Obstetrics Standards and

Procedures 2021
 Rules and Procedures
Obstetrics 2021

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 INDEX
CHAPTER 1
ANTENATAL CARE

1.1 Prenatal health care

1.2 First trimester screening
1.3 Maternal-Fetal Ultrasonographic Evaluation of the Second Trimester
1.4 Third Trimester Ultrasound Growth Monitoring
1.5 Risk of loss of fetal well-being

EPISODE 2
HIGH RISK PREGNANCY

2.1 abortion
2.2 Low placental insertion
2.3 Premature rupture of membranes
2.4 Alterations of the amniotic fluid: polyhydramnios, oligohydramnios and anhydramnios
2.5 Threat of preterm birth
2.6 Lung maturity inducers
2.7 Fetal neuroprotection with magnesium sulfate

CHAPTER 3
MEDICAL COMPLICATIONS OF PREGNANCY

3.1 Emesis and hyperemesis gravidarum

3.2 intrahepatic cholestasis of pregnancy
3.3 Gestational diabetes mellitus
3.4 Thyroid disease in pregnancy
3.5 Diagnosis and treatment of associated hypertensive states
to pregnancy, childbirth and puerperium
3.6 Coagulation disorders during pregnancy and postpartum period
3.7 Sepsis in obstetrics
3.8 Lupus and pregnancy

CHAPTER 4
INFECTIOUS COMPLICATIONS

4.1 Urinary infection in pregnancy

4.2 Management of infections in pregnancy
4.3 Candidiasis in pregnancy
CHAPTER 5
PREGNANCY RESOLUTION

5.1 Procidencia, laterocidencia, procubitus and umbilical cord prolapse

5.2 Fetal death
5.3 Obstetric anesthesia and analgesia
5.4 Uterine rupture
5.5 Premature abruption of normal placenta
5.6 Uterine inversion
5.7 Placental accreta
5.8 Obstetric hemorrhage

CHAPTER 6
PUERPERIUM

6.1 Physiological puerperium

6.2 Puerperal infections

CHAPTER 7
PROCEDURES IN OBSTETRICS

7.1 Laparoscopy during pregnancy

7.2 Uterine curettage and manual uterine aspiration
7.3 Cervical insufficiency and cerclage placement
7.4 Eutocic birth care
7.5 Caesarean section
7.6 Pelvic birth care
7.7 shoulder dystocia
7.8 Forceps Application Procedure
7.9 Manual placenta removal
7.10 Episiotomy and perineal tears
7.11 Obstetric hysterectomy
7.12 Ligation of pelvic vessels
 DIRECTORY

Dr. Jorge Arturo Cardona Pérez

General Director

Dr. Manuel Cortés Bonilla

Medical Director

Dr. Viridiana Gorbea Chávez

Director of Health Sciences Education

Dr. Guadalupe Estrada Gutiérrez

Research Director

Dr. Ramón Alberto Ruiz Tapia

Director of Planning

Mr. Isidro Hernandez Diaz

Director of Administration and Finance
COLLABORATORS
Dr. Sandra Acevedo Gallegos Dr. Alberto Soriano Mitrani
Dr. María del Consuelo Álvarez Cabrera Dr. Samuel Vargas Trujillo
Dr. Lidia Arce Sánchez Dr. Berenice Velázquez Torres
Dr. Jorge Beltrán Montoya Dr. Areli Mariana Zúñiga Guzmán
Dr. Héctor Jesús Borboa Olivares
Dr. Dulce María Camarena Cabrera
Dr. Lisbeth L. Camargo Marin DESIGN
Dr. Armando Cepeda Silva
Dr. Lida Montserrat Cruz Gómez Lic. Ma. of Mercedes Bolaños Vera Lic. Lidia
Dr. Edith del Carmen Cruz Valenzuela Alonso Valencia
Dr. Jonathan Cueto Camara
Dr María Magdalena Enríquez Pérez
Dr. Salvador Espino y Sosa STYLE CORRECTION
Dr. Ricardo Figueroa Damián
Dr. Mariana Flores Fernández Lic. Myrna Carmen Bustos Pichardo Dr.
Dr. Edith Verónica Flores Rueda Patricia Yolanda Padilla Jasso
Dr. Juan Manuel Gallardo Gaona
Dr. Fabiola Gallardo Gómez
Dr. Juan Luis García Benavides
COVER PHOTOGRAPHY
Dr. Myrna S. Godines Enriquez
Dr. María de Lourdes Gómez Sousa Lic. Eduardo Cadena Mendoza
Dr. Viridiana Gorbea Chávez
Dr. Verónica Granados Martínez
Dr. Alfredo Gutiérrez Marín
Dr. Mario E. Guzman Huerta
Dr. Rosa Gabriela Hernández Cruz
Dr. Maylin Alejandra Hidalgo Torres
Dr. Nayeli Martínez Cruz
Dr. Rosa Virginia Merodio Anguiano
Dr. Osvaldo Miranda Araujo
Dr. Roberto Ignacio Montiel Mora
Dr. Jessica Aideé Mora Galván
Dr. José Luis Morales González
Dr. Fela Vanesa Morales Hernández
Dr. Verónica Ortega Castillo
Dr. Carlos Ortega González
Dr. Marco Antonio Ortiz Ramírez
Dr. Flavio Paez Serralde
Dr. Edgar Martín Pérez Aguinaga
Prof. Otilia Perichart Perera
Dr. José Antonio Ramírez Calvo
Dr. Carlos Ramírez Isarraraz
Dr. Víctor Hugo Ramírez Santes
Dr. María Aurora Ramírez Torres
Dr. Alejandro Rendón Molina
Dr. Ana Eugenia Reséndiz Rossetti
Dr. Gerardo de Jesús Reyes Díaz
Dr. Enrique Reyes Muñoz
Dr. Mario Roberto Rodríguez Bosch
Dr. Silvia Rodríguez Colorado
Dr. María José Rodríguez Sibaja
Dr. Jorge Antonio Romano Velazco
Dr. Patricia Romero Vaca
Dr. Margarita C. Ruiz Huerta
Dr. Daniela Sánchez Cobo
Dr. Norma Lidia Sandoval Osuna
Dr. Alejandra Marcela Santiago Aguirre
Dr. Alejandra Beatriz Seligson Ríos
ANTENATAL CARE
 1.1 PRENATAL MEDICAL CARE
INTRODUCTION: PRECONCEPTIONAL APPROACH
Prenatal control refers to the set of actions and procedures that are carried out in order to carry out the
timely diagnosis and treatment of conditions or risk factors that can complicate pregnancy. These
systematic and periodic interventions should be started before pregnancy in order to prevent future
complications. The ideal time to begin the study for any couple who wishes to seek pregnancy is in the
preconception stage.

In the prenatal control consultation, with a risk approach, the purpose is to identify heredity, personal
and pathological history that may be subject to counseling, prevention and treatment. Like any
consultation, it is accompanied by the clinical history, the main diagnostic tool, with special attention to
the obstetric history of previous pregnancies, as well as the immunization status prior to pregnancy,
general and gynecological physical examination, and may even be complemented with an endovaginal
ultrasound. . Clinical studies related to risk factors such as infectious, endocrinological, immunological,
anatomical and genetic should be requested in case of history, in previous pregnancies.

Likewise, studies should be requested to verify active infections due to hepatitis B, hepatitis C, HIV,
herpes, toxoplasmosis and/or cytomegalovirus. During the preconception approach, a thyroid profile
and fasting glucose should be requested in order to detect metabolic endocrine diseases. Those with a
history of adverse perinatal outcomes will require psychological and genetic evaluation.

It is important to note that there are certain immunizations or vaccines whose application conditions
the postponement of pregnancy, these being: hepatitis A (minimum 6 months prior to pregnancy),
rubella (4 weeks prior to pregnancy) and chickenpox (4 weeks). Currently, due to the measles outbreak
worldwide, it is recommended that the adult population that received a single dose of this vaccine
receive 1 booster dose (4 weeks prior to pregnancy).

Regarding hygienic-dietary habits, healthy eating and exercise are recommended, with the aim of
starting pregnancy with an ideal BMI. Alcohol and tobacco consumption should ideally be stopped 3
months before pregnancy.

Due to the possibility of neural tube defects during embryonic development, it is necessary to start
taking folic acid 3 months in advance and continue it during the first trimester. In patients at high risk
for presenting this type of defects (history of a child with a neural tube defect, consumption of
anticonvulsants) the dose will be 4 mg/24 hours; In the case of patients at baseline risk, the
recommended dose is 400 mcg/24 hours.

OVERVIEW OF PRENATAL MEDICAL CARE

After confirming the pregnancy, it must be categorized according to risk factors (Table 1) , in order to
establish the follow-up that will be given to each patient, as well as the laboratory and office studies to
be requested as appropriate.
In Mexico, according to current regulations, a minimum of 5 consultations are described with an ideal
of 8 throughout the 3 quarters (Table 2) . The trend in prenatal care is for visits to be closer together as
the pregnancy progresses. However, most complications that occur in the 2nd and 3rd trimester tend to
evolve insidiously from the first trimester. The current proposal is to invert the pyramid of prenatal
control, thus managing to select those pregnancies with a high risk of complications in the early stages
(Figure 1) .

Table 1. Categorization of risk profile during pregnancy according to history and previous
pathologies

Low risk Intermediate risk High risk Very high risk

Uterine Severe associated

Morbid obesity
abnormalities early maternal age pathology

Low size advanced maternal History of abortions Previous perinatal death

age
Inadequate BMI
Diabetes type 1 and 2
History of IIC Previous
Cardiovascular risk
Multiparity Short chromosomal anomaly
WHO IV
intergenic period
Unwanted Ectopic pregnancy Previous Alcohol/drug dependence
pregnancy Background of IUGR gestational trophoblastic syndrome
Previous uterine disease Uterine malformations
surgery/prior
cesarean section

Multiple gestation IUGR

Inadequate Occupational risk Previous premature birth
Confirmed fetal
vaccination status Mental pathology Cardiovascular risk WHO III
malformation
Gestational diabetes
Cardiovascular Rh negative Uncontrolled gestational
risk Abnormal situation of the
diabetes placenta
WHO I Preeclampsia without severity Preeclampsia with severity
data data
Maternal infection
Cardiovascular risk
WHO II Threat of preterm birth
Isoimmunization
Serious mental pathology Preterm rupture of
Severe anemia Suspected membranes
fetal malformation

Table 2. Number of consultations during

prenatal care
Prenatal consultation Week
1st 6-8
2nd 10 - 13.6
3rd 16 - 18
 4th 22
5th 28
6th 32
7th 36
8th 38 – 41

Figure 1. Prenatal Care Pyramid Investment Proposal

PRENATAL HEALTH CARE: FIRST QUARTER

The first trimester covers from the beginning of pregnancy until 13.6 weeks. During the first prenatal
control visit, a medical history should be taken to identify maternal risk factors, such as: history of
preeclampsia, diabetes, chronic hypertension, chronic kidney disease, autoimmune disorders or
multiple gestation. For a woman with risk factors for developing preeclampsia, aspirin should be
started at a dose of 100-150 mg/24 hours between weeks 12-16. This measure should preferably be
started before week 16, thus reducing the appearance of early preeclampsia (RR 0.33 95% CI 0.19-
0.57), severe preeclampsia (RR 0.47 95% CI 0.26-0.83) and intrauterine growth restriction ( RR 0.56
95% CI 0.44 0.70). If aspirin intake begins after week 16, the risk of early preeclampsia is reduced to a
lesser extent (RR 0.81 95% CI 0.66-0.99). At week 36, aspirin administration should be discontinued. A
complete physical examination should be performed including breasts, measurement of the uterine
fundus and fetal heart rate.

