Obstetric Ultrasound April 2014

WOM/MAT/CLI/GUI/V1/2014/04
MATERINITY GUIDELINE
OBSTETRIC ULTRASOUND
APPROVING COMMITTEE(S)
EFFECTIVE FROM
Maternity
Improvement
Date approved:
Board
November 2012
All staff in the maternity service
11th April
2014
DISTRIBUTION
RELATED DOCUMENTS
STANDARDS
OWNER
AUTHOR/FURTHER INFORMATION
SUPERCEDED DOCUMENTS
REVIEW DUE
KEYWORDS
INTRANET LOCATION(S)
Page 1 of 23
Intranet
Antenatal Risk Assessment, Booking guideline,
Missed Appointments, Multiple Pregnancy,
Diabetes
NHS Fetal Anomaly Screening Programme
Miss. S. Thamban, Consultant Obstetrician and
Gynaecologist
Mr. J. Aquilina - Consultant in Obstetrics and
Gynaecology
Mr. M. Raveendran, Consultant in Obstetrics
and Gynaecology
Mr. M. Gupta, Consultant in Obstetrics and
Gynaecology
Miss. A. Shah, Consultant in Obstetrics and
Gynaecology
Dr T Molykutty, Associate Specialist in
Obstetrics and Gynaecology
Obstetric Ultrasound, Barts and the London,
2011
Fetal Medicine Guidelines, Newham University
Hospital NHS Trust, 2012
November 2015
Ultrasound scanning, fetal assessment,
ultrasound screening, maternal and fetal
assessment unit (MFAU), maternal assessment
unit (MAU), fetal assessment unit (FAU),
anomaly and growth.
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STabPersistence
CONSULTATION
WOM/MAT/CLI/GUI/V1/2014/04
Barts Health
Maternity Improvement Board
Barts and the London unit
(BLT)
Mr. J. Aquilina, Consultant in Obstetrics and
Gynaecology
Newham University Hospital
unit (NUH)
Whipps Cross University
Hospital (WX)
SCOPE OF APPLICATION
AND EXEMPTIONS
External Partner(s)
Page 2 of 23
Miss A. Shah, Consultant in Obstetrics and
Gynaecology
Mr. M. Raveendran, Consultant in Obstetrics
and Gynaecology
Mr M Gupta, Consultant in Obstetrics and
Gynaecology
Not applicable
Included in policy:
For the groups listed below, failure to follow the policy may result in investigation and
management action which may include formal action in line with the Trust's disciplinary or
capability procedures for Trust employees, and other action in relation to organisations
contracted to the Trust, which may result in the termination of a contract, assignment,
placement, secondment or honorary arrangement.
All Trust staff, working within or for the maternity service in whatever capacity
All sonographers, agency staff, students midwives, student nurses and doctors
in training working within the maternity service
Exempted from policy:
The following groups are exempt from this policy
No staff are exempt from this guideline
WOM/MAT/CLI/GUI/V1/2014/04
TABLE OF CONTENTS
1
INTRODUCTION
Implementation
5
5
2
ROLES AND RESPONSIBILITIES
5
3
DATING SCAN
6
4
5
COMBINED (NUCHAL TRANSLUCENCY) SCAN
Maternal Vaginal Bleeding
Vanishing Twin
7
ANOMALY SCANS
Normal Variants (Do not refer or report)
Hard Markers
Hydronephrosis
Ventriculomegaly
9
8
8
9
10
10
11
6
UTERINE ARTERY DOPPLERS
11
7
GROWTH SCAN
12
8
LOW LYING PLACENTA
13
9
MISCELLANEOUS
Twins
Fetal sexing
Inadequate examination
Indeterminate ultrasound findings
Suspected oligohydramnios or polyhydramnios
Preterm prelabour rupture of membranes
Diabetic pregnancy
Fetal presentation and estimated fetal weight
Suspected large for date
Late bookers (after 24 weeks)
10
CERVICAL LENGTH
11
REDUCED FETAL MOVEMENTS
Under 28 weeks gestation:
28 weeks gestation: Decision Tree
13
13
14
14
14
14
14
14
14
14
15
15
15
16
17
12
MANAGEMENT OF SUSPECTED INTRAUTERINE GROWTH RESTRICTION 18
13
RETAINED PRODUCTS OF CONCEPTION
19
14
MANAGEMENT OF ADNEXAL MASSESS DETECTED IN PREGNANCY
19
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15
BREACH OF GUIDELINES/POLICIES
19
16
MONITORING COMPLIANCE
20
17
REFERENCES
Appendix 1: Change Log
Appendix 2 – Impact assessments
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OBSTETRIC ULTRASOUND
1
INTRODUCTION
1.1
This document is set out to provide best-practice guidelines based on current
scientific evidence. This document is neither comprehensive, nor does it set out to
dictate management policy. We encourage staff referring women to the unit to
discuss cases with the obstetric sonographers or Maternal and Fetal Assessment
unit (MFAU) or Maternal Assessment Unit (MAU), so that we may all utilise our time
and resources efficiently.
1.2
The services in the Unit will be divided into the following sections:
1.2.1
Routine ultrasound - nuchal, anomaly and growth scans.
1.2.2
Maternal and Fetal Assessment unit (MFAU) - service for women booked at
Royal London and Whipps Cross and Maternal Assessment Unit (MAU) at
Newham
1.2.3
Fetal Medicine Unit (FMU) - tertiary level referral service for pregnant women
provided by Consultants with Obstetric Ultrasound/Fetal Medicine experience.
Implementation
1.3
Information on how to access guidelines will be included in the orientation pack for
medical staff and midwives.
1.4
The updated paper copy will be attached to guideline notice board, in each clinical
area for four weeks.
1.5
Electronic copies will be distributed to the lead Midwives in each clinical area.
1.6
The guideline will be available via the trust intranet and circulated to guidelines
foldersDefine any specialist terms used in the policy whose meanings may be open
to ambiguity or not obvious to those using the policy.
2
2.1
ROLES AND RESPONSIBILITIES
Fetal Medicine Referrals - If a women needs to be referred to FMU at their
respective location, the appointment should be organised via MFAU or MAU before
the women leaves the department and the date and time of the referral should be
documented on the scan report. The patient should be seen within 3 working days
from the time of the referral
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Fetal Medicine Unit
Telephone
Fax
Newham
020 7363 9172
020 7363 9341
The Royal London
020 3594 2512
020 3594 3218
Whipps Cross
020 8535 6530
020 8535 6480
2.2
FMU Consultant not available - If the FMU consultant is away and a fetal
abnormality is detected which the sonographer feels needs to be seen before the
next available appointment, please refer to other legacy sites (section 2.5).
2.3
FMU Neonatal referrals - Information on Prenatally diagnosed defects/lesions are
discussed at monthly Fetal Medicine MDT meeting at the respective location.
3
DATING SCAN
3.1
All women are offered a dating scan. This is preferably between 10 weeks +0 days–
13 weeks +6 weeks gestation. At this scan viability of the pregnancy is assessed
and ultrasound dates acquired by measuring the Crown-Rump Length (CRL). If any
gross anomalies are suspected or seen refer to FMU.
3.2
The USS date is generally considered more accurate and all pregnancies are now
re-dated:
3.3

