabolism AND • Hx of diabetes in
(
• No known diabetes in 1" degree relatives OR
1" degree relatives AND • Previous IUFD or anomaly
• No previous IUFD or of unknown cause OR
(
ar.omaly of unknown cause AND • Previous infant weighing
• Not member of high prevalence 2 4,000 g OR
of type 2 OM ethnic group* • Glucosuria OR
'
• Unexplained hydramnios
!
No glucose screening required Screen@ GA 24-28 wks
in current pregnancy
+
Screen as soon as feasible
(
c
50-g GCT
I
c50-g GCT
I
No~al Ab~o~al Nom1al"

(< 140 mg/di) (2 140 mg/di) (< 140 mg/di)
(
No furthtr testing 100-g 3-hfOGTT Re-screen@ GA 24-28 wks +
• l
or if symptoms occur
(
2 2 abnormal values 1 abnormal value
...
All normal values
I (c normal fasting value) I (
+
Diagnosis of GDM
..
Not high risk
t ..
Hiah Risk
t
Not high risk
+ -+
t
normal
fasting value
+
GDM class A,
~
i~
r Assess1
t
abnormal
fasting value
+
GDM class A,
· U/A & urine

Urine 24-hr for protein
& creatinine clearance
I
@ 32-34 wks @ 24-28 wks
or if symptoms
occur
t
Repeat 100-g 3-hr OGTI
ru~re
I i
No further
testing (
l
• Diet control
• FPG q 4 wks
FPG 2 105 mg/di OR
2-hr 2 PP 120 mg/di
J •
Blood for BUN, Cr
Fundoscopic examination ± EKG
Diet control
• Insulin Rx
• U/S each trimester • FBS & 2-hr PP q 2 wks (keep FPG < 95 & 2-hr PP< 120 mg/di)
• FMC start @ 28 wks • Serial U/S q 4 wks
~si/~rtt!c~ a~k start@ 32 wks (oc degree of risk)

36 8
• NST/FAS weelkly start@ wks :
• ANC q 2-4 wks in GA< 28 wks & q 1-2 wk in GA 2 28 wks (
t (depends on glycemic control)
Delivery @ GA 38 - 40 wks Delivery @ GA 38.5 - 40 wks
depends on cervical condition depends on cervical condition (
Cl
~: * Hispanic, African, Native American, South or East Asian origins'
These guidelines are designed for general use for most patients but may need t:o be adapted to meet the special needs of a specific patient
( MFM Protocol IS
( Time Plasma glucose (mg/di)

Fasting
( 1 hr ;efci 180
2 hrs
3 hrs
(
• Diet - for both gestational & pregestational diabetes (ADA 2004)
Ideal body weight Daily caloric intake (kcal/kg/d)

\ Underweight (BM! < 19.8) 35
Nonndl weight 30
( Overweight (BM! ;? 30) 25
( •Carbohydrate : fat : protein= 55% : 25%: 20% c3 meals & 3 snacks in ratio 2:1:2:1:2:1
+ Insulin therapy - Use in every dass except OM A1
( •Start with total do:;e of insulin 0.7, 0.8 and 0.9 ii/kg for 1", 2"" and 3'"toimester GA, respectively
•Add insulin 1-2 ii for every 50 mg/di that glucose level is out of target range'
• As pregnancy progress, 1 ii may need for every 20 mg/di of glucose level that is out of target range 2
1 12 hr before breakfast V2 hr before dinner Bedtime

(
S+I S+I
( S+I s
• S = short-acting insulin
( •
•
I = intennediate-acting insulin
Morning/evening dose ~ 2/1
• 5/1 ~ 1/2 morning & 1/1 evening
• If total dose of morning I ?: 50 ii, split dose of S should be given before lunch.
(
+ Specific antepartum assessment for pregestational diabetes
(
• For diabetes dass D (benign retinopathy) & dass F (proliferative retinopathy):
---t fundoscopic exam should be followed up q trimester or more frequent as indicated.
(
(
(
(
( ·(continue next page)
(
MFM Protocol 16
+ Intrapartum glycemic control

Diabetes in pregnancy
.
Normal range
(80-1201mg/dl)
't
No further specific Rx
•
DMA1
Begin & continue 5%0/N/2 100 ml/hr

Monitor CBG stat & q 4 hr
' ...
+
> 120 mg/di
Insulin Rx
---------~Insulin
r-
Intravenous
•
infusion method
Withhold morning
•
DM A2 or Pregestational diabetes
Rx
!Optional
...
Intermittent
•
subcutaneous method
Give 'h of usual

(
(
insulin injection morning insulin dose
(for labojr inducfu:~;~/~ ~~ti~~~~or labolr induction) (

Monitor CBG stat & q 1-2 hr
Begin oxytocin iv. drip as needed (
NSS 250 ml Administer RI
+ RI 25 0 (1 0 /10 ml) in small dose {2-5 0) sc.
iv. infusion accordingly to CBG* maintain glucose 80-120 mg/di
*Low-dose insulin for diabetic women during intrapartum period (CBG: capillary blood glucose) 1•2
< 80 Insulin off 5% D/N/2 (

80-100 0.5 5% D/N/'2
100-140 1.0 5% D/N/2
(
141-180 1.5 Normal saline
181-220 2.0 Normal saline
>220 2.5 Normal saline
+ Elective C/S: - usual insulin the night before qs & withhold morning insulin
- perform C/S early of the day to avoid prolonged fasting period
(
c
- 5%D/LRS iv. insulin boluses doses on a sliding scale as needed q 1-4 hr
- FBS & CBG q 6 hr, maintain plasma glucose 80-120 mg/di
(
• Postpartum
Delivery day • Insulin is withheld; short-acting insulin sc. if glucose > 200 mg/di
• Check glucose level q 6 hrs on delivery day
Day~ postpartum • Type I - same insulin requirement as pre-pregnant dose
• Type Il - same dose of oral hypoglycemic drug
Breast feeding should be encouraged.
(
References:
1. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap Ill L, Wenstrom KD. Williams
Obstetrics. 22"" ed. USA: Mcgraw-Hill; 2005. p. 1170-87. (
2. Moore TR. Diabetes in pregnancy. In: Creasy RK, Resnik R, editors. Maternal-Fetal Medicine:
principles and practice. 5"' ed. Philadelphia: Saunders; 2004. p. 1023-56.
3. American College of Obstetricians & Gynecologists. Gestational Diabetes. ACOG Pract Bull (
2001;(30).
4. Griffith J, Conway DL. Care of diabetes in pregnancy. Obstet gynecol Clin N Am 2004;31 :243-56.
5. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes care (
2006;29(1):543-8.
6. Moore TR. Diabetes rnellitus and pregnancy. Available from:
htto://www.emedicine.com/med/topic3249.htm. (
7. ANMC Women's health service diabetes mellitus in pregnancy screening and management
guidelines. Available from: htto://www.his.gov/Medica1Proorams/MCH/M/DP13.aso#top.
8. Diabetes in pregnancy: Management in Labour. Available from : (
htto://www.rwb.orq.au/rwhcog/maternity.cfm.
as determined by the patient's provider. (last revised December 2006)
(
( MFM Protocol 17
( Management of preterm premature rupture of membrane
PPROM --- suggested by

( 1. Hx offluid leakage
2. Sterile speculum +ve fluid in posterior fomix
3. Nitrazine test +ve for alkaline pH
(
(
1 4. Fem test +ve for arborization
5. ± U/S - decrease AF
Assess dinical of chorioamnionitis

Speculum visualization ± digital examination: ce;vical condition, R/O cord prolapsed
CBC, U/S: fetal presentation, anomalies, EFW, AF, placenta
( Assess fetal well-being: external fetal monitoring, ± BPP
' t
1. ac;tive labo(
( 2. chorioamnionitis - - + YES-----~
I 3. non-reassuring fetal status
( i
NO
(
+ t
•
Counseling for prognosis, options of Rx (risks & benefits)
t t
GA < 24 wk GA 24-<34 wk GA 34-<36wk GA~36wk
(
(
.~'~.1
Optional
termination
Ex~ntRx
(EFW ~ 2500 g.)
of pregnancy Antibiotics*
( Corticosteroid**
(
i
• Observe labor (digital exam as indicated)
•Observe infection (dinical & CBC q 2-3 days)
• Assess fetal well-being: FMC, NST, ± BPP
( I
+
In labor
a1orioamnionitis --.....----+- Delivery
( No chorioamnionitis
Reassuring fetal status Non-reassuring fetal status + GBS prophylaxis
I
( i
Stable for at least 72 hrs.
+
Induce/ qs
t
( i
Possible discharge
Augment
.
labor
: OB
indications
+ F/U ANC q 1-2 wk ---'----•GA~ 36 wk - - - - - ' Vaginal

Assess maternal & fetal conditions delivery
(
NOTES:
( - Antibioties": • Amoxicillin (500 mg) + Erythromycin base (250 mg) oral tid pc for 7 days7
or Erythromycin {250 mg) oral qid pc for 10 days'
•Optional: Initial 48 hrs. -Ampicillin 2 g. iv. q 6 hr""
or.Ampicillin.:2 g. iv. q 6 h~& Erythromycin 250 mg. iv. q 6 hr
( After 48 hrs. - if clinical stable, then switch to oral agents for 5-7 days '
iAmoxicillin (250 mg) oral q 8 ljr &+Erythromycin base (333 mg) oral q 8 hr'
• In case of allergic to penicillin group: initial 48 hrs
( Vancomycin 500 mg iv. q 12 hr' or Clindamycin 900 mg iv. q 8 hr"
- CorticosteroidS**: Dexamethasone 6 mg im. q 12 hr x 4 doses for GA 24 - 34 wk
(
(
MFM ProlOCDI 18
References: (
1. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap III LC, Wenstorm KO, editors. Williams
Obstetrics 2200 ed. USA: McGraw-Hill; 2005. p. 855-73.
2. Garite TJ. Premature rupture of the membranes. In: Creasy RK, Resnik R, editors. Maternal-fetal (
medicine. S"' ed. Philadelphia: Saunders; 2004. p. 721-39.
3. Festin M. Antibiotics for pretenn prelabour rupture of membranes: RHL commentary (last revised :
14 lllne 2003). The WHO Reproductive Health library, No 8, Update Software Ltd, Oxford, 2005. (
4. American College of Obstetricians & Gynecologists. Premature rupture of membranes. ACOG
5. Mercer BM. Preterm premature rupture of membranes: diagnosis and management. Oin perinatol. (
2004; 31: 765-82.
6. Perinatologist Corner - C.E.U/C.M.E. Modules, Maternal Child Health - American Indian and Alaska
Native. Preterm Labor and Preterm Pl""JTiature Rupture of Membranes. Available from: (
llt!J2;}/www.ihs.gov/MedicalProorams/MCH/M/PretennLaborandPretenn.dm.
7. Managing complications in pregnancy. A guide for midwives & doctors. Department of
Reproductive Health & ResP..arch(RHR), WHO. Available from: www.who.int/reproductive- (
hea!tMmoadSvmotoms/Prela~rupture membranes.
8. Giles M, Garland S, Oats JJN. ement
of preterm prelabour rupture of membrane: an audit.
How do the results compare with dinical practice guidelines? Aus N Z J Obstet Gynecol. 2005; 45:
201-6.
(
9. MMWR. Prevention of Perinatal Group B Streptococcal Disease. Revised Guidelines from CDC
August 16, 2002;51(RR11):1-22
10. Duff P. Preterm premature rupture of membranes. Up-To-Date version 14.3. [updated 2006 July
(
11; cited 2006 Nov 20]. Available from: httn://www.uptodate.com.
11. Kenyon S, Boulvain M, Neilson J. Antibiotics for preterm rupture of membranes (Cochrane
Review). In: The Reproductive Health Library, Issue 9, 2006. Oxford: Update Software Ltd.
Available from : http://www.rhlibrarv.com.
(
(
(
(
(
(
(
(
These guidelines ~re designed for general use for most patients but may need to be adapted to meet the special needs of a specifi·c patient
as detennined by the patient's provider. (last revised December 2006) (
(
( MFM Protocol 19
( Management of pretenn labor
( • Contraction 4 / 20 min or 8 / 60 min