The gynecological examination should focus on recognizing anatomical alterations, presence of

bleeding, dilation (as applicable), genital lesions, cervicovaginitis, as well as performing a cervicovaginal
cytology. The prevalence of HPV lesions during pregnancy is reported to be 40% (5% - 65%), while
invasive cervical carcinoma complicates 0.5 - 1: 1,000 of pregnancies.

During this trimester, the laboratories to be performed have the role of screening for conditions that
may cause complications in the 2nd and 3rd trimester. Request blood count (to rule out anemia,
thrombocytopenia), viral panel (HIV, HBsAg and VDRL), blood group and Rh (in case of Rh negative,
request irregular antibodies, isoimmunization is diagnosed with titers of 1:16 or 1:8 with history of a
previous affected son or daughter), fasting glucose and general urine examination.

In patients at risk of sexually transmitted infections, cultures should be requested to verify genital
infections, including Chlamydia , ureaplasma and mycoplasma, the latter two associated with infection -
intramniotic inflammation in 30% and 47% respectively. Likewise, screen for asymptomatic
bacteriuria by urine culture (2 samples with > 100,000 CFU of the same microorganism) between week
12 - 14. In the event of any of these positive cultures, give the corresponding treatment.

Regarding ultrasonographic evaluation, an initial ultrasound should be performed between 6 - 8 weeks

to assess the presence of intrauterine pregnancy, number of gestational sacs and embryos, as well as the
presence of fetal heart rate in each of them. The gestational age established during the first trimester is
the most reliable for assessing fetal growth during the rest of the pregnancy.

This can be established by the date of last menstruation or by ultrasound. If established by ultrasound,
it should be performed between weeks 11 - 13.6, corresponding to a cephalocaudal length of 45 - 84 mm.
The risk of aneuploidies, preeclampsia, intrauterine growth restriction and preterm birth will be
evaluated. If possible, it should be accompanied by biochemical markers such as: human chorionic
gonadotropin (hCG) and pregnancy-associated plasma protein A (PAPP-A).

Risk calculation by maternal age, first trimester ultrasound and biomarkers reduce the use of invasive
prenatal diagnostic tests from 20% to less than 3%, increasing the detection rate of Down syndrome
and chromosomal pathologies from 50% to more than 95%.

IMMUNIZATIONS
It is advisable to assess immunization status prior to pregnancy and administer the influenza vaccine
(only in season) at any gestational age. Tetanus toxoid, reduced diphtheria toxoid, and acellular
pertussis (Tdap) vaccines should be administered between 27 and 36 weeks. Vaccination against
hepatitis A, hepatitis B, meningococcus and pneumococcus should be assessed according to the profile
of each patient. Vaccines for HPV or chickenpox should not be administered during pregnancy.

HYGIENIC-DIETARY HABITS

It is important to provide advice on hygienic-dietary habits during pregnancy. Emphasis should be

placed on completely suspending the smoking habit (involuntary and active) since it increases the risk of
preterm birth and premature rupture of preterm membranes up to 2 times, among others. In the same
way, alcohol consumption should be eliminated to reduce the risk of malformations. Caffeine
consumption in doses >300 mg/day has been associated with abortion (OR: 1.32, 95% CI: 1.24 - 1.40)
and low birth weight (OR 1.38, 95% CI: 1.10 - 1.73). ), so it is recommended that your consumption be
less than this amount. Regarding the control of weight gain, diet, exercise and micronutrient
supplementation, recommendations should be followed according to the trimester (see below). The
consumption of folic acid during the first trimester at doses of 400 mcg/day or 4 mg/day as appropriate,
is essential to prevent defects in the development of the neural tube.

PRENATAL HEALTH CARE: SECOND QUARTER

At each consultation, the maternal evaluation must continue with specific symptoms, as well as vital
signs, weight and height, uterine fundus, fetal movements and fetal heart rate. The laboratory studies to
be performed are part of the screening to identify risk situations, as already mentioned in the first
trimester, these are blood count (anemia and platelets), irregular antibodies (in weeks 10 - 24 and 34 -
36, receiving hyperimmune anti D gamma globulin in weeks 28 - 29 if isoimmunization is found).

An important parameter in this trimester is screening for gestational diabetes, which should be
performed between weeks 24 - 28. There are two possible approaches. In the first, called one-step
strategy, a 75g oral glucose tolerance curve (OGTC) is used and fasting plasma glucose is evaluated at
one hour and two hours. The diagnosis of gestational diabetes is made when any of the measurements
are equal to or greater than the corresponding values (Table 3) .

Table 3. CTOG values approach 1st step

Fast 92 mg/dl
1 hour 180 mg/dl
2 hours 153 mg/dl

The second approach, called a two-step strategy, is carried out as follows: Step 1: Glucose loading with
50g, if the value at one hour is greater than 140 mg/dl, step 2 is carried out, which consists of: CTOG of
100g on an empty stomach. The diagnosis of gestational diabetes is made when at least 2 of the 4 plasma
glucose measurements (fasting: 1 hour, 2 hours and 3 hours after glucose loading) are equal to or
exceed the values shown ( Table 4) . At INPer we perform screening with 75g of glucose with the
following cut-off points for the diagnosis of gestational diabetes: fasting glucose >95mg/dl, 1 hour
>180mg/dl and at 2 hours >155 mg/dl; Two altered values are required to make the diagnosis.

Table 4. CTOG values 2-step approach

Fast 95 mg/dl
1 hour 180 mg/dl
2 hours 155 mg/dl
3 hours 140 mg/dl

In this trimester, the structural ultrasound is performed between weeks 18 - 22, the purpose of which is
the fetal anatomical evaluation without leaving aside the assessment of aspects such as estimated fetal
age and weight, fetal heart rate, placental appearance and location, as well as amount of amniotic fluid.

Likewise, this trimester includes the measurement of cervical length which is performed between weeks
16 - 24 in those patients with risk factors. For a length ≤25 mm, progesterone therapy should be offered
and each case should be individualized.

PRENATAL HEALTH CARE: THIRD QUARTER

During this quarter, the frequency of appointments increases to 2 weeks starting from week 28,
subsequently it will be weekly starting from week 37, continuing until resolution. Maternal evaluation
should continue with specific symptoms, as well as vital signs, weight and height, measurement of the
uterine fundus, fetal movements and fetal heart rate at each consultation. Starting at week 37, a vaginal
examination should be performed in order to assess cervical changes that constitute the beginning of
labor. In this final stretch of pregnancy, laboratory studies are focused on preparing for its resolution,
such as blood count and clotting times, screening for group B streptococcus (GBS) infection with an
anogenital culture between weeks. 35 - 37, if necessary, give intrapartum prophylaxis ( Table 5 ).

Table 5. Indications for intrapartum prophylaxis for GBS

Previous newborn with invasive GBS infection
Asymptomatic GBS bacteria
during ongoing pregnancy

Anus-genital culture positive for GBS

 between weeks 35 - 37

Unknown status on SGB at start of work

delivery with one of the following conditions:

preterm birth
1.
2. Premature rupture of membranes >18 hours
3. intrapartum fever
4. AC amplification test. intrapartum nucleic acid
positive for GBS

Between weeks 32 - 36, a growth ultrasound should be performed to know estimated fetal weight and to
identify cases of intrauterine growth restriction or small fetus for gestational age.

In the same way, the amount of amniotic fluid and the location of the placenta will be reviewed. During
this trimester, the diagnosis of placenta previa and vasa previa is made.

Starting at week 30, you should provide advice on family planning methods allowed during
breastfeeding to avoid a short-term pregnancy. Finally, the route of resolution of the pregnancy must be
evaluated at the end of the pregnancy, individualizing each patient, assessing whether there are
comorbidities or associated risk factors that interfere with the decision on the route of resolution.

SPECIAL CONSIDERATIONS

WEIGHT CONTROL

The weight gain allowed during pregnancy must be established by individualizing each patient
according to the initial BMI (Table 6) . This increase will be gradual and according to the quarter in
question. Regarding the distribution of macro and micronutrients, according to the World Health
Organization (WHO), iron must be strictly supplemented; In adolescents, special attention should be
paid to calcium supplementation.

Table 6. Weight gain during pregnancy according to preconception

BMI

Preconception state BMI (kg/m2) Total profit

Malnutrition <18.5 12.5 - 18kg

Normal 18.5 - 24.9 11.5 - 16kg
Overweight 25 - 29.9 7 - 11.5kg

≥30 5 - 9kg
Obesity (includes all degrees)

DISTRIBUTION OF MACRO AND MICRONUTRIENTS

The distribution of the daily pregnancy diet is composed of: proteins 25% (71 g/day or 1.1 g/kg/day),
fats 15 - 30% (minimum intake of 300 mg/day of docosahexanoic acid), carbohydrates 45 - 65% (175
g/day with low glycemic index). Recommendations for iron intake during pregnancy are 27 mg/day of
elemental iron, with a maximum allowable intake of 45 mg/day; However, for women with multiple
pregnancies or with anemia from the beginning of pregnancy, 60 - 100 mg/day of elemental iron is
administered. The recommended calcium intake during pregnancy is 1.0 - 1.3 g with a maximum intake
of 2.5 g/day (Table 7) .

Table 7. Nutritional requirements during pregnancy

Proteins 1.1g/kg (10 - 35%)
carbohydrates 45 - 65%
Lipids 20 - 35%
Vitamin A 770 µg/dl
Vitamin C 85 mg/d
Vitamin D 660 ul/d
Vitamin E 15 mg/dl
Folate 600 µg/dl
Iron 27 mg/dl

Calcium 14 to 18 years: 1300 mg/d*

19 to 50 years: 1000 mg/d*

EXERCISE DURING PREGNANCY

Exercising prior to pregnancy has been associated with a decrease in gestational diabetes (OR 0.29,
95% CI 0.16 - 0.51), prevention of preeclampsia (OR=0.65, 95% CI 0.43 - 0.99) and reduction in
maternal hypertension (RR 0.70 95% CI 0.51 - 0.96).

Before recommending exercise, the patient's health status, obstetric conditions, as well as associated
risks must be assessed. In the absence of contraindications to carrying out physical effort, the patient
should be encouraged to perform regular, moderate-intensity exercise. Exercise should be aerobic and
resistance; 30 minutes or more of moderate physical activity is recommended in most cases, and
preferably every day of the week. If the patient has not exercised prior to pregnancy, this should be
done gradually.