By CRL up to 84mm in first trimester

By Head Circumference (HC) after 14 weeks gestation or CRL > 84mm
Any fetus with nuchal fold thickening (NT≥3.5mm) should be referred immediately to
FMU before offering first trimester screening for trisomy 21. This is to discuss the
option of invasive assessment and referral to Royal London for fetal
echocardiography at 20 weeks.
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3.4
The management for different early ultrasound findings is itemised in the Table
below.
Ultrasound Findings
Discriminatory Findings
Suspected Hydatiform
mole
Gestation sac is visible,
but no fetal pole
Action
Refer to early pregnancy
assessment unit (EPAU)
Largest sac
Re-scan in 10-14 days
diameter < 25mms (TVS)
in EPAU
Largest sac
Refer to EPAU
diameter ≥ 25mms (TVS)
Gestation sac and pole
visible, but no heart beat
Foetal pole
Re-scan in 10-14 days
< 7mms (TVS)
in EPAU
Foetal pole
Refer to EPAU
≥ 7mms (TVS)
Gestational sac not seen
Negative urinary
No action
Pregnancy test
Positive urinary
Refer to EPaU
Pregnancy test
4
COMBINED (NUCHAL TRANSLUCENCY) SCAN
4.1
Women booking at Barts’ Health will be invited to have this ultrasound scan as the
preferred method of screening for chromosomal and cardiac abnormalities.
4.2
The objectives of the Nuchal Translucency (NT) Scan are to:





4.3
Confirm viability
Pregnancy dating (see page 2)
Diagnose multiple pregnancy and determine chorionicity
Diagnose major structural anomalies
Screen for chromosomal and cardiac abnormalities by measuring nuchal
translucency
The Crown Rump Length (CRL) should be 45-84mm and NT should be measured
4.3.1
If the CRL is <45mm, a repeat scan should be arranged for measurement of
NT
4.3.2
If the CRL is >84mm, discuss further screening i.e. Quad’s test
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4.4
4.3.3
If the NT cannot be measured, and if gestation ≤ 13 week+0days, discuss
with the fetal medicine consultant. A Transvaginal scan to measure the NT
may be offered at the discretion of the fetal medicine consultant. If gestation ≥
13 weeks+ 0 days, refer for Quad’s test
4.3.4
All twins should be offered combined screening (See Multiple Pregnancy
Guidelines). They should be referred to Multiple Pregnancy clinics at the
respective sites within 2 weeks.
4.3.5
If multiple pregnancy is diagnosed, they are referred as A&B as their
nomenclature
4.3.6
Triplets- refer to the Multiple Pregnancy Lead for nuchal translucency
assessment
Printed stored images



If fetal pole is not visible, gestational sac with diameter measurement.
CRL
Magnified NT measurement (care must be taken to differentiate between
the skin and amnion)
Cross-section of cranium, showing 2 hemispheres.

4.5
Action to take:
4.5.1
If any anomalies are suspected or Down’s risk is >1: 150, refer to FMU
4.5.2
If the NT. ≥97.5th centile (3.5mm) refer to FMU for the possibility of invasive
assessment. They will have fetal echocardiography at 20 weeks at the Royal
London regardless whether they accept or decline invasive assessment
4.5.3
All twins will be rescanned according to the Multiple Pregnancy Guidelines.
Maternal Vaginal Bleeding
4.6
If there is a history of significant maternal vaginal bleeding at the time of the first
trimester screening for Down’s syndrome, there have been concerns that this might
change maternal blood levels of the biochemical markers used in the combined
test, perhaps secondary to placental disruption. However it is recommended that
combined test is used in the normal way (calculating the risk based on maternal
age, nuchal translucency, HCG and PAPP-A levels), because current data suggests
that the biochemical marker levels are not significantly different in women with this
history.
Vanishing Twin
4.7
When ultrasound shows that there is an empty second pregnancy sac, the
biochemical markers appear no different to those in a singleton pregnancy and the
combined test of NT, PAPP-A and free beta HCG can be used to calculate the risk.
If ultrasound shows that there is a second sac containing a dead fetus (sometimes
called ‘vanished’ twin), it is possible that there could be a contribution to the
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maternal biochemical markers for many weeks. We recommend that in this event
services undertake the risk calculation based on the maternal age and nuchal
translucency only (i.e. without biochemistry).
5
ANOMALY SCANS
5.1
All women booking at Barts Health are invited to have this ultrasound scan between
18+0 and 20+6 weeks gestation.
5.2
The objectives of the scan are:



Diagnose spina bifida
Diagnose other major fetal abnormality
To screen for ultrasound markers of chromosomal abnormalities in women who did
not have NT or serum biochemistry
5.3
The following should be examined in the fetus: cerebral ventricles, choroid plexus,
posterior fossa, cerebellum, facial profile, lip/hard palate, spinal column (transverse,
coronal and longitudinal), 4-chamber view of the heart and great vessels, chest
contents, diaphragm, stomach, abdominal wall, umbilical cord and vessels, kidneys,
renal pelvic, bladder, all long bones, hands and feet
5.4
The following measurements should be obtained: BPD, HC, TCD, Va, Vp, nuchal
pad, AC and FL.
5.5
If the Abdominal circumference (AC)  5th
Dopplers (see Doppler guidelines)
5.6
The diagnosis of nuchal pad>6mm should prompt referral to FMU as there is a
strong association with Down’s syndrome.
5.7
Printed stored images






centile  perform uterine artery
Standard BPD view
Trans-cerebellar diameter (TCD)
Coronal section of the lips with nasal tip
Abdominal circumference demonstrating AC measurement
Femur length
Sagittal section of spine including spine and sacrum
Normal Variants (Do not refer or report)
5.8
Women should NOT be referred to FMU for further assessment of chromosomal
aneuploidies if the following whether single or multiple are seen in the anomaly
scan and should not be reported on the fetal database:




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Choroid plexus cysts
Dilated cisterna magna
Cardiac Echogenic foci
Two-vessel cord
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Hard Markers
5.9
The following appearance should be reported and the women referred to FMU for
further assessment




5.10
Nuchal fold greater than 6mm
Ventriculomegaly (posterior horn greater than 10mm)
Echogenic bowel (with density equal or greater than fetal bone)
Renal pelvic dilatation greater than 7mm
In fetus with echogenic bowel, maternal blood should be taken for CMV and
Toxoplasmosis before they are seen in FMU.
Hydronephrosis
5.11
All anomaly scans should involve the assessment of the fetal kidneys. If the renal
pelvis appears dilated, the antero-posterior renal pelvis diameter (APRPD) should
be measured.
5.12
Classification of hydronephrosis


At 20 weeks, APRPD >7mm. If ≥10mm, refer to FMU
After 30 weeks, 10mm
Is the risk for Down’s syndrome increased?
5.13

Yes – if the woman has NOT had NT or biochemical screening and is 35years
old at booking
No – if NT or biochemical screening has been performed and is classified as low
risk.

5.14
What follow-up is required?


5.15
If > 7 but <10mm repeat scan at 34 weeks
If ≥10mm, repeat scan at 26 weeks (and 34 weeks if persistent)
Action:

For low-risk women with isolated hydronephrosis please give and explain the
provided information sheets.
If fetal hydronephrosis is associated with other chromosomal markers, dilated
ureters, distended bladder or reduced liquor volume, the women should be
referred to the FMU.
If the fetal hydronephrosis persists into the third trimester, the women should be
referred to FMU.
Women with third trimester fetal hydronephrosis should have this noted on the
delivery page of their hand-held notes.



5.16
Criteria for referral to Miss Ashwini, Consultant neonatal surgeons:



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Megacystitis with patient opting for expectant management
Bilateral hydronephrosis
Unilateral APRPD ≥ 20mm
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Ventriculomegaly
5.17
Refer to FMU if posterior horn >10mm.
5.18
Offer fetal MRI in the presence of




6
additional cranial anomalies,
progressive ventriculomegaly,
previous pregnancy affected by neuronal migration disorder
meningomyelocele (when patients opts to continue with pregnancy)
UTERINE ARTERY DOPPLERS
6.1
The following women should be offered uterine artery Dopplers (UAD).
Group 1 - Any TWO of these factors:
 1st pregnancy
 Pregnancy interval < 6 months or ≥ 60 months
 Maternal age ≥ 35 years
 BMI ≥ 40 at booking (see 4.10.7)
 BMI < 20 at booking
 Family history of pre-eclampsia (mother, sister)
 Multiple Pregnancy
Group 2 - Any ONE of these factors:
 Pre-eclampsia in previous pregnancy
 Previous small for gestational age i.e. BW
 Maternal age> 40 years
 Chronic hypertension,
 Chronic renal disease,
 Autoimmune disease (SLE or antiphospholipid antibodies)
 PAPPA<0.4 Mom in the combined test
 Pre-existing diabetes
 Echogenic bowel
 Previous history of stillbirth
 Previous history placental abruption
 AC or EFW ≤ 5th centile
Group 3 - Past history of any of these factors:
 IUGR± PET that needed delivery before 34 weeks
6.2
All women in all three groups will be offered UAD at 18-20 weeks (at the time of the
anomaly scan). However women in group 3) will be offered UAD at 16 weeks at
Royal London Hospital.
6.3
Who needs follow-up?

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Mean (average of both sides) Pulsatility index (PI) >1.45 transabdominally
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6.4
What follow-up is required in those who are screen positive for uterine artery
Doppler?
Group 1
 Repeat growth-scan at 32 weeks. If this is normal, no further scans are booked.
 If growth velocity has fallen at 32 weeks, follow up scans should be arranged in
the FMU clinic at 2 weeks interval.
Group 2 and 3
 Repeat growth scan at least every 4 weeks (or sooner if any clinical concerns)
6.5
In women at high risk of preeclampsia (from history or positive uterine artery
Doppler), should be commenced on aspirin at or before 16 weeks
6.6
Consider induction of labour between 37 and 38 weeks in those which are screen
positive for uterine artery Doppler
6.7
Any abnormalities in growth velocity, liquor volume or fetal Doppler should be
referred to FMU.
6.8
In women BMI≥ 40, they should have growth scan at 28 and 34 weeks even if UAD
are normal
7
GROWTH SCAN
7.1
Objective – To assess fetal wellbeing and placental function
7.2
Umbilical artery Doppler should form part of routine growth assessment
7.3
Multiple pregnancy - twins or higher-order multiples. For specific scan intervals
according to chorionicity see Multiple Pregnancy Guideline
7.4
The following measurements should be obtained:


BPD, HC, AC and FL.
Liquor volume should be assessed objectively using deepest vertical pool (DVP)
i) DVP<2 is classified as oligohydramnios
ii) DVP>8 are classified as polyhydramnios
7.5
If polyhydramnios is present the client should be referred to the FMU.
7.6
In suspected oligohydramnios and/or reduced growth velocity they should be
referred to FMU and the flow chart at 4.19 should serve as a guideline.
7.7
Printed stored Images



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Standard AC measurement
DVP
Umbilical artery Doppler
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8
LOW LYING PLACENTA
Gestation
Finding
Action
21-23 weeks
Placenta clearly overlaps the os –
unscarred uterus
Rescan at 36 weeks
Anterior placenta, clearly overlaps
the os – previous uterine
surgery/LSCS
Rescan with FMU at 32 weeks to
assess for placenta accreta
Placental edge > 2cms from the
internal os
Label as “low-lying”, if “anterior” or
“posterior” and “Suitable for trial of
vaginal delivery by FMU guidelines”
Placental edge < 2cms from the
internal os
Rescan 1 week, label as “major
praevia” and whether “anterior” or
“posterior”.
Placental edge overlaps the
internal os
Refer to attending clinician ASAP &
MDT plan for birth: LSCS at 38 weeks
Placental edge > 2cms from the
internal os
Label as “low-lying”, if “anterior” or
“posterior” and “Suitable for trial of
vaginal delivery by FMU guidelines”
Placental edge < 2 cm or crossing
the os
Refer to MFAU ASAP: LSCS at 38
weeks
36 weeks
37 weeks
8.1
If the placenta is anterior, note this in the comments so that the clinicians are
prepared to cut through the placenta at LSCS.
8.2
Ideally the transvaginal route is preferable to assess placental site especially in
cases where suboptimal views are obtained trans-abdominally.
8.3
If there are any queries about part of the scan a second opinion should be sought
from a senior sonographer or referred to the doctor in the Fetal Medicine Unit.
8.4
Women who have had a previous caesarean section who also have either placenta
praevia or an anterior placenta underlying the old caesarean section scar at 32
weeks of gestation are at increased risk of placenta accreta and should be
managed as if they have placenta accreta, with appropriate preparations for surgery
made.
9
MISCELLANEOUS
Twins
9.1
Dichorionic twins should have growth scans in the obstetric USS department every
4 weeks from 20 weeks. Monochorionic twins should have scans every 2 weeks at
each respective fetal medicine unit from 16 weeks till 24 weeks, then every 3 weeks
till 30 weeks. They should then be followed up by growth scan in the obstetric USS
department every 3 weeks (see multiple pregnancy guidelines)
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Fetal sexing
9.2
If during the scan the patient wishes to know the sex of her baby, the sonographer
can reveal the sex after explaining that ultrasound is not 100% accurate. Should
any difficulties arise in sexing (i.e. due to position or cord), the patient should be
given the reason for this. A repeat scan is NOT indicated for this indication.
Inadequate examination
9.3
If any part of the examination is inadequate, a re-scan must be booked. Where a
scan is of a poor image quality due to body habitus this should be noted in the
report.
Indeterminate ultrasound findings
9.4
If there are any queries about part of the scan a second opinion should be sought
from a senior sonographer or referred to the FMU.
Suspected oligohydramnios or polyhydramnios
9.5
Unless otherwise stated the request is treated as non-urgent and an appointment
will be made within one week.
Preterm prelabour rupture of membranes
9.6
This is a clinical diagnosis. Request to confirm this diagnosis by USS will be
rejected. There is also no indication to measure the aminiotic fluid index weekly in
cases of preterm rupture of membrane.
Diabetic pregnancy
9.7
Fetal echocardiography should be arranged for pre-pregnancy diabetics at 20
weeks. Serial growth scans should automatically be booked every 4 weeks from 26
weeks gestation and 2 weekly after 36 weeks (at 26, 30, 34, 36, 38 weeks). All
women should have umbilical artery dopplers done routinely as part of the
growth scan even if growth velocity is normal. Do not book routine scans for
GDM not requiring insulin unless there are specific indications like suspected
macrosomia.
Fetal presentation and estimated fetal weight
9.8
Referrals are usually only appropriate after 36 weeks unless premature vaginal
delivery is contemplated. If a breech presentation is confirmed the position of the
legs will be reported, in addition to the estimated fetal weight. If the lie is transverse
after 36 weeks, or if the placenta is reported as low lying after 36 weeks in late
bookers, the woman MUST be reviewed by fetal medicine unit.
Suspected large for date
9.9
Referral for growth scan to estimate fetal size would not be accepted unless there is
polyhydramnios or other risk factors.
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Late bookers (after 24 weeks)
If the fetus is below 2 SD’s then the women should have uterine artery Dopplers
performed to rule out uteroplacental insufficiency. If uterine artery Dopplers are
normal rebook for follow up scan in 4 weeks’ time to check growth velocity. They
should also have attempted full anomaly scan taking account of the limited view at
late gestation.
9.10
10
CERVICAL LENGTH
10.1
At present this should be performed at the discretion of the referring clinician.
Cervical length measurements should ONLY be performed using the transvaginal
route and an empty bladder. They are normally performed at 22-24 weeks or earlier
at the referring clinician’s discretion.
10.2
Who needs cervical length?