• Cervical dilatation 2: 2 an
• Cervical effacement 2: 80 %
(
f
I Wet smear R/O cervicovaginitis
- U/A
+
( Identify cause & treatment ~----''- Oinically correlated with preterm labor
U/S: QI, anomaly, EFW, AF, placenta/ kxation
Tl-5: cervical length {if avaiiable)
( Rbronectin {if available)
c YES NO
Re-evaluate~&:PV in 1-2 hr ·
( I ~--.-------labor continue
t
f •
No labor
J.
Contraindications for tocolysis* Discharge
( I ~
t t Normal ANC
YES NO
( ...
Let labor
+
Tocolysis (GA 24 - 34 wk)
continue
( • Extemal fetal monitoring
•Record 11.S' q 30 min during dosage acfjustment
then q 2 hrs during maintenance
•Record 1/0 q 4 hr
•Steroid for fetal lung maturity acceleration
Persistent uterine ~No uterine

(
i
contraction contraction
(< 1~5 min)
( Increase dose of tocolysis Maintain tocolysis:
PV q 1-2 hr duration depends on drug selected
c:ar:e~;/~'!:at
(
(
l cvmp/ications
Max. doses response
Stop tocolysis
GBS prophylaxis
( Contraindications for tocolvtic therapy*

A. Absolute B. Relative
o Severe PIH o Mild chronic hypertension
o Severe abruptio placentae o Mild abruptio placentae
o Severe bleeding of any causes o Stable placenta previa
o Chorioamnionitis o Maternal diseases e.g. uncontrolled DM,
o Fetal anomalies incompatible with life hyperthyroidism, cardiac disease
0 Fetal death o Fetal anomalies
o Severe IUGR o Mild IUGR
{ o Cervix > 5 an dilated
( as determined by the patient's provider. (Last revised December 2006)
(
MFM ProtOCQI 20
(
posage regimen of tocolvtic drugs
Maintenance
Drug Preparation Loading dose Short
term
Long
term
Lablx
( ,
10 mg oral, then repeat
10, 20 mg 10-20 mg oral q 4-6 hr
Nffedipine
capsule
10 mg oral q 15-20 min
(may maintain up to 34 wk)
- (
max. 40 mg in 1" hr
0.001% sol". 0.01-0.025 mg/min iv.
0.25 mg iv.
Terllutaline (10 mg I NSS
over 1-2 min
(maintain 12 hr after - FBS
1000 ml) contraction ceases) BUN, Cr
20 g of 50% 1-2 g/hr (maintain Electrolyte
4 g of 10% Mgso. iv.
Mgso. MgSO. in 5% 12 hr after - EKG
o;w soo ml < 1 g/min contraction ceases)
(
Dosage of steroid to accelerate fetal lung maturitv
o Dexamethasone 6 mg im. q 12 hr x 4 doses
(
Beferences:
(
Obstetrics 22"" ed. USA: McGraw-Hill; 2005. p. 655-80.
2. Iams JD, Creasy RK. Preterm labor and delivery. In: Creasy RK, Resnik R, editors. Maternal-fetal
medicine. S"' ed. Philadelphia: saunders; 2004. p. 623-61.
(
3. Ozman S. Calcium channel blockers for inhibiting preterm labour: RHL commentary(last revised:
18 January 200S). The WHO Reproductive Health Library, No 8, Update Software Ltd, Oxford, 2005. (
4. American College of Obstetricians & Gynecologists. Management of preterm labor. ACOG Pract Bull
2003;(43).
)
( )
()
(
(
(
( MFM Protocol 21
( Management of IUGR
(
•
Suspected IUGR:
Poor I lagging fundal growth
(
l•
• Poor maternal weight gain
• ,!, maternal perception of fetal movement
U/S confirmation and R/O anomalies:

,!, U/S parameters (BPD, HC, AC, FL)
• t HGAC ratio> +2SD for that GA
(
l
• EFW < 10 percentile
•,!,AF; presence of gr.III placenta@ GA<34 wk
1
IUGR risk assessment
( &counseling
(
( t
'
Non-reassunng
I
Assess: ltetal well-being & AA ·
fetal test
...
t
.
Reassuring fetal test
F/U "fetal growth & AA

GA<34wk GA~34wks - fetal well-being
I
(
(
l
• Risk & Benefit
Evaluation ·
• Corticosteroid
Non-reairing
fetal test
+
Growth arrest
± AA 5 5 an
..
Normal
i
Continue
evaluation
till GA 37-38 wks
( • Continue pregnancy • Termination of pregnancy

• Closed fetal assessment & F/U • Continuous intrapartum fetal monitoring
Remarks:
- If IUGR develops early or severe IUGR or structural anomaly was detected,
fetal chromos0me study br identification of infection may be considered.
(
Reference:
1. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap ill L, Wenstrom KO. Williams
( Obstetrics. 22"" ed. USA: McGraw-Hill; 2005. p. 895-904.
2. Creasy RK, Resnik R. Intrauterine growth restriction. In: Creasy RK, Resnik R, editors. Matemal-
Fetal Medicine: principles and practice. S"' ed. Philadelphia: Saunders; 2004. p. 495-508.
( 3. American College of Obstetricians & Gynecologists. Intrauterine growth restriction. ACOG Pract
Bull 2000;(12).
4. Royal College of Obstetrics and Gynecology (RCOG), Oinical green top guidelines. The
( investigation and management of the small-for-gestational-age fetus . Number 31, November
2002.
5. Harkness UF, Mari G. Diagnosis and management of intrauterine growth restriction. Oin Perinatol
( 2004:31: 743-64.
(
(
(
(
MFM Protoco/22
Management of intrauterine fetal death (

Suspected intrauterine fetal death (IUFD)
(no movement, FHS not audible, etc.)
(
...
Confirm diagnosis ___.. Not IUFD ___.. Normal ANC
± Assess fetal
(
by.r s well-being
IUFD
Patient & husband counseling (
Physical & pelvic exam
CBC, platelet count, coagulogram
(
Coagulopathy Normal coagulogram
1
Unripe+ceivix (
l'
Rx coagulopathy ..- Coagulopathy
as indicated
weekly CBC, platelet count,
coagulogram
No coagulopathy
Wait 2-4 weeks
(
(
• Termination of pregnancy ( oxytocin, PGEi, etc.)
± Stop lactation after delivery
Identification cause ofIUFO
(
• Selected maternal investigations •Selected fetal investigations

(individual consideration) (Individual consideration)
- CBC, platelet count - Fetal exam for gross anomaly, grade of maceration
-VDRL ±autopsy (after parental informed consent)
-FBS, HbA,C - Heart blood culture ± Hb typing ± TORCH IgG & IgM
- Blood group & Rh - Total body x-ray if suspected bony abnormality
- Lupus anticoagulant, anticardiolipin Ab - Oiromosome study (keep @ 4oc, DO NOT FREEZE)
-ANA ¢ From heart blood in case of fresh death
- Thyroid function test (+heparin in sterile syringe or in green top tube) (
- Kleihauer-Betke test ¢ From umbilical cord, chorionic membrane,
(peripheral bl. smear for fetal rbc)
- TORCH IgM & IgG ± Parvovirus
- PCR for a-thalassemia 1
or skin(c attached dermis) or fascia biopsy
in case of macerated fetus: thigh, inguinal region
or Achilles tendon (+sterile NSS in sterile container)
c
• Inspection of placenta, membranes, AF and umbilical cord before sending for pathological diagnosis (
- Maternal side : - Fetal side : ,
Completeness & number of cotyledons Vessels at placental edge
Infarction, retroplacental blood dot Cord insertion
Shape (ring shape, horse-shoe shape, etc.) (central, marginal, battledore, velamentous)
- Placental weight Extrachorial placenta
- Cord : Length Meconium-stained or doudy membrane
Number of vessels - AF: Volume, color, consistency, ± Gram stain
Notch (true, false), hematoma, stricture
(
• Grade of maceration' Features Duration of intrauterine demise
0 ¢ ~Preboiled" reddened skin < 8 hours
I ¢ Skin slippage & peeling > 8 hours (
II ¢ Extensive skin peeling 2-7 days
¢ Red serous effusions in chest & abdomen
due to hemoglobin staining (
III ¢ Liver yellow-brown ~ 8 days
¢ Turbid effusion
¢ May be mummified (
These guidetines are designed for general use for most patients but may need to be adapted to meet the special needs of a specific patient
(
(
MFM Protocol 23
(
IUFD/Stillbirth Form
( Name................................................ HN .................. Date of Delivery .................................... .
Prenatal: U/S finding or Dx .•••••••••••••••••••••••••••••••••••••• Other PND ••••.••••••••••••••••••••••••••••••••••••••••
Method of delivery ..........................................•........•................. by •..••••.....•.•••.•.•••• •••••••••.••.....
(
Matemal Testing [Key: Y= yes; N= no] Fetal Examination [Key: + present; - absent; ? unsure]
- FBS ....................................................... . - Weight ... ..................... Sex .............................
( -HbA 1C .................................................. . - Head circumference ......................................cm.
- CBC, platelet count · - Crown-heel length ................................... .....•cm.
- Degree of maceration grade................................
( - Head: ........ Normal ....... Hydrocephalic
........ Anencephalic .......• Collapsed
- VDRL .................................................... . ......••• Other (describe) ............................•
( - Blood group ABO................ Rh ............. . - Eyes: ......... Normal ........ Epicanthus
-ANA .......................................•........ .....• .......•. aose together ......•• Far apart
- Lupus anticoagulant ..•........................... .......•• Up slanting ......•. Down slanting
( ......... Abnormally small ......... Abnormally large
- Anticardiolipin antibody ......................... ......... Other (describe) ............................. .
- Nose: .......• Normal
( - Thy~oidfunction test ......... Other (describe) .............................. .
TSH ..................................................... - Mouth: ....... Normal ......... Cleft lip
FT3 .....................................................• ......... Oeft palate ......... Large tongue
( FT4 ...................................................... ......••. Small chin
- Kleihauer-Betke test ..... ...................•..... .......•. Other (describe).............................. .
- TORCH titers - Eurs: .......... Normal ......... Tags
( Toxoplasmosis ....................................•
Rubella ........................................•.. :....•
......•. . Lowest (top below eyes)
......... Pits ......... Symmetric
CMV ...................................................... ......••. Other (describe) .....................•........•
( Herpes ·················································· - Neck: ......... Normal ......... Excess skin
- Hb typing ................................................ . ......... Cystic mass ·
Partner's Hb typing ..........•....................... ......... Other (describe) ............................._.
( Placental Examination - Chest: ....... . Normal .•....... Asymmetric
[Key: + present; - absent; ? unsure] ......... Small
( - Weight ......................................................
- Maternal side: ..• Completeness of cotyledons
......... Other (describe) ..............................•
•......• Infarction - Abdomen: ......... Normal ......... Distension