It is recommended to do it at room temperature or have air conditioning and adequate hydration. On

the other hand, activities that involve an increased risk of falls, abdominal trauma or excessive load on
the joints are not recommended during pregnancy. Diving should be avoided due to the fetal risk of
decompression sickness secondary to the formation of bubbles within the lungs.

Good perinatal outcomes depend on adequate preconception counseling and prenatal care.

It is important that the patient understands the importance of close monitoring during pregnancy to
achieve optimal results at birth.

BIBLIOGRAPHY

1. Castillo E, Poliquin V. No. 357-Immunization in Pregnancy. J Obstet Gynaecol Can. 2018;40(4):478-

489

2. Centeno-Pérez M, Mata-García A, Plascencia-Ordaz M, Benítez-Salinas F, Campos-Rosas B.

Perinatal nursing self-care model. Perinatology and Human Reproduction. 2017;31(3):151-159

3. American Diabetes Association. Classification and Diagnosis of Diabetes: Standards of Medical

Care in Diabetes—2018. Diabetes Care. 2018;41:S13-S27

4. National Center for Child and Adolescent Health. Vaccination Manual, 2017 edition

5. Tunçalp Ӧ, Pena-Rosas J, Lawrie T, Bucagu M, Oladapo O, Portela A, et al. WHO

recommendations on prenatal care for a positive pregnancy experience-going beyond survival. BJOG.
2017;124(6):860-862

6. Moller A, Petzold M, Chou D, Say L. Early prenatal care visit: a systematic analysis of regional and
global levels and trends of coverage from 1990 to 2013. Lancet Glob Health. 2017;5(10):e977-e983

7. Rolnik DL, Wright D, Poon LC, O'Gorman N, Syngelaki A, de Paco Matallana C, et al. Aspirin
versus Placebo in Pregnancies at High Risk for Preterm Preeclampsia.
N Engl J Med. 2017;377(7):613-622

8. Poon L, Wright D, Rolnik D, Syngelaki A, Delgado J, Tsokaki T, et al. Aspirin for Evidence-Based
Preeclampsia Prevention trial: effect of aspirin in prevention of preterm preeclampsia in subgroups of
women according to their characteristics and medical and obstetrical history. Am J Obstet Gynecol.
2017;217(5):585.e1-585.e5

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10. Mexican official standard. NOM-007-SSA2-2016, for the care of women during pregnancy,
childbirth and the postpartum period, and of the newborn

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pregnancy outcomes in low-risk women. J Perinatol. 2016;36(3):178-181

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Obstet Gynecol. 2015;126(6):e135-42

13. Lambertino J, Villegas S. Rh alloimmunization in pregnant women, a look at the diagnosis and its
therapeutic approach. Ginecol Obstet Mex. 2014;82:744-754

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15. American College of Obstetricians and Gynecologists. Committee Opinion No. 548: Weight gain
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Obstet Gynecol 2013; 41:102-113

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 1.2 SCREENING OF THE FIRST QUARTER
INTRODUCTION
Ultrasound is a non-invasive, reproducible, fast and safe technology that is positioned as the obstetric
tool par excellence. During the first trimester of pregnancy it is useful to confirm intrauterine
pregnancy, establish a gestational age and during 11.0 - 13.6 weeks, it is crucial for screening for
aneuploidies.

INDICATIONS
All pregnant women between 11 - 13.6 weeks, regardless of their risk factors, should be sent to the first
trimester clinic of the Department of Fetal Medicine to perform the first trimester Maternal-Fetal
evaluation.

The list of indications was published by the American College of Obstetrics and Gynecology/American
College of Radiology/American Institute of Ultrasonographic Medicine/Society of Ultrasound
Radiologists (ACOG/ACR/AIUM/SRU) which includes:

• Confirmation of an intrauterine pregnancy

• Evaluation of suspected ectopic pregnancy
• Definition of the cause of transvaginal bleeding
• Pelvic pain evaluation
• Estimation of gestational age
• Diagnosis of multiple pregnancy and its chorionicity
• Confirmation of cardiac activity
• Imaging study for chorionic villus biopsy
• Diagnosis of fetal abnormalities
• Measurement of nuchal translucency in high-risk pregnancies
• Evaluation of suspected gestational trophoblastic disease

CONTRAINDICATIONS
There are no absolute contraindications, however, special consideration should be given to patients with
transvaginal leaks, emotional instability, and musculoskeletal injuries that make supine position
difficult or impossible.

GOALS
Corroborate the number of embryos, in multiple pregnancy: diagnosis of amnionicity and chorionicity,
identification of embryonic heartbeat, estimation of gestational age, detection and measurement of TN,
observe embryonic morphology, determine uterine and adnexal pathology.

REQUIREMENTS
Have certified personnel, be performed in real time, with a transabdominal or transvaginal approach.

The minimum characteristics of the equipment are: real-time image, gray scale, two-dimensional
ultrasound, transabdominal and transvaginal transducer, ability to freeze image and zoom, electronic
calliper, ability to print or store images.
CEPHAL-CAUDAL LENGTH
It is the primary measurement to date pregnancy; there is high agreement between ultrasonographic
measurements and the date of the last menstruation in women with regular menstrual cycles.

It is the first fetal measurement that is performed, it consists of measuring the length from the cephalic
pole to the caudal pole with the fetus in a neutral position (Image 1). Between 6.0 - 9.0 SDG fetal
position makes little difference in the measurement.

1. Caudal skull length

To carry out this measurement, some of the requirements are the following:

• Sagittal section of the fetus, which will be enlarged so that it takes up most of the screen
• Avoid fetal position in hyperflexion/hyperextension
• The measurement, when possible, should be obtained in the mid-sagittal plane.
• With the genital tubercle and fetal spine longitudinally in view and measurement of a straight
line that includes the maximum length from the skull to the fetal cauda

EVALUATION OF FETAL ANATOMY

The most appropriate anatomical evaluation should be between 11.0 and 13.6 SDG, including the head,
neck, face, spine, thorax, heart, abdomen, and extremities.
 Table 1. Comprehensive evaluation of fetal anatomy in the first trimester
Organ Presence / normal
Head
• Presence
• Skull bones
• Midline integrity
• choroid plexuses

Neck • Normal appearance

• Nuchal translucency
Expensive
• Eyes
• Nasal bone
• Normal profile
Column • Vertebrae
Chest • Symmetrical lung fields
• Masses
Heart • cardiac activity
• Four cameras
Abdomen
• Stomach
• Bladder
• Kidneys
Abdominal wall • Umbilical cord insertion
• Defects
Extremities • Four limbs
Placenta • Size and texture
Cord • Three glasses

Expensive

Structures that can be identified include the orbits, profile, and nasal bone.

Nasal bone

The absence of nasal bone is considered a soft marker of aneuploidies, which is associated with, but is
not a diagnostic marker. In a mid-sagittal plane, the nasal bone can be seen as a line of greater
echogenicity than the skin (Image 2) .

2. Nasal bone
Nuchal translucency (TN)

The TN is a hypoechoic structure located under the skin of the posterior part of the fetal neck and
represents a collection of fluid in this space. It can be identified and measured in all pregnancies, but it
can be detected increased in cases of aneuploidies or congenital heart diseases (Image 3) .

3. Nuchal translucency
Chest

The lungs are seen as echogenic structures and must be symmetrical. The diaphragm can be observed
as an intact structure that separates the lungs from the intra-abdominal contents (Image 4) .

4. Sagittal section of the chest. Fetal thorax and diaphragm. Transabdominal USG at 12.2 SDG

Heart

The development of the fetal heart begins at 4 weeks, it can be detected ultrasonographically at 5 SDG.
Cardiac structures identifiable in the first trimester include the four-chamber image, the outflow tracts
are fully developed and can be observed by the end of the first trimester (Image 5) .

5. Cut four chambers of the heart, transabdominal USG 13.0 SDG

Kidneys and bladder

The kidneys can be visualized around 9 SDG, the bladder can be visualized from 12.0 SDG.
Identification of these structures is important and the bladder should be considered as a normal
measurement in a 6 mm midsagittal section (Image 6) .
 6.. Fetal bladder with two umbilical arteries, transabdominal USG 12.0 SDG

Gastrointestinal tract

In the embryonic period, at the beginning of the 8th week the midgut herniates into the umbilical cord
and, after a 90° rotation, returns to the abdominal cavity by the end of the 12th week.

The absence of the stomach can also be observed in the case of esophageal atresia, however, it requires
multiple studies with persistence of the findings (Image 7).

7. Physiological herniation, echogenic mass protruding through the umbilical cord. USG 9.3 transvaginal SDG

Abdominal wall and umbilical cord

Normal insertion of the umbilical cord can be observed at 12.0 SDG. The number of vessels in the cord
can be observed on a gray scale section or using color Doppler to show the arteries adjacent to the
urinary bladder.

RISK CALCULATION FOR DOWN SYNDROME

INITIAL RISK OR PRIORI RISK

All pregnant women are at risk of having a fetus with chromosomal defects, but each woman's
individual risk depends on the initial risk (based on maternal age and gestational age) multiplied by a
series of likelihood ratios, which in turn, they depend on the results of the screening tests performed
during pregnancy (Table 1) .

Table 1. Risk for trisomy 21 by maternal age

Maternal Age Gestational age Maternal Age Gestational age

12 16 20 40 12 16 20 40
20 898 1053 1175 1527 32 388 455 507 659
21 887 1040 1159 1597 33 322 378 421 547
22 872 1022 1140 1482 34 262 307 343 446
 23 852 999 1114 1448 35 210 246 274 356
24 827 969 1081 1406 36 165 193 216 280
25 795 933 1040 1352 37 128 150 168 218
26 756 887 989 1286 38 98 115 129 167
27 710 832 928 1206 39 75 88 98 128
28 655 768 856 1113 40 57 67 74 97
29 593 695 776 1008 41 43 50 56 73
30 526 617 688 895 42 32 38 42 55
31 457 536 597 776

MEASUREMENT OF NUCHAL TRANSLUCENT

EM + nuchal translucency

In screening for chromosomal defects, each TN measurement for a given craniocaudal length
represents a probability ratio that will be multiplied by the a priori risk to calculate the final risk. The
higher the TN measurement, the higher the likelihood ratio and therefore the higher the calculated risk.

Fetal nuchal translucency and maternal serum biochemistry

In pregnancies with fetuses with trisomy 21, the concentration of free ß-human chorionic gonadotropin
(ß-HCG) in maternal serum is higher than in normal fetuses, while pregnancy-associated plasma
protein A (PAPP-A) is lower (approximately 2 multiples of the median [MoM] and 0.5 MoM,
respectively). However, in trisomy 21, the deviation of PAPP-A is lower and free ß-HCG is higher as
pregnancy progresses.

Therefore, it is necessary to take these temporal changes into account for risk calculation (Table 2) .