10.3
Women who have had a previous 16-32 week spontaneous delivery
Who does NOT need cervical length?


Previous 1st trimester miscarriages
Spontaneous rupture of membranes
10.4
Cervical length at 12-14 weeks prior or post cervical cerclage are of little benefit and
are not indicated
10.5
If the cervical length is ≤ 25mm (+/- cervical funnelling),the women should be
referred to their respective fetal medicine unit
10.6
Printed stored images

11
Cervical length
REDUCED FETAL MOVEMENTS
11.1
There is insufficient evidence to recommend formal fetal movement counting using
specified alarm limits. Women should be advised to be aware of their baby’s
individual pattern of movements.
11.2
If they are concerned about a reduction in or cessation of fetal movements
after 28+0 weeks of gestation, they should contact their maternity unit.
11.3
If women are unsure whether movements are reduced after 28+0 weeks of
gestation, they should be advised to lie on their left side and focus on fetal
movements for 2 hours. If they do not feel 10 or more discrete movements in 2
hours, they should contact their midwife or maternity unit immediately.
11.4
Women who are concerned about RFM should not wait until the next day for
assessment of fetal wellbeing.
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11.5
All clinicians should be aware of the potential association of decreased fetal
movements with key risk factors such as fetal growth restriction (FGR), small-forgestational-age (SGA) fetus, placental insufficiency and congenital malformations.
11.6
USS when required must be performed within 24 hours or when service is next
available
11.7
Caregivers should be aware of the increased risk of poor perinatal outcome in
women presenting with recurrent RFM.
Under 28 week’s gestation:
11.8
If a woman presents with RFM prior to 24+0 weeks of gestation, the presence of a
fetal heartbeat should be confirmed by auscultation with a Doppler handheld device.
11.9
If fetal movements have never been felt by 24 weeks of gestation, referral to a
specialist
11.10
fetal medicine centre should be considered to look for evidence of fetal
neuromuscular conditions.
11.11
If a woman presents with RFM between 24+0 and 28+0 weeks of gestation the
11.12
presence of a fetal heartbeat should be confirmed by auscultation with a Doppler
handheld device.
11.13
If there are risk factors for fetal compromise or abnormal examination
findings, refer to USS
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28 weeks gestation: Decision Tree
First presentation of reduced fetal movements (RFM) at >28+0
Detailed history including risk factors for stillbirth and fetal growth restriction (FGR)
History confirms RFM
Auscultate for FH with sonicaid to exclude intrauterine fetal death (IUFD)
FH not present
FH present
CTG
Refer to USS
Suspicious or
pathological FHR
Normal FHR
Refer to LW
Continue with RFM or
risk factors for
FGR/stillbirth
Reduced SFH
USS growth
+/- Doppler’s
Perception of
RFM resolved and
no risk factors for
FGR/stillbirth
Normal SFH
Reassure/give advice
re: further episodes of
RFM. If further
episodes of RFM refer
to MFAU
11.14
Ensure woman has ANC appointment arranged for one week either with community
midwife, General Practitioner or hospital.
11.15
Advise women to come back to hospital/ contact her midwife if RFM occurs.
11.16
Women with recurring reduced fetal movement will need to be reviewed by a doctor
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12
MANAGEMENT OF SUSPECTED INTRAUTERINE GROWTH RESTRICTION
High risk of SGA fetus based
on history, biochemistry or
uterine artery Doppler
Symphysis fundal height
indicating small for dates
th
Single AC or EFW<10 centile
Serial measurement crossing centile
UA Doppler
th
Pi ≤ 95
centile
th