( ........ Retroplacental blood clot
........ Structural abnormal
......... Omphalocele ......... Gastroschisis
......... Hernia ......... 3-vessels cord
(describe) ........................... ......... Other (describe) ................................
- Fetal side: ......... Meconium-stained - Back: ......... No'111al ......... Scoliosis
( ......... Abnormal cord insertion ......... Spina Bifida (defect level... ...•.........•.)
(describe) ........................... . ......... Kyphosis
... .... .. Extrachorial placenta ......... Other (describe) ............................... .
( - Umbilical cord: Length ........................cm . - Genitalia: .........• Normal ......... Imperforate anus
......... Cord vessels (2 / 3 / 4) ......... Ambiguous genitalia
......... Notch (true / false) (describe) ....................................... .
( ......... Stricture ......... Male .......... Hypospadia
......... Hematoma .......... Chordee
- AF: Volume ................................................. . .......... Undescended testes
( Color .................................................... . ......... Other (describe) ........................••
Gram stained ....................................... . ......... Female ......... Normal urethral opening
Other (describe) .................................. . .......... Oitoromegaly
- Pathology: YES / NO ......... Other (describe) ..... .
Result ..................................................
(
( (continue next page)
These guidelines are designed for general use for most patients but may need to be adapted to meet the special needs of a specific. patient
as determined by the patient's provider, (Last revised December 2006}
(
( MFM Protocol 25
(
Management.~f,pregnancy GA<?: 40 weeks I
Accurate gestational age by 2 in 3 of
( . • GoodLNMP
• Early ANC (before 12 weeks)
• U/S (14-26 weeks)
( +
GA40weel<s
( +
Assess fetal well-being: NSf/FAS
1
.+
Reactive NST/FAS Non-reactite NSf/FAS
(
i
Daily FMC
or non-reassuring pattern
t
See NST/FAS, OCT guideline on page 2
( t
(HS<ffl"'R<CJ +
Continue pregnancy
+
Delivery
(
I
( i
41 w°teks
NSf/FAS assess ± U/S for AFI ( ± BPP)
•Counseling risk & benefit
( t
• Termination of pregnancy
• . t
(
Unri~
.. cervix
PGE2 vaginal supp.

..
Ripe cervix
.
Oxytocin iv. drip
C/S
as any OB indications
for ripening cervix for induction

I • I
Intrapartum contiluous FHR monitoring
( t
Successful
t
C/S
t
Unsuccessful
vaginal delivery as any OB indicatkins induction*
( Remarks
Evaluation Bishop's scores everyday before & after induction.
If Bishop's scores s 6, then ripening cervix with PGE2 1 tab vg supp. (s 2 tabs/day).
( *Unsucressfi.JI induction :
Optional- after counseling risk & benefit; with normal maternal & fetal conditions
o Try AROM @ 2"" day of induction & continue induction oxytocin iv. drip e
( : If remain in latent phase for ~ 12 hr --> C/S
o Not enter labor within 2 days, then repeat 2"" induction within 3 days after 1" induction
: If unsuccessful induction again --> consider C/S
( Reference:
Obstetrics 22"" ed. USA: McGraw-Hill; 2005. p. 535-45, 881-92.
( 2. Resnik JL, Resnik R. Post-term pregnancy. In: Creasy RK, Resnik R, editors. Maternal-fetal
medicine. 5"' ed. Philadelphia: Saunders; 2004. p. 663-9.
3. American College of Obstetricians & Gynecologists. Management of postterm pregnancy. ACOG
4. Briscore D, Nguyen H, Mencer M, Gautum N, Kalb DB. Management of pregnancy beyond 40 weeks'
gestation. Am Fam Physic 2005:71(10);1935-41.
5. Crowley P. Interventions for preventing or improving the outcome of delivery at or beyond term. In:
The Cochrane Library, 15sue 2, 2006. Olichester, UK: John Wiley & Sons, Ltd.
6. Rouse DJ, Owen J, Hauth JC. Criteria for failed labor induction: Prospective evaluation of a
standardized protocol. Obstet Gynecol 2000;96(5) :671-7.
(
MFM Protorol 24 (
Additional studies in fetus Fetal Examination [Key: + present; - absent; ? unsure]
- Photographs YES I NO - Limbs : Length - normal, short, long
- X-rays YES / NO Form - normal, symmetric missing parts
Result .....................................................
- Culture YES /NO
Position - normal, abnormal
- Arms: Length Form Position
(
Result .................................................... . Right
- Chromosome study YES /NO Left
Result .................................................... . - Legs: Length Form Position (
- Hb typing YES I NO Right
Result .................................................... . Left
- TORCH YES / NO - Hands: #Fingers Webbing Syndactyly
Result .................................................... . Right
Left
- Feet: # Toes Webbing Wide space (
- Autopsy YES / NO (between 1"
Result .................................................... . & 2""toe)
Right .......... . (
Left
- Others (describe) ................................................... ..
(
Cause of fetal death ................................................................................................................................... ..
(
Attending Physician.................................................. Date ........................ .
(
(
Reference:
Obstetrics. 22 00 ed. USA: McGraw-Hill; 2005. p. 677-81.
2. Oiapter 6: The macerated stillborn fetus. In: Wigglesworth JS. Perinatal Pathology. 200 ed. WB
Saunders; 1996. p. 78-86.
3. American College of Obstetricians & Gyn~logists. Genetic evaluation of stillbirths and neonatal (
deaths. ACOG Committee Opinion 2001;(257).
4. Lindsey JL Evaluation of fetal death. Available from:
htto:/lwww.emedicine.com/MED/topic3235.htm.
5. Evaluation of the Stillbirth. Available from: http:/lwww.obfocus. .
(
6. Loss of fetal movements. A guide for midwives & doctors. Department of Reproductive Health &
Research(RHR), WHO. Available from: http:/lwww.who.int/reproductive- (
health/imoadSymptoms/Loss fetal movements Sl31 S133.html.
(
as detennined by the patient's pi:ovider. (Last revised Dec.ember 2006)
(
(
MFM Protocol 26
Management of third trimester bleeding

with suspected placenta previa
(
Admit, record VS, start iv. fluid, NPO
CBC, cross matching
NoPV&PR
(
Assess maternal & fetal condition
(
Massive bleeding No massive bleeding
Unstable patient Stable patient
Non-reassuring fetal condition Reassuring fetal condition (
+
Resuscitation
(
Conti.tied I
No ctire bleeding
active bleeding Stable patient
or Non-reassuring Reassuring fetal condition (
fetal condition
U/S for placentai site & GA (

Questionable
4
Placenta previa
...
No previa (
t
Indication
for delivery
I ..
No indication
for rlivery
i
look for other
causes of bleeding
Doubl~ set-up Observe & re-evaluate &Rx
t :+ Assess mother & fetus
No previa Placenta
previa
i + +
GA 34 - <37 wks
I
GA 2: 37wks
Look for
other causes
&Rx
C/S
Prelrm labor r ++
N°[~r
+
In libor
Emergency
Tocolytic drug
( 1" line= MgS04)
J Expectant Rx
Restrict activity
C/S
Stable until
(
Consider steroid Steroid for GA< 34 wks 2: 37 wks
Assess mother & fetus Assess mother & fetus witt1 persistent
(
I I placenta prevla
If anyt conditions lifter repeat U/S
c
• Rebleed maternal life-threatening (
• Non-reassuring fetus, GA 2: 28 wks
+
Emergency C/S Elective C/S
Reference:
1. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap III LC, Wenstorm KD, editors. Williams
Obstetrics 22"' ed. USA: McGraw-Hill; 2005. p. 819-23.
2. Oark SL Placenta previa and abruptio placentae In: Creasy RK, Resnik R~ editors. Maternal-fetal
medicine. s'"
ed. Philadelphia: Saunders; 2004. p. 707-22.
3. Royal College of Obstetrics and Gynecology (RCOG), Oinlcal green top guidelines. Placenta previa
and placenta previa a=eta : Dlag,nosis and management. Number 27, Revised October 2005.
4. American College of Obstetricians & Gynecologists: Placenta a=eta. ACOG Committee Opinion. (
2002;(266).
5. Ko P. Placenta prevla. 2004. Available from: htto:l/www,emedicine,com/emera/tooic427.htm.
6. Oyelese Y, Smulian JC. Placenta previa, placenta accreta, and vasa previa. Obstet Gynecol (
2006;107(4): 927-41.
as determined by the patient's provider. {Last revised December 2006) (
( MFM Protocol 27
Management of third trimester bleeding

with suspected placental abruption
(
Admit, record vs; start iv. fluid, NPO
CBC, coagulcgram, cross matching
( Assess maternai & fetal conditions
U/S for detection of alruption (not R/O if normal finding)
(
t t
Other causes of bleeding Suspected or proved
(
..I
placen'I Abruption
( Rx causes
. GA < 34 wks
.
Mi>nitor - maternal condition
•
GA ~ 34 wks
I
l
Dead fetus
+
Beware of
( · - fetal condition coagulopathy
( Reassuring fetal condition Non-reassuring fetal condition

and or
No maternal complication Maternal complication
( l
Continue pregnancy ..
Resuscitation to stabilize patient
• Beware of further abruption • Termination of pregnancy