Table 2. Risks and biochemical markers

Anomaly B-hCG PAPP-A TN (MN)
Euploidy 1.0 1.0 1.8
T21 2.0 0.5 3.5
T18 0.2 0.2 5.1
T13 0.3 0.4 3.9
45,X 1.2 0.5 40

POP-UP BOOKMARKS

venous duct

The ductus venosus is a unique shunt in the fetus from the hepatic portion of the umbilical vein to the
inferior vena cava that directs almost 50% of the oxygenated blood flow from the placenta. Abnormal
flow in the ductus venosus in the first trimester is associated with chromosomal defects, cardiac
anomalies, and poor perinatal prognosis. The blood flow in the duct has a typical waveform. High-
velocity flow normally occurs during ventricular systole (S wave) and ventricular diastole (D wave) and
lower velocity positive flow during atrial contraction (A wave) (Image 8) .
8. Venous duct with a present wave

TRICUSPID REGURGITATION MEASUREMENT

Normal flow through the tricuspid valve during diastole is biphasic; the first is due to the increase in
flow at the beginning of ventricular diastole and the second increase is due to atrial contraction. Any
flow through the tricuspid valve during systole represents abnormal tricuspid regurgitation (Image 9) .
 9. Tricuspid regurgitation

The results of the screening for aneuploidy, which in the first phase includes age + translucency and
places the patient in one of the following 3 groups:

1. Low risk of chromosomopathies: probability less than 1:999, structural ultrasound is suggested
between 18 - 22 weeks of gestation

2. Intermediate risk of chromosomopathies: probability less than 1:101 and greater than or equal to
1:999, it is suggested to use emerging markers such as nasal bone, venous duct and tricuspid
regurgitation and biochemical markers to reduce the rate of false positives and locate the patient in low
or high risk groups

3. High risk of chromosomopathies: probability greater than or equal to 1:100, a definitive diagnostic
method such as karyotyping with G banding or microarrays is suggested.

First trimester screening is performed in the INPer Department of Fetal Medicine.

COMPREHENSIVE FIRST QUARTER SCREENING

INVASIVE PROCEDURES IN THE FIRST QUARTER

PREECLAMPSIA/IUGR SCREENING

Only by questioning risk factors for preeclampsia, up to 33% can be predicted. To date, it has been
suggested that algorithms that combine maternal characteristics, mean arterial pressure (MAP),
uterine artery Doppler (IPm Ut ) and biochemical testing within 11 to 13.6 weeks could potentially
identify about 77% of preterm preeclampsia <37 weeks gestation and 47% of postterm preeclampsia
>37 weeks with a false positive rate of 10%. Although the detection rate is not very high, it has been
shown that the administration of low doses of aspirin before 16 weeks of gestation reduces the risk of
preterm preeclampsia (RR 0.11, 95% CI 0.04 – 0.33), but not postterm ( RR 0.98, 95% CI 0.42 – 2.33)
(Table 3) .

Table 3. Requirements for measuring uterine arteries

Para-sagittal section of the uterus at the level of the
internal cervical os (OC)
Requirements for measuring uterine
arteries Using pulsed Doppler with sample volume 2 - 3 mm,
isonation angle less than 30 degrees, scanning speed 2 - 3
cm/sec
 Table 4. Detection rate through screening
Early preeclampsia late preeclampsia
FP 5% FP 5%
FR 33% (24.6 - 42.7) 24.5% (17.1 - 33.8)
FR+ IPm Ut 49.7% (40.1 - 59.3) 33.1% (24.7 - 42.8)
FR+PAM 53.5 (43.8 – 63.0) 27.0 (19.3 – 36.4)
FR+ IPm Ut +PAM 66.5% (56.8 - 75) 34.3% (25.7 - 44.0)
FR+ IPm Ut +PAM +PAPP-A and PLGF 77.8% (68.7 - 84.8) 35.2% (26.6 - 45)

PRETERMINAL BIRTH
By questioning risk factors, up to 30% of patients who will have a preterm birth before week 34 can be
detected, with maternal risk factors plus abdominal cervical length measurement with a value less than
0.89 MoM (0.82 - 0.94) can only predict 54.8% (44.7 - 64.6) of preterm births before week 34, so it is
necessary to measure cervical length vaginally between weeks 18 - 24 to improve the prediction rate
( Table 5) .

Table 5. Requirements to measure cervical length

empty bladder
5MHz transvaginal transducer

Gently place the probe into the anterior vaginal fornix to ensure a sagittal
Cervical length week 18 view of the cervix (identify the internal cervical os, external cervical os,
- 21 cervical canal, and endocervical mucosa)
The image so that the cervix occupies at least 75% of the image
Measure the distance between internal and external cervical os
Take 3 measurements (and photographs) and record the shortest length
measurement
BIBLIOGRAPH
Y
1. Akolekar R, Syngelaki A, Sarquis R, Zvanca M, Nicolaides KH. Prediction of early, intermediate
and late pre-eclampsia from maternal factors, biophysical and biochemical markers at 11-13 weeks.
Prenat Diag 2011;31:66-74

2. Greco E, Gupta R, Syngelaki A, Poon LC, Nicolaides KH. First-trimester screening for spontaneous
preterm delivery with maternal characteristics and cervical length. Fetal Diagn Ther 2012;31:154-61

3. Nicolaides KH. Screening for chromosomal defects. Ultrasound Obstet Gynecol 2003;21:313-21

4. Salomon LJ, Alfi revic Z, Bilardo CM, Chalouhi GE, Ghi T, Kagan KO, et al. ISUOG practice
guidelines: performance of first-trimester fetal ultrasound scan. Ultrasound Obstet Gynecol.
2013;41(1):102–13

5. Bromley B, Shipp TD, Lyons J, Navathe RS, Groszmann Y, Benacerraf BR. Detection of fetal
structural anomalies in a basic first-trimester screening program for aneuploidy. J Ultrasound Med.
2014; 33(10):1737–45

6. Iliescu D, Tudorache S, Comanescu A, et al. Improved detection rate of structural abnormalities in

the first trimester using an extended examination protocol. Ultrasound Obstet Gynecol. 2013;42:300–9

7. J. Sonek, MD, RDMS, K. Nicolaides Additional First-Trimester Ultrasound Markers Clin Lab Med
30 (2010) 573–592

8. O'Gorman N, Wright D, Syngelaki A, et al., Competing risks model in screening for preeclampsia
by maternal factors and biomarkers at 11-‐13 weeks gestation. Am J Obstet Gynecol 2016;214(1):103
e1-‐103 e12

9. Roberge S, Villa P, Nicolaides KH, et al. Early administration of low dose aspirin for the prevention
of preterm and term pre-eclampsia: a systematic review and meta-analysis. Fetal Diagn Ther
2012;31:141-‐6

10. Sananès N, Schuller E, Gaudineau A, Kohler M, Guerra F, Weingertner AS, Fritz G, Viville B,
Langer B, Nisand I, Favre R., What is predictive of preterm delivery in the first trimester: isthmus or
cervical length? Prenat Diagn. 2013 Sep;33(9):894-‐8

11. Liao Y, Wen H, Ouyang S, Yuan Y, Bi J, Guan Y, Fu Q, Yang X, Guo W, Huang Y, Zeng Q, Qin Y,
Xiang H, Li S. Routine first-trimester ultrasound screening using a standardized anatomical protocol.
Am J Obstet Gynecol. 2020 Oct 27:S0002-9378(20)31267-9. doi: 10.1016/j.ajog.2020.10.037. Epub ahead
of print. PMID: 33127430

1.3 MATERNAL-FETAL ULTRASONOGRAPHIC

EVALUATION OF THE SECOND TRIMESTER

DEFINITION
Ultrasonography is widely used for prenatal evaluation of fetal growth, anatomy, and its environment
(placental and amniotic fluid characteristics). The second trimester evaluation is also ideal for
performing predictive tests mentioned later.
The main goals of routine second trimester ultrasound are:

• Determine the vitality of the fetus

• Determine the number of fetuses and chorionicity in multiple gestations
• Determine gestational age
• Review fetal anatomy
• Determine placental location and characteristics
• Evaluate the amniotic fluid
• Evaluate second trimester ultrasonographic markers for chromosomal alterations
• Perform Doppler evaluation of uterine arteries as screening for preeclampsia and intrauterine
growth restriction
• Measure cervical length for preterm birth screening

Second trimester Maternal-Fetal ultrasonographic evaluation should be performed between 18 and 22

weeks of gestation. During this period, there are ideal conditions (fetal size and amount of amniotic
fluid) to make a comprehensive evaluation of the aforementioned points. If a structural evaluation is
required in a pregnancy outside this gestational age, the specific case must be discussed with the doctor.
Department of Fetal Medicine.

Requirements for carrying out the procedure:

1. The second trimester Maternal-Fetal ultrasonographic evaluation must be performed on all

pregnant women who undergo prenatal care at the Institute.
2. Ideally the patient should be between 18 - 22 weeks gestation. The scope and limitations of the study
must be explained to the patient prior to carrying out the study, as well as the possible results that
can be obtained.
3. It may be reported as normal, incomplete or pathological.
4. In case of an inconclusive finding that requires follow-up, the patient will be summoned to the
corresponding clinic.
5. High resolution ultrasound equipment must be available.

Contraindications

There is no absolute contraindication for performing maternal-fetal ultrasound evaluation in the

second trimester; however, particular cases should be considered in patients with uterine dynamics and
hospitalized in intensive care.
Ultrasonographic examination:

Fetal anatomical evaluation: Measurement of fetal structures (DBP), head circumference (CP),
abdominal circumference (AP), femur length (LF) must be carried out, as well as evaluation of the
tubular bones.

1. Head: Check size, shape, integrity and bone density. Identification of intracranial structures from
the 3 basic cuts: transventricular, transthalamic and transcerebellar

• Transthalamic: the frontal horns of the lateral ventricles, the thalamus and the hippocampal
gyrus are identified. In this section, the BDP and PC (Biparietal Diameter and Head
Perimeter) are measured.
• Transventricular: includes visualization of the frontal horns, the cavum of the septum
pellucidum and the posterior horns of the ventricle with the choroid plexuses inside
• Transcerebellar: it is a more inferior cut, obtained by a discrete obliqueness of the transducer
towards the back of the head in relation to the transventricular and transthalamic cuts. It
includes the cavum of the septum pellucidum, the anterior horns of the VL, the thalami, the
cerebellum and the cisterna magna with a correct visualization of the occipital bone.
Measurement of the transverse diameter of the cerebellum and the anteroposterior diameter of
the posterior fossa

2. Face: identification and visualization of the upper lip, including midface profile, orbits, nose and
nostrils

3. Neck: evaluation of the contour and arrangement of neck structures, look for lumps, masses or
collections

4. Chest: verification of contour integrity, evaluation of lung structure and echogenicity. The
diaphragmatic interface can be visualized as a hypoechoic dividing line between the thoracic and
abdominal contents.