• Closed fetal monitoring
( • Consider corticosteroid
I
C/S
l
• Vaginal route (prefer)
(as OB indications) • Rupture of-membrane as early as possible
( • Continuous fetal monitoring (for alive fetus)
c
( ± oxytocin use caution)
( i
Vaginal delivery
( Reference:
1. Cunningham FG, Leveno Kl, Bloom SL, Hauth JC, Gilstrap III LC, Wenstorm KD, editors. Williams
2. Oark SL. Placenta previa and abruptio placentae In: Creasy RK, Resnik R, editors. Maternal-fetal
medicine. S"' ed. Philadelphia: Saunders; 2004. p. 707-22.
3. Deering SH. Abruptio placentae. 2005. Available from:
htto://www .emedicine.com/med/topic6.htm.
4 . Oyelese Y, Ananth CV. Placental abruption. Obstet Gynecol 2006;108(4): 1005-16.
(
( MFM Protocol 29
( Uterotonic drugs
Drugs Preparation Dose Maximum caution

(
a. 10 units im.,
Oxytocin: repeat if necessary For iv. bolus :
( siintocinon® 10 iu/ml b. 10-40 units in NSS - hypotenslon,
500-1000 ml iv. infusion • ar'rhythmia
rate 125 ml/hr
( Ergometrine :
0.2 mg/ml
0.2 mg im. (preferred) Repeat up to 5 doses Transient
Methergin® c
or iv. caution q 2-4 hrs hypertension
( Prostagalndin E2 :
a. 500 µg im. or
intramyometrially
a. Repeat up to
3 doses q 15 min Avoid in
Sulprostrone 500 µg/amp b. 500 µg in NSS 250 ml b. 330 d/min; . Bronchial
( (Nalador®) iv. infusion in 30-120 min
(40-160 d/min)
total dose 1,500 µg
in 24 hr
asthma
Hisoprostol: 0.8 - 1 mg (4 - 5 tabs)

( Cytotec~
200 µg/tab
rectal suppository
- -
( Reference:
( 2. Bowes WA Jr, Throp JM Jr. Oinical aspects of normal and abnormal labor. In: Creasy RK, Resnik
R, editors. Maternal-Fetal Medicine: principles and practice. S"' ed. Philadelphia: Saunders; 2004.
p. 678-9.
( 3. Royal Women Hospital CPG 2005. Primary postpartum hemorrhage: management. Available
from: www.rwh.orq.au/emplibrarv/rwhcpq/Manaqement of pph.odf.
4. American College of Obstetricians & Gynecologists. Postpartum hemorrhage. ACOG Pract Bull
2006;(47).
5. Rogers MS, Chang AMZ. Postpartum hemorrhage and other problems of the third stage. In:
James DK, Weiner CP, Steer PJ, Gonik B, editors. High risk pregnancy. 3"' ed. Philadelphia:
( Sauders; 2005. p. 1559-78.
6. Dildy III GA. Postpartum hemorrhage: New management _option. Clin Obstet Gynecol
2002;45(2):330-44.
( 7. Smith JR. Postpartum hemorrhage. Emedicine from WebMD. Last Updated: June 13, 2006
Available from: www.emedicine.com/med/topic3568.htm.
(
(
(
c
.{
(
(
( as determined by the patient's provider. (last revised December 2006)
MFM Protocol 28
(
Manaa~~:~--~~!'~~~um hemorrhage . fi (
• call for help
• V/S check
• Uterine massage
• Uterotonic drugs: Ergometrine/Oxytocin/Prostaglandin E,/F2•
• Retain urinary catheter (
t
Resuscitation
• Insert large bore iv. (;,16g)
• Crys"..alloid inf1.1si'Jn (0.9% NSS or LRS)
+ colloid < 1,500 ml in 24 hr
c
• X-match ± coagulogram, CBC platelet, BUN, E1yte (
• call anesthetist
• Continue measure blood loss
• Fluid balance chart
(
t
Assessment
TONE: TISSUE: TRAUMA: THROMBIN:

(
Assess uterir.e Placenta check Birth canal & Coagulopathy
conti;action uterine q-auma check or bleeding disorders (
t .-=--.YES
f :
Utenne
T
Bimanual
GoodV
at~ny . contra~vered ~
. . ,.
Work up
Complete
Incomplete
delivered
. ed
Uncertain
Tear
B'rthf
1 cana I
c ~leeding ru~ture
T
Suture
T
Laparotomy
f
Uterine
invepion
T
Uterine
Uterine
for other
t
Nb
Work up
l
uterine for other causes for suture replacement causes Blood
compression Explore uterus or hys"..erectomy component (
+ U~rotonics or ' r e replacerent
(
Resptnse Rx Fail to ,Jponse Rx
+ +.
Observe dinical Bleeding continues (
Routine postpartum care t
Transfer to OR
t (
Continue resuscitation
• ABC (Airway/Breathing/Orculation)
(
•
i
Continue replace fluid (volume expander+ blood components)
• Uterine massage Repeat uterotonics {if not already repeated)
Optional.· (
i
.,,_!""""
.t
.""'"'"'?· -
t
. . - - - - . - • Laparotomy
Optional:
• Uterine artery ligation
• Internal iliac artery ligation
(
(
Response Rx* Not Response • IHynch suture
+
• Leave for 24 hrs.
• Antibiotics iv.
• Uterotonic infusion
or Failed Rx**
+
·1 (
Transfer to ICU.
Remarks: * Response Rx = bleeding immediately stop after procedure

** Not response or failed Rx = bleeding decrease or continue after procedure
MFM Protocol 30
Management of Rh D negative (
.
Rh D negative mother
Father's Rh blood gr.(serotype & genotype)

(
Rh D negative Rh ~positive (
...
No further management Maternal Anti D titer (Indirect Coombs' test)
U/S: GA, siQ9s of hydrops fetalis (
Ne/ative
t
Td:er ff. 1:1:---:::::::Titert<: 1:16
f.
signst f
hydrops fetalis
Give Anti-D IgG 300 11g im. * F/U titer t Optional~
- @ GA 28 wks q 2-4 wks Amniocentesis OR Paternal genotype
- when potentially sensitize events for ' (if available) (
o Invasive PND
o External cephalic version
' fetal genotype
(PCR) ·
"' t
Heterozygous
t
Homozygous
0 2"", 3"' trimester bleeding t I t (
Rh D negative fetus Rh D positive fetus
+
Routine care & No further Rx (
Serial amniocentesis •
for A po.,.,
Ser.al MCA Dopplers
q2wk
(
•
Liley rorve
t
Liley rorve If MCA peak systolic velocity
+ (
- Zone 1: repeat 2-4 wk : Upper zone 2 or 3 - > 1.S MOM
- Low zone 2: repeat 1-2 wk OR or-> 9S%
Quenan rorve : intrauterine (
•
transfusion zone
Fetal bkxx! sampling .-----~-----'
~------Fetal
t
Hct <: 30%
t
Fetal Hct < 30%
t I
't
(
Delivery at term
t
Immediate
.
<: 3S wks
Delivery
< 3~wks
Blood transfusion
(
newborn, blood group for Rh - Keep Hct <: 30%
• t - Group 0, Rh negative
Rh D negative Rh D positive - 30-100 a;/ each transfusion
... ... - Give q 1-2 wks, then 3-4 wks (
No further
management
Anti-D IgG 300 119 im.
wittlin 72 hrs.•
Mother: Kleihauer Betke
.
- Stop after GA~ 3S wks
. ...
Delivery at GA 37 wks (
(add elution) test**
or Direct coombs' test Newborn: Direct coombs' test
+
or Rosette .test Bilirubin, Hb, Hct
Newborn: Direct coombs' test
!lilirubin, Hb, Hct
~: (
- * UK: 100 119 (SOO IU) at GA 28 wks, 34 wks & after delivery
Anti-D IgG SO 11g im. in case of 1" trimester abortion, ectopic pregnancy & 1" trimester procedure.
- • If there is likely to be severe fetal anemia or hydrops before 27 wks 7 fetal blood sampling (
- 11 Half-life of Anti-D IgG is 24 days: if delivery occurs within 3 Wks after 1" dose of Rh IgG,
postdelivery dose may not be administered.
- ** SO 11g Anti-D IgG protects 2.S ml. of retal rbc or S ml. of whole blood (if fetal Hct SO%) (
Maternal blood volume (MBV) " S,000 ml. in normal-sized normotensive women at term
Fetal blood volume MBV x maternal Hct x % fetal cells in KB
in maternal drculation Newborn Hct
as detennined by the patient's provider. (Last revised December 2006) (
(
( MFM Protoccol 31
( Reference:
Obstetrics. 22"' ed. USA: McGraw-Hill; 2005. p. 661-72.
( 2. Moise KJ Jr. Hemolytic disease of the fetus and newborn. In: Creasy RK, Resnik R, editors.
Maternal-Fetal Medicine: principles and practice. s"' ed. Philadelphia : Saunders; 2004. p. 537-161.
3. Harkness UF, Spinnato JA. Prevention and management of RhD isoimmunization. Clin Perinatrnl
( 2004:31; 721-42.
4. American College of Obstetricians & Gynecologists. Management of alloimmunization during ·
pregnancy. ACOG Prac Bull 2006;(75).
(
(
(
(
(
(
(
(
(
(
These guidelines are designed for general use for most patients but may need to be adapted to meet the special needs of a specific patiient
( as determined by the patient's provider. (Last revised December 2!006}
( Mm Protorol 33
( Reference: .
Obstetrics. 22"" ed. USA: McGraw-Hill; 2005. p. 911-48. .
( 2. Malone FD, D'Alton ME. Multiple gestation. In: Creasy RK, Resnik R, editors. Maternal-Fetal
Medicine: principles and practice. 5"' ed. Philadelphia: Saunders; 2004~ P• 513~36,
3. American College of Obstetrk:ians & Gynecologists. Multiple gestation: Corilplid;ited twin, triplet,
( . and high-order multifetal pregnancy. ACOG Pract Bull 2004;(56).
4. Clin ObstetGynecol 2004;47:118-273.
(
(
(
(
(
(
(
~determined by the patient's provider. (Last revised December 2006)
MFM Protorol 32
(
,1fE,~llil- . . (
:- Detennine Zygosity: suggestive dichorion of U/S finding if presence of
- 2 separated GS @ GA < 8 wks
- Membrane thickness ~ 2 mm
- 2 separated placentas
- Twin-peak or Lambda sign (in 1" trimester)
- Different gender of fetuses
- Awareness regarding potential complications
• Anemia : need 60-100 mg element iron + 1 mg folic supplement/ day a (
• Pretenn labor, preeclampsia
- Fetal surveillance- Early U/S
- Serial U/S q 4 wks, or q 2 wks in case of IUGR or growth discordance
- NST/FAS ± BPP weekly: same as indicated In singleton
(
- All twin fetuses should be delivered by GA 40 wks
- Counseling for increase risk of fetal Down syndrome if maternal age <? 33 years'
(
Twin pregnancy
+
U/S confinnation of fetal pri;sentation, EFW & AF volume
Notify anesthetist & pediatricians
(
Counseli ssibili of risk
Vx/Vx Non-V,xJNon-Vx l
•
Vaginal
delivery
< 2ltks
..
"l
<? 28 wks
(
Vaginal delivery
Evaluate if 2"' twin
1. significantly larger in size than 1" twin
2. estimated weight < 1,500 g
3. other C/I for vg. breech delivery
OR 4. no available of skilled obstetrician (
5. no available immediate anesthesia
6. other OB indications for C/S
(
NO YES
+
Progression of labor (
t I t
YES NO--+ Uterine dysfunction C/5
' t or other OB indications
Vaginal delivery of 1" twin
U/S: Detennine t1resentation of 2"' twin
Fetal heart rate monitoring (
+ Abdomjnal & PV exam
•
1
2,J twin 2"" twin
longitudinal lie transverse lie
l
vaginal
Delivery
External cephalic version of 2"" twin
Sufstu1
Vaginal
• uns{c:esstu1
Attempt internal podalic version
delivery or C/S
Remarks : Placental examination is required after delivery (may help for determination of zygosity) I
\
These guidelines are designed for general use fur most patients but may need to be adapted to meet the special needs of a specific patient
as determined by the patienrs provider. (Last revised December 2006)
MFM Protooof 3'1
(
Anti-HIV +ve in pregnancy (
Pregnancy (
I
+
Anti-HIV +ve (after confirmed & counseling)
. .. . +
No ANC, Unknown Anti-HIV
f Present @ term or in labor
t
Disease
..
Detection all" ANC
c
Bl.: CD4, CBC pit., BUN, Cr,
NoANC
Present @ term or in labor
AST, ALT, VORL, HBs Ag
CD4 < 200