5. Heart: basic echocardiography using two-dimensional ultrasound and application of color Doppler.
Check the situation and subjective estimate of the size of the heart in relation to that of the thorax.
Analysis of the 5 basic cuts. Subjective estimation of the diameters and crossing of the aorta and
pulmonary artery and their relationship to the trachea. Check the appropriate heart rate with an
expected rate of 120 to 160 bpm

6. Abdomen: confirmation of visceral situs. Identification of the characteristics of the gastric chamber,
liver and arrangement of the intrahepatic vessels, arrangement and echogenicity of the intestinal loops
and integrity of the abdominal wall. Identification of the fetal insertion of the umbilical cord. Subjective
evaluation of the structure of the cortex and renal parenchyma and estimation of the anteroposterior
diameter of the renal pelvis. Identification of the urinary bladder and the intrapelvic course of the
umbilical arteries

7. Vertebral column: identification of the arrangement, ossification and integrity of the different
vertebral segments in the 3 planes

8. External genitalia: evaluate the correct morphology. Gender reporting should be considered only
with the consent of the mother and/or father.

9. Extremities: confirm the integrity and arrangement of the 3 segments of each of the 4 extremities;
upper extremities, appreciate the opening of the hand and the presence of the 5 fingers, lower
extremities, check the characteristics of the sole of the foot, the presence of the 5 fingers, the heels and
the orientation of the foot with the leg

10. Placenta and umbilical cord: structure and thickness. Evaluation of the lower pole of the placenta
and its relationship with the internal cervical os by transabdominal and transvaginal ultrasound

11. Amniotic fluid: qualitative evaluation. Quantitative evaluation (maximum pocket 2 - 8cm)

12. Uterine artery Doppler: the pulsatility index of both uterine arteries is evaluated and compared
with the cut-off points according to gestational age

EVALUATION OF SECOND QUARTER ULTRASOUND MARKERS FOR

CHROMOSOMIC ALTERATIONS
The most common chromosomal alterations are trisomies 21, 18, 13 and Turner syndrome (monosomy
X). There are some ultrasonographic findings that can guide the diagnosis of any of these pathologies:

Presence of major malformations

• Nuchal fold greater than 6mm

• Hyperechogenic intestine
• short femur
• short humerus
• Intracardiac echogenic focus
• choroid plexus cyst
• Dilation of renal pelvises
• Mild ventriculomegaly

The evaluation and calculation of the new risk is obtained by applying the probability coefficients (LR)
for isolated or combined anomalies and there is a detection rate of between 60 - 70%.

POTENTIAL RISKS AND COMPLICATIONS

By maintaining thermal and mechanical indices less than 1, there are no potential risks. The ALARA
(As Low As Reasonably Achievable) principle must be followed.

This type of ultrasound is also called structural ultrasound since it studies the fetal anatomy and
placental uterine irrigation in detail. Most of the severe anatomical alterations can be diagnosed, as well
as fetal growth and the pulsatility index of the uterine arteries, characteristics of the placenta, among
others. Another utility in the second trimester study is to also determine the risk of premature birth, by
measuring the cervix transvaginally.
BIBLIOGRAPH
Y

1. Gynaecol Can 2009;31(3):272–275 2.- Grandjean H, Larroque D, Levi S. The performance of

routine ultrasonographic screening of pregnancies in the Eurofetus Study. Am J Obstet Gynecol
1999;181:446-54

2. Practical Guide for performing a routine second trimester ultrasound. Inter Soc Ultrasound Obstet
Gynecol, 2012

3. Pilu G, Nicolaides K, Ximenes R, Jeanty P. Diagnosis of fetal abnormalities, the 18-23 weeks scan,
Fetal Medicine Foundation Online Education, 2002

4. Second trimester ultrasound screening protocol, maternal-fetal medicine clinical guidelines,

Hospital Universitari Clinic Barcelona, 2008

5. World Health Organization. Report on the Regional Consultation Towards the Development of a
Strategy for Optimizing Fetal Growth and Development. WHO Regional Office for the Eastern
Mediterranean: Cairo, 2005

6. Diagnosis of fetal non-chromosomal abnormalities on routine ultrasound examination at 11-13

weeks' gestation

7. Syngelaki A. Chelemen T. Dagklis T. Allan L. Nicolaides KH Ultrasound Obstet Gynecol. 2019; 54:
468-476
 1.4 ULTRASOUND GROWTH MONITORING
OF THE THIRD QUARTER

BACKGROUND
Fetal growth is one of the most important indicators of the health of a pregnancy. Alterations in fetal
growth represent a marker of adverse perinatal outcomes and in recent years have also been identified
as a marker of health and disease in adult life.

Fetal growth monitoring improves the identification of fetuses with alterations in the growth curve with
the aim of implementing timely interventions aimed at reducing the morbidity and mortality associated
with these pathologies. Currently, the most used strategy for the evaluation of fetal growth is the
estimation of fetal biometry by ultrasound at some point in the third trimester; however, it has been
reported that up to 50% of cases of growth alterations are not detected prenatally. with this strategy.

AIM
The fetal growth surveillance algorithm in the third trimester is designed to optimize follow-up
ultrasonographic evaluations, monitoring fetal growth in a clinically structured manner, with the aim of
improving the identification of fetuses with growth alterations and therefore at risk. of adverse
perinatal outcomes.

GROWTH MONITORING ALGORITHM

Monitoring of fetal growth by ultrasound in the third trimester at the Institute will be carried out on an
individualized basis according to the presentation of risk factors associated with fetal growth
alterations.

In all patients, a second-level ultrasound will be performed to evaluate fetal growth between weeks 34 -
36 of gestation. In this evaluation, fetal biometry will be performed (biparietal diameter [BPD], head
circumference [WC], abdominal circumference [AC], femoral length [LF]), the estimated fetal weight
(EPF) and the growth percentile for age will be determined. gestational and Doppler evaluation of the
uterine arteries (Aut) will be performed; Fetal presentation, placental location and measurement of
amniotic fluid will also be reported.

In addition to this evaluation, in some women other evaluations will be performed at 28 and 32 weeks of
gestation according to risk stratification based on clinical and obstetric history, as well as findings in the
second trimester ultrasound, in which the growth surveillance pathway (Figure 1) .

Those women who do not present risk factors for growth alterations and in whom the Doppler
evaluation of the AUt in the second trimester is normal, will be assigned to route A of fetal growth
monitoring, in which after the second trimester structural ultrasound An evaluation of the growth
curve will be carried out between 34 - 36 weeks of gestation. Women with a normal Doppler evaluation
of the Aut in the second trimester, who present any of the factors considered as intermediate risk for
the presentation of growth disorders (ad) will be assigned to route B of fetal growth monitoring, in
which will evaluate the growth curve at 32 and 36 weeks of gestation. Finally, all women with abnormal
Doppler evaluation of the Aut in the second trimester, defined as a mean pulsatility index greater than
the 95th percentile and those who present any of the factors considered high risk for the presentation of
growth disorders (gm ) will be assigned to route B of fetal growth monitoring and 3 evaluations of the
growth curve will be made at weeks 28, 32 and 36 of gestation.

Growth monitoring in patients diagnosed with pregestational or gestational diabetes, as well as in twin
pregnancies, will be carried out in accordance with the guidelines of the diabetes and twin pregnancies
clinic, respectively.

Additional evaluations of fetal growth may be scheduled according to more complex criteria: diagnosis
of preeclampsia, identification of flattening of the growth curve in first-level ultrasound, etc.

DRIVING
1. Normal fetal growth
An adequate fetal growth curve will be considered when the PEF for gestational age is between the 20th
and 80th percentiles for gestational age. These fetuses are within the low-risk group for adverse
perinatal outcomes, therefore, once the established evaluations have been carried out according to the
assigned growth path, their second-level follow-up will be concluded.

2. Abnormal fetal growth

The 10th and 90th percentiles of the PEF for gestational age will be used as cut-off points to identify
those fetuses that are small and large for gestational age, respectively. The PEF less than the 3rd
percentile for gestational age or between the 3rd - 10th percentile for gestational age with alterations in
the hemodynamic evaluation will be the criteria used for the diagnosis of intrauterine growth
restriction. This group of fetuses has a higher risk of adverse perinatal outcomes and will be given
individualized follow-up in the Fetal Growth Clinic (cubicle 6).

3. Fetal growth less than the 20th percentile or greater than the 80th percentile
This situation can be explained by a normal variation or flattening of the growth curve, so these
patients will be referred to the Fetal Growth Clinic for evaluation of additional parameters that will
determine follow-up.

Checklist for growth disorders

Yeah No
a) Over 40 years of age
b) History of a child <2.5 kg or preeclampsia >34 SDG
c) Smoking during pregnancy
d) In vitro fertilization
 Checklist for growth disorders
Yeah No
f) Pregestational/gestational diabetes
g) Chronic hypertension
h) Chronic kidney disease
i) Systemic lupus erythematosus
j) Antiphospholipid antibody syndrome
k) History of death
l) History of IUGR or preeclampsia < 34 SDG
m) High risk for IUGR due to first trimester screening

Figure 1. Algorithm for monitoring fetal growth in the third trimester according to risk stratification by clinical and obstetric history and evaluation of the uterine
arteries (Aut) in the second trimester
BIBLIOGRAPH
Y

1. Lindqvist PG, Molin J. Does antennal identification of small-for-gestational age fetuses significantly
improve their outcome? Ultrasound Obstet Gynecol. 2005;25(3):258–64

2. Barker DJP. Adult consequences of fetal growth restriction. Clin Obstet Gynecol. 2006;49(2):270–
83

3. Villar J, Papageorghiou AT, Pang R, Salomon LJ, Langer A, Victora C, et al. Monitoring human
growth and development: A continuum from the womb to the classroom. Am J Obstet Gynecol.
2015;213(4):494–9

4. Ganzevoort W, Thilaganathan B, Baschat A, Gordijn S. Fetal growth and risk assessment: is there
an impasse? POINT. Am J Obstet Gynecol [Internet]. 2018;(January):74–82. Available from:
https://doi.org/10.1016/j.ajog.2018.10.007

5. Hanson M, Kiserud T, Visser GHA, Brocklehurst P, Schneider EB. Optimal fetal growth: A
misconception? Am J Obstet Gynecol [Internet]. 2015;213(3):332.e1-332.e4. Available from:
http://dx.doi.org/10.1016/j.ajog.2015.06.027

6. O'Gorman N, Salomon LJ. Fetal biometry to assess the size and growth of the fetus. Best Pract
Res Clin Obstet Gynaecol [Internet]. 2018;49:3–15. Available from: https://doi.org/10.1016/j .
bpobgyn.2018.02.005

7. Sovio U, White IR, Dacey A, Pasupathy D, Smith GCS. Screening for fetal growth restriction with
universal third trimester ultrasonography in nulliparous women in the Pregnancy Outcome Prediction
(POP) study: A prospective cohort study. Lancet. 2015;386(10008):2089–97

8. Williams M, Turner S, Butler E, Gardosi J. Fetal growth surveillance – Current guidelines, practices
and challenges. Ultrasound. 2018;26(2):69–79

9. Figueras F, Gratacós E. Update on the diagnosis and classification of fetal growth restriction and
proposal of a stage-based management protocol. Fetal Diagn Ther. 2014;36(2):86–98

10. Figueras F, Gratacos E. Stage-based approach to the management of fetal growth restriction.
Prenat Diagn. 2014;34(7):655–9
 1.5 RISK OF LOSS OF FETAL WELFARE

INTRODUCTION
It is an international consensus that the use of the term “fetal distress” is inappropriate and imprecise
and not very specific. As a diagnosis it has a very low positive predictive value, such is the case that
many of the diagnosed newborns will be born clinically in good condition, with an Apgar and/or
umbilical cord gasometry within normal limits.

Based on this, it has been proposed to change the term to “risk of loss of fetal well-being” which should
be based on serious clinical situations (such as normal placental abruption, cord prolapse, etc.) or on
alterations in the different tests that are used, at all times, to control fetal well-being.

We could again incur abuse and misuse of this term, for this reason we must be careful and have
extensive knowledge of normal conditions (physiology) and hypoxic-ischemic pathology
(pathophysiology), as well as the diagnostic tests that we have available for evaluate fetal status.

DEFINITIONS
Risk of loss of fetal well-being: it is the interpretation that the clinician makes of the fetal state and in
which its well-being cannot be assured. It must be supported by clinical signs or results of tests
evaluating fetal status.

Fetal asphyxia: it is a critical state secondary to an alteration in the exchange in the intervillous space
that produces biochemical and hemodynamic modifications, leading to hypoxia, hypercapnia and the
subsequent acid-base imbalance causing various manifestations in the fetus.

STATISTICS
Approximately 130 million boys and girls are born annually in the world; Almost 3.3 million are
stillborn and more than 4 million die in the first 28 days of life. According to the data provided, 25% of
these deaths had a diagnosis of asphyxia, especially in the early neonatal period. The WHO points out
that more than a million newborns who survive asphyxia develop sequelae such as cerebral palsy,
various learning problems and other neurodevelopmental problems.

RISK FACTOR'S
Risk factors can be divided into:

Maternal conditions prior to pregnancy

• Antiphospholipid syndrome and other thrombophilias

• Hyperthyroidism either due to lack of control or due to the medications used
• heart disease

• Systemic lupus erythematosus or other collagen diseases

• Chronic renal failure
• Mellitus diabetes
• Systemic arterial hypertension
• Anemia and malnutrition

Conditions related to pregnancy

 • Pregnancy-induced hypertension (gestational hypertension, preeclampsia, eclampsia)
• Intrauterine growth restriction
• Alloimmunization (fetal hemolytic disease)
• Alterations in the amniotic fluid (oligohydramnios-some cases of polyhydramnios)
• Post-term pregnancy
• Pathology in twins (feto-fetus transfusion, discordant growth, dead twin, etc.)
• History of death due to unknown cause
• Confirmed hypomotility

DIAGNOSTIC ASSISTANTS
According to each case, one of the following tests will be applied.

ANTEPARTUM

Cardiotocography (PSS and PEVA). It is a non-invasive method that allows evaluating the risk of loss
of fetal well-being by recording and observing the characteristics of the fetal heart rate (FHR), under
basal conditions (PSS) or with a vibroacoustic stimulus (PEVA).

The tests will be carried out from week 32 of gestation, at younger ages only in special situations, to
search for ominous data and after discussion of the case. It is interpreted as reactive and non-reactive.

Reactivity criteria:

• Normal FHR (110 - 160 beats per minute)

• Normal variability (type I or II)
• Ascents at least 2 in 10 minutes of 15 beats of amplitude and 15 seconds of duration
• Fetal movements present
• Absent uterine activity (or isolated contractions)

PEVA. It is performed after a non-reactive PSS in which there are no ominous data. It evaluates
changes in FHR in response to a vibroacoustic stimulus, with the aim of reducing false positives (FP) of
the non-stress test, since PSS may be non-reactive simply because the fetus is in a physiological moment
of sleep. or rest.

Biophysical profile. It is one of the fetal well-being tests that evaluates the presence or absence of
various biophysical variables in the fetus using ultrasound and cardiotocography.

The variables studied are:

• Heart rate, analyzed by cardiotocography

• respiratory movements
• body movements
• Muscular tone
• Amniotic fluid

The last four variables are analyzed by ultrasound, each variable has a value of 0 or 2 giving a total of
10, maximum. Decision making is made always taking into account the clinical context and not only the
biophysical profile score.

Doppler flowmetry. In cases of suspected intrauterine growth restriction, to establish the correct
diagnosis, classify the fetus and follow-up. The vessels that are evaluated, depending on the case, are:

• Fetal: umbilical artery, middle cerebral artery, ductus venosus, umbilical vein, including
calculation of cerebroplacental index
 • Maternal: uterine arteries

INTRAPARTUM TESTS

Intrapartum cardiotocographic recording. Intrapartum electronic fetal monitoring is perhaps the most
widely used form of monitoring fetal status.

Three stroke patterns are identified:

CATEGORY I. The stroke is normal and has the following characteristics:

• Baseline fetal heart rate is between 110 - 160 bpm, adequate variability, has no early, late, or
variable decelerations and may or may not have accelerations.
• With this type of trace, the greatest probability is that you will find a normal acid-base state at
the time of the study. It does not require any specific intervention.
CATEGORY II. It is considered an indeterminate (non-reassuring) stroke.
• This type of trace does not necessarily predict an altered acid-base state, however, it does not
meet the requirements for classification in categories I or III.
• Some of the characteristics it may present are the following: bradycardia not accompanied by
absence of variability, tachycardia, minimal variability, absence of variability not accompanied
by decelerations, recurrent variable decelerations or with a slow return to baseline.
• This type of tracing requires close monitoring and constant evaluations, taking into account
the clinical circumstances at all times. Depending on the clinical setting, intrauterine
resuscitation maneuvers could be used.
CATEGORY III. The strokes are abnormal. This type of trace is associated with alterations in the acid-
base state at the time of the study. Features of these strokes include:
• Absence of variability along with any of the following characteristics:

-Recurrent late decelerations

-Recurring variable slowdowns
-Bradycardia
-Sinusoidal pattern

Resuscitation maneuvers are indicated in this category:

• Identify the etiological factor and install corrective measures for each particular case
• Check uterine activity for tachysystole. In case of positive detection
-Discontinue oxytocics
-Application of tocolytics
• Change of position to left lateral decubitus
• Assess O2 supplementation to the mother
• Explore the state of hydration and, according to clinical assessment, correct it with loads of 250
cc of Hartmann's solution.
• Verify absence of hypotension, if present, take corrective measures
• Vaginal examination to establish obstetric birth conditions
• Investigate procidence or procubitus of the cord, if positive, place in Trendelenburg or
Genupectoral position and reject the presentation with immediate birth via abdominal route.
• Search for data on vaginal bleeding and its characteristics, to integrate diagnosis and establish
behavior according to it.

If the alterations persist, the birth should be performed immediately.

As in all fetal surveillance tests, we must consider that they can be a useful tool, when they are well
indicated and when the person who interprets them is well trained not only for the interpretation of the
trace, but for the complete interpretation of the clinical context both in the mother as in the fetus.
TREATMENT
There is no consensus for decision-making when we are faced with a case of risk of loss of fetal well-
being, some of the scientific associations such as the American College of Obstetricians and
Gynaecologists (ACOG), the Canadian Society of Gynecology and Obstetrics (SCGO), Spanish Society
of Gynecology and Obstetrics (SEGO), among others, have issued recommendations based on the
available evidence, and based on this we make the following considerations:

In the first fetal measurement performed, we measure the length from the cephalic pole to the caudal
pole with the fetus in a neutral position.

Between 6 - 9 SDG the fetal position makes little difference in the measurement.

• Women with risk factors for presenting any adverse perinatal outcome should be subjected to
close antepartum surveillance (PSS, biophysical profile, modified biophysical profile, Doppler,
etc.) as appropriate; as well as intrapartum if it is decided that this is the best option for
termination of pregnancy
• The start of surveillance is at 32 weeks for most cases, however, according to each situation, it
should be considered to start surveillance at weeks 26 to 28 of gestation (this taking into
consideration the viability limits of each institution)
• When the risk factor is still present, surveillance with the most appropriate test should be
carried out weekly, every 72 hours, or even daily according to the fetal state, as long as these
tests are essential for decision making.
• Oligohydramnios (with the vertical pocket technique less than 2cm, or with the amniotic fluid
index less than 5cm) is not in itself an indication for termination of pregnancy. The gestational
age, maternal conditions and fetal conditions in general will have to be considered and each
case will be analyzed in particular to make the best decision, assisted by all the tests available
and applicable to each situation.
• Doppler flowmetry has so far demonstrated its usefulness mainly in fetuses with intrauterine
growth restriction, considering the evaluation of the different vessels that guide us in relation
to fetal deterioration.
• In cases of fetal anemia, the evaluation of the systolic peak of the middle cerebral artery has
proven useful as an indirect method to determine the degree of anemia; however, its limitations
must be considered.

When deciding the moment and route of birth, the following factors must be considered:

• Maternal condition that allows or does not allow labor

• Alterations presented in the surveillance tests applied that translate the fetal state (in case of
ominous data the route of choice is the abdominal one)
• Favorable cervical conditions to decide the vaginal route
• Immediate Birth Benefit

It will be important to consider that the main reason why a pregnancy with imminent risk is prolonged
is so that the fetus can gain weight or maturity that improves its prognosis without increasing the risks
for the mother.
BIBLIOGRAPH
Y

1. ACOG clinical management guidelines for obstetrician-gynecologists. Intrapartum fetal heart rate
monitoring: Nomenclature, Interpretation, and general management principles. ACOG practice
bulletin no. 106, July 2009

2. Canada; British Columbia Perinatal Health Program. J Obstet Gynaecol Can 2007;29 (suppl 4):S3-
56

3. Liston R, Sawchuck D, Young D, Society of Obstetrics and Gynaecologist of Canada. Fetal health
surveillance: antepartum and intrapartum consensus guideline. J Obstet Gynaecol Can. 2007
Nov;29(11):909

4. Vintzileos AM. Antenatal assessment for the detection of fetal asphyxia. An evidence base approach
using indication-specific testing. Ann NY Acad Sci 2000;900:137-50

5. Vogel JP, Souza JP, Mori R. Maternal complications and perinatal mortality: findings from the
World Health Organization Multicountry Survey on Maternal and Newborn Health. BJOG 2014;121
(Suppl 1):76-88

6. Walton JR, Peaceman AM. Identification, assessment and management of fetal compromise. Clin
Perinatol. 2012;39:753-68

7. World Health Organization. Neonatal and perinatal mortality: country, regional and global
estimates. WHO Library Cataloging- in - Publication data 2006
 HIGH RISK
PREGNANCY
2.1
ABORTION
DEFINITION
It refers to the completion of pregnancy with or without spontaneous expulsion of the product of
conception before 20 weeks of gestation. From this entity, some definitions emerge according to the
variety of abortion (Table 1).