t •
CD4 ~ 200
+
rapid anti-HIV
or abn. LFTt~ 2 1~1 & all o er lab.=O.K. screening
consult Inf. Med.

orHct < 30%
CPD. f!nilih <ll·f-----.

Regimen A
AZT
Start medication
@ 28 wk5 RegimenB
or later if late ANC AZT+3TC
counseling n+ve -ve
\
1 counseling ~
ti
ConsiJ start
specific Rx & planning
by Inf. Med.
If
Abnormal •
Lab./Oinical
ic
AsSess- CBC pit q 1 mo
@ 34 wks
+ve in rm
i
. ANC High risk dinic
- la!:: II (except anti-HIV)
- CD4, BUN, Cr, AST, ALT
-ve
(
Regimen A•
Intrapartum
I "Intrapartum
Regimen B Regimen A
Intrapartum
Normal care
&ANC
(
AZT + NVP Az:r + 3TC AZT+ NVP
Intrapartum: /fQ AROM Fetus: !fQ NG tube suction

(
!fQ Internal fetal monitoring Delivery ( ± elective C/S) · Gentle mouth suction
Avoid 08 operative procedures :i: TR (Except resuscitation is needed)
/fQ wt K Injection @ LR
Regimen A Regi111enB
t I •
+ ...
Baby
Mother Baby Mother
... ... ... ...
No medication AZT 4-6 wks r:Jo medication AZT4-6 wks
i + NVP tngle dose
i i
F/U Inf. Med. F/U Inf. Ped. F/U Inf. Med. F/U Inf. Ped.
~= Az:r = Zudovidine Inf. Med. =Infectious medicine

NVP = Nevirapine Inf. Ped. =Infectious pediatrics (
3TC = Lamivudine
(
(
as determined by the patienrs provider. (Last revised December 2006) (
(
( MFM Protocol 35
( Medication
( Regimen Drug 11.,bo~~ · Administration Note
Regimen A
( AZT(HiO mg)
..
2. cap oral pc dh & 3 cap oral pc 11!u
• Antepartum
or AZT(250 mg) 1 cap oral bid pc
( AZT(iOci mg) 3 cap oral stat then AZT(lOO mg)
• Intrapartum
plus NVP(200 mg) 1 tab oral stat 3capq3hr
( • If false labor . New NPV @ trµe labor(apart from 1" dose > 48 l)r)
Atr(lOO mgj •· 3 cap oral 4 hr before surgery
( • If elective C/S
NVP(200 riig) 1 tab oral 4 hr before surgery
.
N_YP 2.mg/kg : : ::·:: oral siiigle dose
( • Fetus
. i#11S Air ~P i mgikg Ci(al q 6 hrs for 4-6 wk
Regimens ·
( ,Atf(lQO mg) 2 cap oral pc 1'ih & 3 cap oral pc 11!u
• Antepartum or AZT{2SO mlJ) 1 cap oral bid pc
( plus3TC (lSO mg) · 1 tab oral q .1 2 hr
AZT(lOO mg) . 3 cap oral stat then repeat doses{ both)
( • Intrapartum
plus 3TC (150 mg) 1 tab oral stat q 3 hr
AZT(lOO. mg) 3 cap oral 4 hr before surgery
• If elective C/S
( p/us3TC(150mg) :· ' 1 tab oral 4 hr before surgery
•Fetus AZT syrup 2 mg/kg oral q 6 hrs for 4-6 wk
(
{
(
(
(
(
(
(
(
( as determined by the patient's provider. (Last revised December 2006}
I..
(
( MFM Protocol 37
( Reference:
( 2. Gibbs RS, Sweet RL, Duff WP. Maternal and fetal infectious disorders. In: Creasy RK, Resnik R,
editors. Maternal-fetal medicine. 5th ed. Philadelphia: Saunders; 2004. p. 760-2.
3. American College of Obstetricians & Gynecologists. Rubella and pregnancy. ACOG Pract Bull
( .1992;(171).
4. CDC. Control and prevention of rubella: evaluation and management of suspected outbreaks,
rubella in pregnant women, and surveillance of congenital rubella syndrome. MMWR 2001;50
(RR12):1-23. Available from: http:l/www.cdc.gov/mmwr/prevjew/mmwrhtml/rr5012al.htm.
5. Morgan-capner P, Crowcroft NS. Guidelines on the management of, and exposure to rash illness
in pregnancy (including consideration of relevant antibody screening programs in pregnancy).
( Commun Dis Public Health 2002;5(1) :59-71.
(
'
(
(
(
(
(
(
(
(
(
(
(
(
as determined by the patient's provider. · (Last revised December 2006)
r
MFMProOOoo136 \
Management of rubella in preanancv
..~~rnl!fi~';i't.i:;1J1~llr
_F!'efi~IMlfa'.~~tll.~i:::--m1~~~~~g!1/;l11lilM:W~f-,~"J~~~~~
~m~!lt~~~ll!b~~ ~~~~{Q~~~l~~--~~
r'
\
Pregnant woman EXPOSED to rubella infection (no dinical)
1
History wittfdorumented Unknown imtune

1
status
of im,runity Exposure+:!> 30 days Exposuret> 30 days

Reassure, no infection (
r \
IgG -ve IgG +ve IgG -ve IgG -ve lgG +ve IgG +ve
IgM -ve lgM '-lie IgM +ve lgM -ve lgM +ve IgM-ve
+ +
__J
+ + + +
No prior Prior infection Possible Reassure Recent 1nco!us1ve
infection · Immune recent recent No Infection (aarte)
& Susceptible Infection Infection infection (
\
to rubella Repeat testing Refer to MFM

~ within 1-2 wk . for counseling
Repeat testing within · (
2-4 wk:j after contact
...
IgG -ve
..
IgG -ve or +ve
t 4 times IgG
Confirmed Diagnosis of
... · (
IgM -ve lgM +ve --+Recent (acute) rubella infection
+ +
No recent
rubella Infection
Counseling potentiai risk of
congenital rubella infection In fetus
(
~: If rash develop - refer to patient crash illness protocol.
Pregnant woman with rash or dlnlcal suspicious of rubella Infection

+
[ • Possible viral culture (if available)]
• Rubella lgG* (ELISA) [IU/ml]
• Rubella JgM (ELISA)
IgG vef
IgM ;-ve
lgG 'tie
IgM ;-ve '
IgG-vlor
IgM +ve
+ve
c
•
If serum taken
..
If serum taken
•
If serum taken
..
If serum taken
+
Most likely
within 10 days > 10 days within 10 days > 10 days Recent rubella infection
after rash onset after rash onset after rash onset after rash onset I
+
Rppeat +
within 1-2 wkf Repeat w1·th+. 1
·n 2-3 wks
1
+ 2-3 wks
Repeat within iI {
f 't f t •
Not recent ...
+
Stable t 4 times lgG Stable IgG +ve or -ve lgG -ve+ infection t 4 times IgG
+ ~ i
lgM +ve lgM -ve (No immune) + ( I
~----------~ Confirmed Diagnosis of
·t · - --------------
Not recent condusive
(r~:~~) Recent (aru+) infection
Refer to MFM Counseling potential risk of
for counseling congenital rubella infection in fetus
Remarks (
* Paired serum lgG are marked in the request forms and used for interpretation.
- lgM may not be detectable before day s after rash onset and dedine at 6°" wks.
c
False +ve IgM: persons parvovirus infections or +ve heterophile test (indicating infectious (
c
mononucleosis) or +ve rheumatoid factor.
- If the investigation were late (2: 6 wks after onset of rash), the presence of IgG with -ve lgM could
not tell whether there is recent, past infection or immunization.
PMK lab. interpretation: serum IgG (ELISA) +ve = 2:10 IU/ml; -ve = < 10 JU/ml
These guidelines are designed fur general use for most patients but may need to be adapted to meet the special needs of a specific patient
MFM Protocol 38
(
Management of herpes simolex genitalis in pregnancy \
Take Hx@ 1" ANC: (

- previous genital HSV infection
- sexual partner's Hx of genital HSV infection
YES NO
t (
1
Advise condom use
± abstinence or avoid sex during pregnancy
t 1"-episode genital HSV infection
Recurrent genital HSV infectior.
I I
+
Not in labor
++
@ delivery/ir1 labor GA ~ 36 wks GA 32 -< 36 wks GA<32 wks
i i
l
+I 'tt It "
I
Supportive Rx consider PROM No ROM PPROM