Table 1. Abortion varieties

Presence of genital bleeding and/or uterine contractility. Without cervical
Threatened abortion modifications

When the expulsion of a part of the product of conception has occurred

incomplete abortion and the rest is still in the uterine cavity

Complete abortion The expulsion of the product of conception has been total
It occurs when, after the death of the product of conception, it is not
Deferred abort expelled spontaneously. This entity represents a period between ovular
death and the diagnosis.

Abortion in evolution It is characterized by the presence of persistent genital bleeding, clinically

recognizable uterine activity and cervical modifications (effacement and
dilation) incompatible with the continuity of pregnancy.

Unavoidable abortion Variety that makes the continuation of pregnancy impossible, generally due
to the existence of genital hemorrhage or rupture of membranes, even
without cervical modifications or recognizable uterine activity

septic abortion Any of the previous varieties in which intrauterine infection is added

In addition to the previous definitions, it is important to identify the concept of early pregnancy loss,
which refers to a non-viable, intrauterine pregnancy, with a gestational sac present with or without an
embryo inside, which does not have a heartbeat, with a gestational age. less than 13 weeks.

EPIDEMIOLOGY
Bleeding during the first trimester occurs in up to 25% of patients. Spontaneous abortion is the most
common cause of pregnancy loss, with a prevalence between 10 - 25% of all pregnancies. 50 - 75% of
abortions occur in the context of biochemical pregnancies. Having a frequency of up to 80% of cases
before 12 weeks.

RISK FACTORS, PATHOPHYSIOLOGY AND ETIOLOGY

The risk factors described with greater importance according to age are the following: patients between
20 - 30 years of age have a probability of pregnancy loss between 9 - 17%, which increases notably after
35 years of age with 20% risk, women 40 years old have a 40% chance of having an abortion, while
those over 45 years of age have up to 80% risk of having an abortion. In the same way, the probability
of having a subsequent abortion increases according to the number of previous losses.
 2.1
In general, women during their first pregnancy have a 15% chance of having an abortion; if they have
ABORTION
had a previous loss, the risk does not increase; while, with two previous losses it increases to 25%. It has
been described that women with 4 previous abortions have up to a 54% chance of having a subsequent
abortion during the next pregnancy.

Approximately 50% of first trimester abortions are attributed to chromosomal abnormalities. Within
this group, the most common are trisomies (13, 16, 18, 21 and 22); Of the monosomies, the most
common is that associated with the X chromosome.

Other causes commonly associated with abortion are anatomical, infectious, autoimmune, hormonal or
metabolic, environmental and occupational. It has been attributed that endocrine alterations,
represented by thyroid disease or uncontrolled diabetes, increase the risk of abortion with OR 8.3 (CI
2.65 - 26.1).

DIAGNOSIS
The clinical picture is characterized by suprapubic abdominal pain and/or transvaginal bleeding;
However, in some cases, such as missed abortion, there may be an asymptomatic course and it may be
diagnosed in routine ultrasounds. As an initial approach, clinical history and physical examination
should be used. Chorionic gonadotropin (hCG) and transvaginal ultrasound are used as auxiliary
studies for diagnosis.

The discrimination zone is defined as the serum hCG level above which intrauterine pregnancy is
expected to be seen by transvaginal ultrasound. Currently this zone is between 1,500 to 3,000 mIU/ml, it
is accepted that at levels >3,500 mIU/ml, the probability of observing an intrauterine gestational sac is
99%, otherwise we could consider an ectopic pregnancy.

For its part, the use of transvaginal ultrasound helps to verify the type of abortion. Fundamental
concepts and measurements must be known for the proper use of this tool (Table 2) . In case of
suspicious criteria or doubt regarding the ultrasonographic findings, it is recommended to perform a
second ultrasound with an interval of 7 - 14 days.

Table 2. Diagnostic criteria and SOS ultrasound abortion breasts

Diagnostic criteria Suspicion criteria
LCC ≥ 7mm WITHOUT FCF LCC < 7mm and no FCF
OS ≥25mm and WITHOUT embryo SG of 16 - 24 mm without embryo
Absence of embryo with FHR 7-13 days after
Absence of embryo with FHR ≥ observing the SG without Yolk sac
2 weeks of USG with SG without Yolk bag
Absence of embryo with FHR 7-10 days after
observing SG with Yolk sac
Absence of embryo > 6 SDG post LMP
empty amnion
Absence of embryo with FHR ≥
11 days of USG with SG with Yolk bag Elongated Yolk bag (>7mm)
Small gestational sac in relation to embryo size
(<5mm)

During the evaluation of the patient, special attention should be paid to the presence of abortion in any
of its varieties combined with febrile syndrome (>37.5°C), hypersensitivity to the mobilization of the
uterus and adnexa, and leukorrhea with or without evidence of shock ( hypotension, tachycardia,
tachypnea). In this scenario, it is a septic abortion which requires antibiotic management and
intrauterine evacuation as soon as possible.

TREATMENT
It can be divided into expectant, medical and surgical. Expectant management can be given to patients
with pregnancies less than 8 weeks; it has been reported that complete expulsion is achieved in
approximately 80% of these patients. This type of management may be more effective in those women
with incomplete abortion.

Regarding medical treatment, the recommendations of the World Health Organization (WHO)
postulate that it should be used ideally in pregnancies less than 10 weeks without comorbid conditions
such as infection or fetal genetic anomalies. In general, the use of misoprostol 800mcg vaginally is
indicated with the option of an extra dose if necessary with an interval of no less than 3 hours and no
more than 7 days after the first dose. In the same way, if administration of mifepristone is available 24
hours prior to misoprostol, it should be used. The different administration schemes of misoprostol with
mifepristone are seen in (Table 3).
 Table 3. Different administration schemes of misoprostol with mifepristone

Success rate
Regime Advantages or disadvantages Gestational age
(%)

Mifepristone 600mg PO followed by

misoprostol 400mcg PO after 48 92 You must return for the >49 days
hours (FDA) administration of misoprostol

Mifepristone 200mg PO, followed by

misoprostol 800mcg VV, VB OR SL 95 - 99 More effective, Shorter time >63 days
24-48 hours later (ACOG) to expulsion, lower adverse
effects, Lower cost, More
convenient

Likewise, if mifepristone is not available, the International Federation of Gynecology and Obstetrics
(FIGO) establishes an administration scheme for the medical management of abortion in pregnancies
less than 13 weeks (Table 4) . Success rates, with complete expulsion, have been reported under the
misoprostol regimen 71 - 84%, while with the use of mifepristone + misoprostol the success of the
treatment increases RR 1.25 (95% CI 1.09 - 1.43).

Table 4. Administration scheme for the medical management of abortion in pregnancies less than 13
weeks
< 13 weeks gestation 13-20 weeks of gestation
Deferred abort Deferred abort
800mcg VV every 3 hours (2 doses) or 200mcg VV/VSl/VB every 4 to 6 hours
600mcg VSl every 3 hours (2 doses)

Incomplete abortion 600mcg PO single dose or Unavoidable abortion

400mcg VS single dose or 400 - 800mcg VV single 200mcg VV/VSl/VB every 6 hours
dose
Cervical preparation for surgical abortion 13 to 19
Cervical preparation for surgical abortion 400mcg weeks: 400 μg VV 3 to 4 hours before the
VSl 1 hour before the procedure or procedure
VV 3 hours before the procedure >19 weeks: it is necessary to combine with
another therapeutic modality

Under the legislation currently in force in Mexico (NOM 007 SSA2-2016), for the care of women during
pregnancy, childbirth and the postpartum period and of the newborn, in gestations greater than 10
weeks, in-hospital management must be carried out under the following recommendations:

• Spontaneous abortion (1st trimester): start 600 - 800mcg (vaginal or sublingual), repeat after 3
hours after assessment, maximum 2 doses
• Incomplete abortion (1st trimester): 400 - 600mcg (vaginal or sublingual)

to. Cervical ripening prior to instrumentation: 400mcg vaginally 2 - 3 hours before the
 procedure
• Fetal death (2nd trimester or 13 - 17 weeks): 200mcg vaginally every 6 hours maximum 4 doses
(total 800mcg)

To monitor medical abortion treatment, it is recommended to perform a transvaginal ultrasound 7 - 14

days after treatment in order to observe the absence of an intrauterine gestational sac.

In case of septic abortion, an antibiotic regimen should be started with PGSC (penicillin G sodium
crystalline) 3 million units every 4 hours and gentamicin 80 mg every 8 hours intravenously. Once the
results of the cultures have been obtained with the antibiogram, the antimicrobial regimen must be re-
evaluated.

The use of hydrocortisone 3g intravenously is accepted as an impregnation dose, and subsequently 1g

IV every 8 hours for 24 hours.

Uterine evacuation should be carried out as soon as possible and when hemodynamic stability
conditions indicate it; In addition, a period of 6 to 8 hours of impregnation with antibiotics has passed.
It is preferred to perform a manual uterine aspiration procedure (see surgical treatment).

SURGICAL TREATMENT
The use of surgical treatment is recommended in the following conditions: excessive and persistent
bleeding, hemodynamic instability, evidence of infected retained tissue, and suspicion of gestational
trophoblastic disease. Instrumented uterine curettage (IUL) or manual uterine aspiration (MVA) can
be performed, the latter being preferred in the following cases:

• Uterine height less than 11cm and cervical dilation less than or equal to 1cm
• septic abortion
• Delayed abortions greater than 10 weeks, after cervical ripening

Manual vacuum aspiration has a complete abortion rate of 99.2%, it can be performed in pregnancies
between 6 - 16 SDG, with the advantage of less blood loss and pain compared to LUI.

Complications of the surgical procedure include: hemorrhage, retained products of conception, uterine
atony, cervical laceration, uterine perforation or rupture, disseminated intravascular coagulation and
infection.

The use of antibiotic prophylaxis has been proposed by some experts, administering 200 mg doxycycline
in a single dose 1 hour before the procedure, however, its benefit has not been proven.

If the patient is Rh negative, the application of anti-D immunoglobulin is recommended 72 hours after
the procedure (300 mcg intramuscular), especially in pregnancies with a gestational age greater than 10
weeks.

FORECAST
Outpatient medical treatment has a good prognosis when the diagnostic approach has been adequate,
as does combined medical and surgical treatment in pregnancies greater than 10 weeks of gestation. In
case of 2 or more abortions, the study protocol for recurrent pregnancy loss should be initiated.
PREVENTION
The pre-pregnancy consultation is a fundamental part when the couple has recurrent pregnancy loss
since identifying specific factors with subsequent treatment prior to pregnancy can improve the
prognosis. In case of infections such as Chlamydia, Neisseria, Ureaplasma and Mycoplasma , relevant
treatment is mandatory.

Post-abortion contraception is important when the suspicion and diagnostic confirmation of pathologies
additional to pregnancy have been diagnosed, with the aim of achieving adequate specific treatment, in
these cases both the application of IUD or subdermal implant according to the eligibility criteria. of the
WHO.
 BIBLIOGRAPH
Y
1. ACOG. Clinical Management Guidelines for Obstetricians–Gynecologists. Early Pregnancy Loss.
Obstet Gynecol. 2019;133(76):168–86

2. Hendriks E, Macnaughton H, Mackenzie MC. First trimester bleeding: Evaluation and

management. Am Fam Physician. 2019;99(3):166–74

3. National Institute for Health and Care Excellence (NICE). Ectopic pregnancy and miscarriage:
diagnosis and initial management | NICE guideline [NG126]. NICE Guidel [Internet]. 2019;(December
2012). Available from: https://www.nice.org.uk/guidance/ng126/informationforpublic

4. Morris JL, Winikoff B, Dabash R, Weeks A, Faundes A, Gemzell-Danielsson K, et al. Figo's

Updated Recommendations for the Use of Misoprostol Only in Gynecology and Obstetrics Authors.
2017; 145(85):157-65

5. Ceja Kelly GA, Salas Gutíerrez M de L, Rios Castillo B. Clinical Practice Guide for the diagnosis
and treatment of spontaneous abortion and initial management of recurrent abortion. Cat Maest
Clinical Practice Guides IMSS-088-08. 2009;1–50

6. National Abortion Federation. 2020 Clinical Policy Guidelines for Abortion Care. 2020; Available
from: https://prochoice.org/education-and-advocacy/cpg/

7. Kapp N, Eckersberger E, Lavelanet A, Rodriguez MI. Medical abortion in the late first trimester: a
systematic review. Contraception [Internet]. 2019;99(2):77–86. Available from:
https://doi.org/10.1016/j.contraception.2018.11.002
 2.2 LOW PLACENTA INSERTION
DEFINITION
According to the consensus of the American Institute of Ultrasound in Medicine (AIUM), it is
recommended to use the term placenta previa for that which directly covers the internal cervical os
(OCI) and the term low-insertion placenta will be assigned when the placental edge is located less than
20mm from the internal cervical os. Placenta normally located when the edge is located >20mm from
the cervical os.

EPIDEMIOLOGY
The prevalence of low-lying placenta is approximately 3 in every 1,000 pregnancies, while placenta
previa can complicate up to approximately 1 in every 200 births. The annual incidence of this in the
United States is 2.8 to 4.8 per 1,000 births in singleton pregnancies and 3.9 per 1,000 in multiple
pregnancies, compared with a global prevalence of 5.2 per 1,000 births.

RISK FACTOR'S
Among the main risk factors for its presence we find:

• anterior placenta previa

• Previous cesarean sections: one cesarean section RR 4.5 (95% CI 3.6 – 5.5), two cesarean
sections RR 7.4 (95% CI 7.1 - 7.7), three cesarean sections RR 6.5 (95% CI 3.6 – 11.6) and for 4
or more RR 44.9 (CI 95% 13.5 - 149.5)
• Smoking OR 1.42 (95% CI 1.3 - 1.5)
• Maternal cocaine use
• Maternal age over 40 years OR 1.08 (95% CI 1.07 - 1.09)
• History of spontaneous or induced abortion
• Multiparity

PATHOPHYSIOLOGY AND ETIOLOGY

The mechanism to which the endometrial damage that is generated is attributed is a previous scar or
damage to the lower uterine segment that can encourage placental growth, in the unhealed segment, in
addition to less uteroplacental perfusion, increasing the surface area required for placental insertion
and can cause the placenta to invade the lower uterine segment.

The term placental migration has been used to explain a “resolution” of the low-set placenta since as
pregnancy progresses, the stationary lower placental edge moves away from the cervical os with the
development of the lower uterine segment. In fact, it has been observed that the uterine segment
increases from 0.5cm to more than 5cm at term. Second, it is thought that the placenta undergoes a
process called trophotropism by growing toward the area of the uterus with the best blood supply
(typically the fundus), in turn, the portion of the placenta closest to the cervix recedes and atrophies. .

The apparent placental 'migration' after development of the lower uterine segment during the third
trimester of pregnancy results in resolution of the low placenta in 90% of cases before term, however it
should be noted that this is less likely in women with a previous cesarean section.

DIAGNOSIS
The diagnosis of placenta previa or low placenta should not be made before 18 to 20 weeks of gestation
and the provisional diagnosis should be confirmed after 32 weeks of gestation or earlier if the clinical
situation warrants it.

1. Clinical manifestations

Painless vaginal bleeding may occur in the second or third trimester. Bleeding is thought to occur from
disruption of placental blood vessels in association with the development and thinning of the lower
uterine segment, as well as from separation of the placenta from the underlying decidua resulting from
contractions, cervical effacement, and cervical dilation.

Between 70% and 80% of patients with placenta previa will have at least one episode of bleeding,
around 20% will have uterine activity before bleeding, and less than 10% remain asymptomatic until
term.

It is important to mention that obstetric hemorrhage due to low-insertion placenta manifests in 30% of
cases in the second trimester.

The presentation of early onset hemorrhage (less than 30 weeks) carries with it a higher risk of blood
transfusion and a high association with perinatal morbidity and mortality.

2. Cabinet

Ultrasound can rule out a placenta previa and low insertion with a high negative predictive value at any
gestational age. If the placental edge is 2cm or more from the internal cervical os, the placental location
should be reported as normal.

If the placental edge is less than 2cm from the internal cervical os, but without covering it, the placenta
should be labeled as a low-lying placenta.

Transabdominal and transvaginal ultrasound provide the best means for diagnosis. Although
transabdominal ultrasound can detect at least 95% of placenta previa, transvaginal ultrasound has a
diagnostic accuracy close to 100%.

Transvaginal ultrasound has a PPV of 93.3% and NPV of 97.6% with a false negative rate of 2.3% in
predicting placenta previa in women who had been classified as low insertion on a second trimester
abdominal evaluation, with a sensitivity of 87.5% and specificity of 98.8%.

The diagnosis of placenta previa obtained in the second trimester will persist into the third trimester in
26% of cases, while a low placenta will persist in only 2.5% of cases. It is recommended that when the
diagnosis is made, serial ultrasounds should be included to evaluate the location of the placenta and
fetal growth, avoid vaginal examinations, and provide advice on alarming data.

It is important that within the ultrasonographic evaluation the placental location (including laterality),
the characteristics of the placental edge (considering the thickness, the presence of a sinus) and
associated findings (succenturiate lobe, insertion of the cord near the cervix) are clearly described. ).

Cervical length has been used as a predictor of bleeding. Compared with women with a normal cervical
length, those with a short cervix (less than 25mm) have an RR of 7.2 (95% CI 2.3 - 22.3) for massive
hemorrhage due to placenta previa.

TREATMENT
In patients with persistence of low insertion or placenta previa at 32 SDG who are asymptomatic, a
transvaginal evaluation is recommended at 36 SDG in order to plan when to end the pregnancy.
OIC coverage of 2cm or more at any time in the third trimester is highly predictive of the need for
cesarean section, and in general, any degree of OIC coverage after 35 weeks is an indication for
cesarean section.

When the placental edge is more than 2cm from the OCI, a trial of labor can be offered with a high
probability of a safe vaginal delivery, without requiring any change in regular obstetric management.

In patients with low placental insertion, the termination route will be planned according to the
evolution of the pregnancy, the ultrasound findings and the distance between the placental edge. If the
distance from the placental edge and the OIC is between 0 and 2cm, the probability of cesarean section
due to placenta previa is high, ranging between 40 to 90%, although vaginal delivery may be a
possibility.

According to some studies in women with placental borders between 11 - 20mm distance from the OCI
and who were taken to labor, more than 90% had a vaginal delivery without significant intrapartum
bleeding, confirming that not all women with a placental edge less than 2cm from the OCI require
cesarean section.

If the distance from the placental edge to the OIC is 11 to 20mm, management is expectant, the trial of
labor is indicated as long as there is a high-risk obstetric unit, and cesarean section is reserved only for
cases that develop an intrapartum indication.

If the placental edge is less than 10 mm from the internal cervical os, delivery by elective cesarean
section is indicated, since the risk of obstetric hemorrhage is high.

A cycle of lung maturity scheme may be considered before 34 SDG in those patients at high risk.

When planning the cesarean section, an interdisciplinary team must be integrated with the
participation of anesthesiology, neonatology, and blood banking in the face of the need to use blood
products.

FORECAST
The probability of bleeding is greatest in the third trimester when the placental edge is within 2cm of
the internal cervical os. Likewise, a greater association of fetal misrepresentation, preterm labor,
congenital anomalies, and amniotic fluid embolism with placenta previa has been documented.

Patients with placenta previa have an increased risk of hemorrhage during a cesarean section
compared to patients undergoing this procedure for any other indication, RR 3.97 (95% CI 3.24 – 4.85),
with the anterior placenta being the most related to hemorrhage.
BIBLIOGRAPH
Y
1. Bhide A Prefumo F Moore J et al. Placental edge to internal os distance in the late third trimester
and mode of delivery in placenta praevia. BJOG. 2003; 110: 860-864

2. Taga A, Sato Y Sakae C et al. Planned vaginal delivery versus planned cesarean delivery in cases of
low-lying placenta. J Matern Fetal Neonatal Med. 2017; 30: 618-6223

3. Vintzileos, A., Ananth, C. and Smulian, J. (2015). Using ultrasound in the clinical management of
placental implantation abnormalities. American Journal of Obstetrics and Gynecology, 213(4), pp.S70-
S77

4. Al Wadi K, Schneider C, Burym C. Evaluation of the safety of labor in women with a placental
border of 11 to 20 mm from the inside of the cervical body. Journal of Obstetrics and Gynecology of
Canada. 2014; 36 (8): 674-677

5. Jauniaux ERM, Alfirevic Z, Bhide AG, Belfort MA, Burton GJ, Collins SL, Dornan S, Jurkovic D,
Kayem G, Kingdom J, Silver R, Sentilhes L on behalf of the Royal College of Obstetricians and
Gynaecologists. Placenta Praevia and Placenta Accreta: Diagnosis and Management. Green-top
Guideline No. 27a. BJOG 2018
 The first Standards and Procedures of
Obstetrics were published in 1984, over
time there have been various updates, the
last publication being in 2003.

The launch of the 2021 edition of the

Standards represents a great effort, which
aims to share updated information and
our institutional experience in the field of
perinatal health.

The content of the standards is divided

into sections to facilitate its
understanding, as well as to promote a
comprehensive approach to pregnant
women and the complications that may
arise from it.

The topics included are the following:

prenatal care, high-risk pregnancy,
medical complications of pregnancy,
infectious complications, resolution of
pregnancy, puerperium, and obstetric
procedures.

The Institute thanks all the collaborators

who participated in the preparation of
these Standards, recognizing the
enormous effort given to this work.

We hope that its content is a support and

guide for your clinical practice.
INPer
Ethics and Humanism

NATIONAL INSTITUTE
OF PERINATOLOGY
Isidro Espinosa de los Reyes