± antiviral Rx* antiviral Rx* 1 + +I
+ daily suppressive ... consider (
consider
1. active lesions @ birth canal
(cannot cover during vaginal delivery)
or 2. prodromal symptoms
in last 4 wks
of pregnancy
+-------i
I
qs antiviral Rx* counseling
7-14 days risk & benefit
1 ·
(
I If in labor or (
f t indications Optional: Expectant Rx
YES NO for delivery +Antiviral Rx*
qs
t
Vaginal delivery
.. t ± Antibiotics (for PPROM)
' - - - - - - - continue monitoring
(
regardless of ROM carefully draped maternal & fetal conditions
(If opt for vaginal delivery try to cover all lesions
= avoid invasive procedure)
(
Viral shedding
o 1" episode primary genital herpes infection = 1" 3 months after lesions healed (HSV-2)
o Recurrent genital herpes infection = 3-5 days (average 1.5 day) (
*Antiviral Rx: - Acyclovir 200 mg oral 5 times a day or 400 mg oral 3 times a day for 7-10 days
· - Daily suppressive Rx: 400 mg oral twice a day
(
- Recurrent HSV Rx: Acyclovir 400 mg oral 3 times a day for 5 days \~
Postnatal can!: - Avoid direct contact between lesions & neonate.
- Precaution of hygiene care.
- Breast feeding is not contraindicated unless obv~ous lesion @ breast(s).
Reference: .
1. Cunningham FG, leveno KJ, Bloom SL, Hauth JC, Gilstrap III LC, Wenstorm KD, editors. Williams (
Obstetrics 22"" ed. USA: McGraw-Hill; 2005. p. 1307-10. \
2. Gibbs RS, Sweet RL, Duff WP. Maternal and fetal infectious disorders. In: Creasy RK, Resnik R.
editors. Maternal-fetal medicine. 5"' ed. Philadelphia: Saunders; 2004. p. 766-8.
3. American College of Obstetricians & Gynecologists. Management of herpes in pregnancy. ACOG
(
4. CDC Sexually Transmitted Diseases Treatment Guidelines 2006. MMWR Recommendation &
Reports. 2006;55(RR11):16-20. Available from: htto:llwww.cdc.gov/std/treatment/.
(
5. Royal College of Obstetrics and Gynecology (RCOG), Oinical green top guidelines. Management
of genital herpes in pregnancy. Number 30, March 2002.
6. Prevention of perinatal Herpes: prophylactic antiviral therapy? Oin Obstet Gynerol;42(1):134-48.
7. Ascher R. Genital Herpes in pregnancy. Last Updated: April 11, 2006. Available from :
htto:llwww.emdicine.com/med/topic3554.htm.
8. Herpes genitalis. Available from : htto:llwww.fuOotebook.com/ID205.htrn.
as determined by the patienr s provider. (Last revised December 2006)
(
( MFM Protocol 39
Management of syphilis in pregnancy
( Suspected
primary chancre lesion
Oinical suspected
secondary syphilis
VDRL screening
(1" visit & 32-34 wks)
t -+
( 'f
Dark-field microscope
I t
VDRL
Positive N;,gative---+VDRL-----l-1-----------~
If non-reactive
( repeat within 2 wks
( Non-reactive Reactive
eTPHA +ve
Reactive
cTPHA-ve
Initer ·:5 1: 4 + - - - - ;
c proved Hx of Rx Work up for
t
( & no risk of recurrence • Hx taking other systemic diseases
( l
Normal ANC
See remark*
t & partner's bl. VDRL
Partner's VDRL reactive-+ Rx

cTPHA+ve
-+
(
<!~dr
• > 1 yr duration • Neurological symptoms or signs
• Unknown duration • Evidence of active tertiary syphilis
(
i (aortitis, gummas, iritis)
• Concomitant HIV infection
(
Benz Pen G 2.4 mu im.**
(1.2 mu e~ch buttock)
I
Benz Pen G 2.4 mU
im. weekly x 3
I
i
• Consult infectious medicine
• CSF for VDRL, Cf"
count, protein
(
..
Decrease titer
MontljlyVDRL
t
• Persistent titer
NJative
or not done
Positive: pl!cvrosis
t protein ,level
( till non-reactive • 4 folis rising titer i & VDRL-.ctive
(
(
l
Normal ANC
+
Rx fC1ilure---~ Benz Pen G 2.4 mU
im. weekly x 3
t
Monthly VDRL.1-------~
( ± CSF study postpartum)
Aq. Pen G 3-4 mu iv.
q 4 hrs for 10-14 days**
(or alternative Rx')
F/U VDRL q 3 mo I
(
till 12 mo. postpartum +
• Persistent titer Decrease titer
• 4 folds rising titer till non~reactive
t
( Consult infectious medicine F/U VDRL q 3 mo till 12 mo,
then @ 18 & 24 mo or non-reactive
~=
- * Repeat bl. VDRL within 1 mo, if still ,;1:4-> no Rx & F/U VDRL q 3 mo; if t titer-> Rx
- ** Recommend 2"" dose (1 wk later) after initial dose Rx, esp. In women Ir. 3"' trimester or
( with secondary syphilis
- •Alternative Rx: Procaine Penicillin 2.4 mU im. OD. + Probenecid 500 mg. oral qid for 10-14 days
- If history of allergy to penicillin, use either 1 or 2 (individual judgment after counseling risk & benefit)
1. Use erythromycin sterate for Rx & infant should be treated postpartum.
2. Penicillin desensitization before giving penicillin Rx (consult immunology for intervention)
(
(
( MFMProtocol41
( Management of STDs in pregnancy
( Disease Drugs
( Gono"hea
• Unfomplicated Ceftriaxone 125 mg im. single dose
(ex, urethra, rectum) Cefixime 400 mg oral single dose
or Spectinomycin 2 g im. single dose
( (Plus Rx of chlamydia! infection unless it is R/O)
• Disseminated Recommended: Ceftriaxone 1 g im. or iv. q 24 hrs for 24-48 hrs
Alternative : Cefotaxime or Ceftizoxime 1 g iv. q 8 hrs for 24-48 hrs
( or Spectinomycin 2 g im. q 12 hrs for 24-41! hrs
After improvement: follow by Cefixime 400 mg oral bid to complete 7 days
•Meningitis Ceftriaxone 1-2 g iv. q 12 hrs x 10-14 days
( • Endocarditis Ceftriaxqne 1-2 g iv. q 12 hrs x 30 days
Non-gonococcal Recvm~ed:
( Azithromycin 1 g oral single dose
Amoxydllin 500 mg oral tid x 7 days
Altemative :
( Erythromydn base 500 mg oral qid x 7 days
Erythromydn base 250 mg oral qid x 14 days
( Trichomoniasis Metronidazole 500 mg oral bid x 7 days or 2 g oral single dose

(PMK: use 400 mg oral tid x 7 days or 2 g oral single dose)
( Chaneroid Azithromydn 1 g ornl single dose

Ceftriaxone 250 mg im. single dose
Erythromydn base 500 mg oral qid x 7 days
(
Vaginal amdidiasis Clotrimazole 100 mg vg supp. x 6 days or 2 tabs vg supp. x 3 days
Nystatin 100,000 u 1 tabs vg supp. x 14 days
( Bacterial vaginosis Metronidazole 250 mg oral tid x 7 days or 500 mg oral bid x 7 days
(PMK: use 400 mg oral bid x 7 days)
( Oindamydn 300 mg oral bid x 7 days
Metronidazole gel 0.75%, 5 g intravaginally OD x 5 days
Clindamydn cream 2%, 5 g intravaginally @ bedtime x 7 days*
(
~: * Use only in 1" half of pregnancy
( Reference:
( 2. Gibbs RS, Sweet RL, Duff WP. Maternal and fetal infectious disorders. In: Creasy RK, Resnik R,
editors. Maternal-Fetal Medicine: principles and practice. S"' ed. Philadelphia : Saunders; 2004.
p. n6-89.
( 3. CDC Sexually Transmitted Diseases Treatment Guidelines 2006. MMWR Recommendation &
Reports. 2006;55(RR11):1-100. Available from: http://www.cdc.gov/std/treatrnent/.
(
,{
(
(
t These guidelines are designed for general use for most patients but may need to be adapted to meet the special needs of a specific. patient
(
MFM Protocol 40
(
Reference: (
2. Gibbs RS, Sweet RL, Duff WP. Maternal and fetal infectious disorders. In: Creasy RK, Resnik R,
editors. Maternal-Fetal Medicine: principles and practice. s"' ed. Philadelphia : Saunders; 2004.
p. 772-6.
3. CDC Sexually Transmitted Diseases Treatment Guidelines 2006. MMWR Recommendation & (
Reports. 2006;55(RR11):22-35. Available from: htto:/lwww.cdc.gov/std/treatmenti.
4. Obstetrics Guidelines: Syphilis: diagnosis and management in pregnancy. University of Illinois
Medical Center. Reviewed: July 2004.
5. Perinatologist Corner - C.E.U/C.M.E. Modules, Maternal Child Health - American Indian and Alaska
(
Native. Syphilis in Pregnancy. Available from:
ht!D:/lwww.jhs.gov/MedicalProorams/MOl/M/Syohpreg.cfm.
6. Cerrato P. Updating the CDC's treatment guidelines: Syphilis. Contemp Ob Gyn 2004;3:82-104.
(
( \
( ')
(
(
(
( '\
(
(
(
(
(
(
These guidelines are designed for general use for most patients but may need to be adapted to meet the special needs of a specific pabent
(
(
MFM Protocol 42
(
Management of hyperthyroidism in pregnancy (
f • (
Maternal Fews
Initial Rx: - PTU 100-600 mg/d U/S ± Fetal ecnocardiography
(or methimazole* 10-40 mg/d) • Establish correct GA (
- fl-blocker • Beware of IUGR, fetal goiter, CHF, stillbirth
(propanolol 20-40 mg x 3/d)
(
Caution: Beware of agranulocytosis - - - - - -
(CBC if fever + sore throat)
Agranulocytosis
+
Maon~lylFT"'1 FTtio~' TSH s !... . (
&
1
irnca eva' a n
Normal TFT in 6-8 wks

top mr1cation
• Consult internal medicine for evaluation (

(keep FT4 in high normal range) • Consider thyroidectomy
Clinical euthyroid (2"" trimester, after 2 wks of Iodine Rx)
...
! dose of PTU < 300 mg/d
(
(May be discontinued before delivery till postpartum)
~:
(
• * Report fetal anomaly: cho<:nal atresia, T-E fistula, facial anomalies, aplasia cutis.
• If PTU 2: 600 mg/d, breast-feeding should be withheld.
(
Management of thyroid stonn
Dx: dinical - fever, tachycardia out of proportion to fever,

change mental status, vomiting, diarrhea, " arrhythmia
(Possible precipitate by PIH, anemia, sepsis, labor)
+ (
Serum FT., FT3, TSH
BUT Rx should not be withheld pending the results
+ .
PTU 1 g oral stat -+then 150-200 mg oral q 6 hrs
(
...
1 hr later (
•Sodium iodide 500-1,000 Jg iv. q 8 hrs ,
or supersaturated solution of potassium iodide (SSKI) 2-5 drops oral q 8 hrs (
or Lugol's solution 10 drops oral q 8 hrs
(Hx of iodide -induced anaphylaxls-+ lithium carbonate 300 mg oral q 6 hrs)
• Dexamethasone 2 mg iv. q 6 hrs x 4 doses (
• fl-blocker (propanolol, labetalol, esmolol) for control tachycardia
•N.fluid
• Control fever
• Rx of the perceived underlying cause
(
Remarks: (
m1 Rx: • Pregnancy should be postponed 6 months after mI Rx.
• Contraindication in pregnancy, especially after 10-12 wks
• If 1311 was used, Rx: SSKI + PTU in 7-10 days after exposure. (
These guklelines are designed fur general use for most patients but may need to be adapted to meet the special needs of a specific patient
as derermined by the patienrs provider. (Last revised DeCl!mber 2006)
(
(
( MFM Protocol 43
( References:
Obstetrics 22"" ed. USA: Mcgraw-Hill; 2005. p. 1189-98.
( 2. Nader S. Thyroid disease and pregnancy. In: Creasy RK, Resnik R, editors. Maternal-fet.al
3. American College of Obstetricians & Gyn!!CC>logists. Thyroid disease in pregnancy. ACOG Pract Bull
( 2002;(37).
4. AAC£. Thyroid Guidelines. Endocr Pract. 2002:8(6):457-69..l\vailable from:
htto://www.aace.com/clin/guidelines/hyoo hyoer.odf.
5. Nguyen PH. Autoimmune thyroid disease and pregnancy. Available from:
( htto://www.emedicine.com/med/topic.
6. Clinical practice guideline: Investigation and management of primary thyroid dysfunction. Available
from: htto://www.topalbertadoctors.org/NR/rdonlyres/88147592~AE5D-4CAB-B77D-
( 502E6C7CFOB9/0/thyroid guideline.odf.
("
(
(
(
(
(
(
(
(
(
(
(
( MFM Protocol 45
( Management of heart disease in pregnancy
( Detection / known of heart disease @ prenatal care
Assess - Underlying cardiac lesii ( ± echocardiography) & medication use
( By co-,evaluate & proper Rx cardiologistc

- Functional class assessment: FC (NYHA)
- U/S for confirm GA & fetal assessment
( Contraindication No contraindir.ation
'f for P'T!Jnancy 't . ~for
pregnancy
( GA within 1" trimester GA 2"" - 3•• trimester
(
Tenninationt f pregnancy ~ Continue pregnancy
(After counseling risk) .t
+ proper contraception 4 • Counseling possibility of risk
• ANC high risk dlnlc
( • Assess:
- Risk factors of heart failure:
anemia, arrhythmia, infection
( Assess whether patient - Clinical of heart failure, FC & medication Assess whether
ccongenital heart disease? • U/S assess fetal growth q 4 wks anticoagulant use?
'f I 't & fetal well-being @ ~ GA 32 wks 'f I 't
(
• •
YES NO NO YES
• Counseling risk of • Counseling teratogenic effect

congenital heart disease in fetus & possibility of risk
• Consult pediatric cardiologist • Consult hemato!ogist
for fetal echocardiography for co-evaluate & proper Rx
( @GA i0-24 wks
Plan for labor & ·delivery
@GA36wks
( • Consult anesthetist for plan of proper anesthetic method during labor
• Consult cardiologist for plan of any specific intrapartum management
• Plan for labor induction @ term is preferable during work day time
• Elective qs for OB indications & maternal conditions
(
+
Intrapartum
( • Monitor VS q 1-2 hr, beware of heart failure
• Semirecumbent position wlth lateral tilt
• Notify cardiologist for co-evaluate & proper Rx
( • Adequate analgesia or epidural anesthesia
• Neither oxytocin Iv. bolus nor ergotamine iv.
• Bacterial endocarditis prophylaxis 30 min. before delivery**
( Vaginal detery F/E c
or qs for OB indication
(
( • Not recommend epidural anesthesia in:
- Women with intracardiac shunts, in whom flow may be reversed (right to left within heart or aorta):
pulmonary hypertension, Eissenmenger's syndrome, aortic stenosis1•2, hypertrophic subaortic stenosis2
.{ - Controversy for hypertrophic obstructive cardiomyopathy' ( = C/I for spinal analgesia)
- Complex cyanotic congenital heart disease: TOF, Ebstein's anomaly, etc. ,_,
- Coarctation of aorta
(
( (continue next page)

as determif!ed by the patient's provider. (Last revised December 2006)
(
MFM Protocol 44
(
Management of liver disease in pregnancy
Clinical suspected of liver disease
Blood LFT ± Hepatitis profile*

1
(
Consult GI. Med. 'f f ..
tor co-evaluation -ve HBsAg +ve Other types
& proper Rx 14-------- R/O viral hepatitis I
,.::---------:i
of hepatitis
... (
Passive & Active Consult GI. Med.
ALT> 1,000 U/L
Exdute Toxin
..
ALTS 1,000 U/L
Review clinical context

Immunoprophytaxis
of newborn
( ± partner's
for evaluation
& proper Rx
(not emergency)
(
(e.g. acetaminophen overdose), & GA @ development hepatitis B profile)
hypotensive episode,
(
liver infarction or rupture
I
+
Fever, leukocytosis, RUQ pain
with or without jaundice
I
•
• Preeclampsia associated
with hemolvsis, DIC,
thrombocytopenia
i
• Associated
renal failure,
(
(
•
hypoglycemia, DIC
t t t
NO YES Consider HELLP Consider acute fatty liver
(
+
I
i Syndrome
(common in late
of pregnancy
(common in 3"' trimester)
Exdude
drug-induced
liver disease,
•New onset
pruritus
t
RUQU/S 2"" -3"' trimester)
I I (
hyperemesis Intrahepatic Attempt prtmpt delivery
gravidarum cholestasis & Beware of coagulopathy
of pregnancy Exclude cholelithiasis
(common in or liver abscess
3"' trimester) (
~=
* Recommended serological tests:
Hepatitis A IgM, Hepatitis B surface Ag (HBs Ag) & hepatitis B core Ab (HBc Ab),
Hepatitis C Ab, CMV IgM, HSV IgM, & Epstein-Barr virus IgM
(
References:
(
2. Landon MB. Diseases of the liver, biliary system and pancreas. In: Creasy RK, Resnik R, editors.
Maternal-fetal medicine. S"' ed. Philadelphia : Saunders; 2004. p. 112~-45 .
3. American College of Obstetricians & Gynecologists. Viral hepatitis in pregnancy. ACOG Education
(
Bull 1998;(248).
4. Bacq Y. Approach to liver disease occurring during pregnancy. Up-To-Date version 1.4.3. [updated (
2006 August 17; cited 2006 Nov 20]. Available from: htto:l/www.uptodate.com.
5. Hunt CM, Sharara AI. Liver disease in pregnancy. Am Fam Physic 1999. Available from:
www.aafu.org/afp/990215ap/829.html.
(
(
(
as determined by the patient's provider. {last revised December 2006)
(
MFM Protocol "6
(
- Standard regimen for high risk group
Ampicillin 2 g iv. or im., plus gentamicin 1.5 mg/kg iv. (max. 120 mg), 30 mins before
the procedyre; then ampicillin 1 g iv. or amoxicillin 1 g orally, 6 hrs after the initial dose.
(
- Regimen for Ampicillin/Amoxicillin/Penicillin-allergic patients
• • Vancomycin 1 g iv. over 1-2 hr, plus gentamicin 1.5 mg/kg iv. or im. (max. 120 mg),
1 hr before the procedure; may be repeated 8 hrs after initial dose.
(
- For moden1te risk group
The same regimen, except that gentamicin & 2"" dose of ampicillin may be eliminated. (
o The American College of Cardiology & American Heart Association suggest that BE prophylaxis be
administered intrapartum to patients at risk only presence of suspected bacteremia or active infection.
o The American College of ObstetrK:s and Gynecologists (2003) suggests:
(
_ BE prophylaxis is gpJjQJJgJ in high risk patients who undergoing uncomplicated obstetric delivery.
_ High risk patients who undergo obstetrics delivery complicated by intraamniotic infection (
should receive prophylaxis.
(
- Contraception: • estrogen-progesterone contraceptives = relatively contraindication
• sterilization should be considered (after clinical stable)
(
References:
1. Cunningham FG, Leveno Kl, Bloom SL, Hauth JC, Gilstrap III LC, Wenstorm KD, editors. Williams
(
obstetrics 22nd ed. USA: McGraaw-Hill; 2005. p. ~017-41.
i.
Blanchard DG, Shabetai R. Cardiac diseases. In: Creasy RK, Resnik R, editors. Maternal-fetal
3. Reisner LS, Kuakowski KM. Anesthetic considerations for complicated pregnancy. In: Creasy RK,
Resnik R, editors. Maternal-fetal medicine. 5"' ed. Philadelphia: Saunders; 2004. p. 1243-60.
4. American College of Obstetricians & Gynecologists. Prophylactic antibiotics in labor & delivery.
ACOG Pract Bull 2003;(47).
5. caulin-Glase T, Setaro JF. Pregnancy and cardiovascular disease. In: Burrow GN, Duffy TP, Copel
JA. Medical complications during pregnancy. 6"' ed. Philadelphia: Elsevier Saunders; 2004.
p. 103-25.
6. Mushlin PS, Davidson KM. Cardiovascular in pregnancy. In: Datta S, editor. Anesthetic and
obstetric management of high-risk pregnancy. 3"' ed. New York: Springer-Verlag; 2004. p. 155-
206.
(
(
(
(
(
(
(
(
These guidelines are designed for general use for most patients but may need to be adapted t.o meet the special needs of a specific patient
as detemiined by the patient's provider. (Last revised December 2006)
(
(
( MFM Protocol 47
( Anticoagulation management in pregnancy
Patient with anticoagulant medication

(
Visit for preconception care Visit for pr.enatal care
• Counseling teratogenic effect & possibility of ris
( • Consult hematologist for co-evaluate & proper
O!ltional
( Change to heparin since preconception Change to heparin Continue warfarin
(
.,,,. ~ "'."""- I
in 1" trimester of pregnancy
Optional: after counseling risk & benefit

until 36 wr-s
Continue pann Change totwarfarin

Monitor aPTT or Anti-factor xa* Monitor PT*
GA 13-36 wks
t
Change to heparin
Monitor aPTT or Anti-factor Xa*
_.-
Delivery: • Check coagulogram & X-match PRC 2 u
• Beware of intrapartum & po:;tpartum hemorrhage
• Beware of spinal hematoma if regional anesthesia
'.-
se·
. · -. . . .
( Anticoagulant
agent
Route
Therapeutic prolongation
of coagulati:>n to achieve
Underlying disease
PT INR 3.0-4.5 times of control Mechanical valve prosthesis

Warl'arin era I
PT INR 2.0-3.0 times of control Thromboembolism
intravenous aPTT INR 2.0-3.0 times of control Mechanical valve prosthesis
Unfractionated
or subcutaneous
heparin aPTT INR 1.5-2.5 times of control Thromboembolism
injection
( Low-molecvlar-
weight heparin
subcutaneous
injection
Anti-factor Xa level 0.5-1.5 IU/ml Thromboembcli:;m
( c
- Before start anticoagulant - need lab. Ix: CBC platelet count, coagulogram & IJ/A
- Beware of heparin-induce thrombocytopenia:
-->check platelet count on day 5 of Rx, then periodically during 1" 2 wks of Rx
( - Unfractionated heparin is stopped just before delivery ("' 4-6 hrs prior to expected time of delivery)
- Low-molecular-weight heparin: should be stopped at least 24 hrs before delivery'
- If heparin still effective at time of delivery:
( • Protamine sulfate (1 mg/ 1,000 U of administered heparin) iv. slowly should be given
• No more than 50 mg over any 10-minutes period
- If delivery supervenes while taking warfarin:
5 7
• Option: C/S should be performed'· •
• Beware of fetal trauma during delivery from bleeding tendency
• Avoid instrumental procedure: internal monitoring, F/E, V/E
• Vit K & FFP can be used to reverse effects of warfarin2• 7
(
,( - Restart of anticoagulant Rx • vaginal delivery: may be started @ 6 hrs after delivery
- \
• C/S: may be started @ 24 hrs after delivery
• IV. heparin & oral warfarin should be started simultaneously,
( then heparin can usually be .discontinued after 5-7 days
- Breast feeding: warfarin can be safely given in breast-fed mother
- Contraception: estrogen-progesterone contraceptives = relatively contraindication
(
These guidelines are designed for general use fOf" mOst patients but may need to be adapted to meet the special needs of a specific patient
as detennined by the patient's provider. (Last revised December 2006}
(
(
MFM Protoc:ol 49
( Antibiotic prophylaxis for perinatal group B streptococcal infection
( Evaluate risk factors for GBS infection
(
Anteprtum •
•
c
l ± Vaginal & rectal GBS swab culture
@GA 35-37 wks {if available)
Previously infant invasive GBS disease
GBS bacteriuria during current pregnancy
( • Vaginal & rectal GBS swab culture +ve during current pregnancy
Intraoartum • c
Unknown GBS status any of the following:
- DelivPry @ GA < 37 wks
( - Amniotic membrane rupture <!: 18 hrs
- Intrapartum fever <!: 38.0°C (100.4°F)
( .
Any of tile risk facto:ls present
I
No risk factor
( +
Give intrapartum
+
No intrapartum
antibiotic prophylaxis antibiotic prophylaxis neeoed
(
Regimen Treatment
Recommended Penicillin G 5 mu iv. loading, then 2.5 mu iv.

q 4 ~.rs until delivery
Altemative Ampicillin 2 g Iv. loading, then 1 g iv. q 4 hrs
( or 2 g iv. q 6 hrs until delivery
I' penlcillin-allerglc
( • Patients not @ high risk for anaphylaxis Cefazolin 2 g iv. loading, then 1 g iv. q 8 hrs
until d:livery_ _ _____ _
( • Patient @ high risk for anaphylaxis and

c
GBS susceptible to clindamycin & erythromycin
Oindamycin 900 mg iv. q 8 hrs until delivery or
Erythromycin 500 mg iv. q 6 hrs until delivery
------. --.-~-·--·- ··--·-------·- -- ---- -····-·--·---
( • GBS resistant to clindamycin or erythromycin

Vancomycin 1 g iv. q 12 hrs until delivery
or susceptibility unknown
( ~:
- Intrapartum prophylaxis not indicated:
c
• Previous pregnancy +ve screening rulture (not in current pregnancy)
( • Planned elective qs in absence of labor or membrane rupture (regardless of maternal culture status)
• -ve screening culture in late gestation of current pregnancy, regardless of intrapartum risk factors
- If the patient is receiving treatment for amnionitis with an antibiotic agent active against group B
streptococci (e.g. ampicillin, penicillin, dindamycin or erythromycin), additional prophylactic antibiotics
are not needed. ·
References:
2. Center of Disease Control and Prevention: Prevention of perinatal group B streptococci disease.
Revised guidelines from the CDC. MMWR 51(RR-11):1, 2002b.
3. American College of Obstetricians & Gynecologists. Prevention of early-onset group B
( streptococcal disease in newborns. Committee Opinion 2002;(79).
4. Money DM, Dobson S. The prevention of early-onset neonatal group B streptococcal disease.
J Obstet Gynecol Can 2004;26(9):826-32.
These guldelines are designed for general use for most patients but may need to be adapted to meet the special needs of a specific patient
( as determined by the patient's provider. (Last revised December 2006)
(
MFM Protocol 48
References: (
1. Cunningham FG, Leveno Kl, Bloom SL, Hauth JC, Gilstrap III LC, Wenstorm KD, editors. Wiliiams
Obstetrics 22"" ed. USA: Mcgraw-Hill; 2005. p. 1022-3, 1081-8.
2. Creasy RK, Resnik R, editors. Maternal-fetal medicine. S"' ed. Philadelphia : Saunders; 2004. p. (
838-40, 850-4.
3. Bonow RO, Carabelio B, de Leon AC Jr, et al. Guidelines for the management of patients with
valvular heart disease: Executive summary. A report of the ACGAHA task force on practice (
guidelines (Committee on management of patients with valvular heart disease). Circulation
1998;98:1949-84.
4. American College of Obstetricians & Gynecologists. Thromboembolism in pregnancy. ACOG Pract
Bull 2000;(19).
(
5. Siu S, Colman JM. Cardiovascular problems and pregnancy: an approach to management.
Oeveland Oin J Med 2004;71(12):977-85.
6. Thron SA. Congenital heart disease: pregnancy in heart disease. Heart 2004;90:450-6.
(
7. Gaasch WH, North RA. Management of pregnant women with prosthetic heart valves.
Up-To-Datev~ 14.3. [updated 2006 August 17; cited 2006 Nov 20]. Available from :
hrtp:/lwww.uotocfate.com.
(
(
(
(
(
(
(
(
These guidelines are designed for general use" for most patients but may need to be adapted to meet the special needs of a specific patient
as determined by Ille pat;eors provider. (Last revised December 2006)
(
(
MFM Protocol 50
(
Guideline for genetic counseling (
(
Singleton pregnancy with maternal age 2: 35 years on expected date of delivery
Twin pregnancy with maternal age 2: 33 years on expected date of deliver('
Previous child with neural tube defect {NTD)
Previous child with abnormal chromosomes (
c
Known parent{s) balanced translocation
c
Known parent{s) chromosome abnormalities: inversion, aneuploidy
Mother known to be sex-linked carrier
Couple at risk for single gene defect
(
c
Fetus major structural defect identified by U/S In current pregnancy
Some cases with repetitive early pregnancy losses (
(
Abnormal chromosomes
Neural tube defect {
Congenital abnormalities
Hydrops fetalis
Thalassemia disease (
Patients shou!d be referred to genetic clinic for counseling & prenatal diagnosis
at GA s 20 weeks.
References: (
1. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap ID LC, Wenstorm KD, editors. Williams
2. Jenkins TM, Wapner RJ. Prenatal diagnosis of congenital disorders. In: Creasy RK, Resnik R,
editors. Maternal-fetal medicine. S"' ed. Philadelphia: Saunders; 2004. p.235-73.
3. American College of Obstetricians & Gynecologists. Prenatal diagnosis of fetal chromosomal
abnormalities. Prac Bull 2001;(27). (
(
(
(
(
(
(
(
(
as detennined by the patient's provider. {Last revised December 2006)
(

PMK Management Protocol in MFM 2007

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••

•• Cfimca{ <Practice <]uicfe(ines

•• Departmen of Obs etrics & Gynecology

Phramo g u tao Hospital

Department of Obstetrics & Gynecology

Editorial staffs: Suphavit Muttamara, MD.

•• Maternal Fetal Medicine Unit

•• Printed by S. Sermmitr Pubishlng, Co. Ltd., Bangkok, Thailand

•• Maternal Fetal Medicine Unit

•• Patients who should be referred to high risk preanancy clinic

Patients who have medical complications

Hx taking, esp. medical complication-----<• Consult medicine

.... .. Scoret8 -10

Repeat NST/FAS weekly

•Reactive: FHR acceleration l! 2 times that include all of the followings

•• • Negative no late or significant variable decelerations

•• • Equivocal-hyperstimulatory : deceleration that occurs when contractions more frequent

No fetal indication for intervention

Fetal asphyxia suspected

Deliver if ;,. 37 wk, otherwise repeat testing

•• 4 Probable fetal asphyida

Labor curve (Friedman's)

Rest ± Sedation (narcotics)

•• Factors: Excessive sedation or epidural analgesia

Unfavorable cervical condition - thick, uneffaced, or undilated

Re-evaluate in 1-l hr(s)

( Treatment - Amniotomy if not done - Good contraction

Re-evaluate in 1-2 hr(s)

( Outcome Vaginal delivery qs

( When regional·anesthesia is used,

( Management of anemia & abnormal Hb in pregnancy

[Anemia = Hct< 33%; Hb < 11 g/dl]

Partner's Hb typirg :~;:1~~ an~~ia Ane~a

Management of breech presentation (

External cephalic version (ECV)-----+---Elective C/S @ 38-40 wk (

• EFW 2,000-3,500 g • Not frank breech • Preterm EFW < 1,500 g

X-ray pelvimetry & fetogram

Favoralie pelvis Unfavortble pelvis

Management of mild preeclampsia (

Diagnosis: • BP ;z 140/90 mmHg in previous normotensive patient (

( Management of severe preeclampsia

Diagnosis : BP systolic 2: 160 mmHg OR diastolic 2: 110 mmHg

• Prevention of convulsion (1" line = MgSO.)

GA 124 wks GA 241< 32 wks GAT32wks

**Expectant Rx is NOT considered in ;,_ 1 of the followings: (continued)

Management of pregnancy with diabetes (

Risk assessment for GDM should be done at 1" prenatal visit

No~al Ab~o~al Nom1al"

· U/A & urine

~si/~rtt!c~ a~k start@ 32 wks (oc degree of risk)

( Time Plasma glucose (mg/di)

• Diet - for both gestational & pregestational diabetes (ADA 2004)

Ideal body weight Daily caloric intake (kcal/kg/d)

1 12 hr before breakfast V2 hr before dinner Bedtime

+ Intrapartum glycemic control

Begin & continue 5%0/N/2 100 ml/hr

Give 'h of usual

(for labojr inducfu:~;~/~ ~~ti~~~~or labolr induction) (

< 80 Insulin off 5% D/N/2 (

( Management of preterm premature rupture of membrane

PPROM --- suggested by

Assess dinical of chorioamnionitis

+ F/U ANC q 1-2 wk ---'----•GA~ 36 wk - - - - - ' Vaginal

( Management of pretenn labor

Partner's Hb typirg :~;:1 ania Ane~a

(for labojr inducfu:~;~/~ ti~~or labolr induction) (