Pi>95 centile and
EDF present
AREDV
Repeat ultrasound
(fortnightly)
UA Doppler
Repeat UA
MCA Doppler
Doppler twice
weekly
AC & EFW
Repeat UA
and DV
Doppler
daily
Delivery
Delivery
Delivery
Consider delivery at
37-38 weeks
Recommend delivery by
37 weeks
Recommend delivery
by 37 weeks if
Consider delivery > 34
weeks if static growth
over 3 weeks
Consider delivery before
32 weeks after steroids if
Consider steroids if
delivery by cs (as per
RCOG guidelines)
-abnormal DV Doppler
and/or CTG provided ≥24
weeks and EFW>500g
-static growth over 3-4
weeks
-MCA Doppler pi <5
centile
th
Recommend steroids
if delivery is by cs (as
per RCOG guidelines)
Page 18 of 23
Recommend delivery by
32 weeks after steroids
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13
RETAINED PRODUCTS OF CONCEPTION
13.1
Pelvic ultrasound is very specific (low false-positive rate) in the detection of third
trimester retained products of conception but not very sensitive, i.e. a negative
ultrasound will not exclude retained products in approximately 60% of women who
present with bleeding.
13.2
Pelvic ultrasound is therefore not indicated in the management of women
who are admitted in the puerperuim with bleeding from the lower genital tract.
These women should be managed on the basis of their clinical signs and
symptoms. Ultrasound is only indicated if there is a suspicion that placenta is
incomplete in asymptomatic women.
14
14.1
15
MANAGEMENT OF ADNEXAL MASSESS DETECTED IN PREGNANCY
Simple cysts greater than or equal to 5cm diameter or complex cysts (with
solid/cystic components) of any size should be referred to the Fetal Medicine
Department for review and further management.
BREACH OF GUIDELINES/POLICIES
If staff have concerns regarding adherence to this guideline they should raise the
issue immediately with the senior midwife, a member of the medical team or senior
sonographer.
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16
MONITORING COMPLIANCE
Key Element to
be Monitored
Lead
Combined scan
–
gestation
combined scan
performed,
offering
combined
screening
Anomaly Scan –
gestation
performed.
Percentage
carrying
out
correct
time
frame.
Reduced
fetal
movements.
Percentage Over 28+0 weeks
with a history of
reduced
fetal
movements
having CTG to
Antenatal & Proforma
Newborn
Screening
Coordinator
Page 20 of 23
Antenatal &
Newborn
Screening
Coordinator
Lead
Obstetrician
for
fetal
medicine
Monitoring
Tool
Proforma,
National
screening
committee
key
performance
indicators
Proforma
Monitoring
Frequency
Committee to review
the results and
receive the reports
Acting on
recommendations
Annual – feed National
screening Sonographer monthly
back
to committee/
meeting
meeting
Sonographer monthly
quarterly
meeting
Feedback to
community midwives –
through email and
community forum
Annual
National
screening Sonographer monthly
committee/
meeting
Sonographer monthly
meeting
Feedback to
community midwives –
through email and
community forum
Part of 3 yearly Results feedback to
Labour Ward forum
audit cycle
the maternity and
gynaecology
audit will undertake
recommendations
meeting
Implementation of
practice changes and
lessons learned.
Sharing best practice
Feedback to community
midwives – through
email and community
forum
Lessons will be shared
with all relevant staff
groups
Feedback to community
midwives – through
email and community
forum
Lessons will be shared
with all relevant staff
groups
Reports
will
be
circulated to all relevant
clinical areas, Emailed
to all relevant staff
groups.
Required
changes to
practice will be identified
and actioned with a
WOM/MAT/CLI/GUI/V1/2014/04
Key Element to
be Monitored
exclude
fetal
compromise.
Women
that
have an USS
Women
presenting with
recurrent RFM
referred
for
growth scan /
liquor
volume
assessment
Lead
Monitoring
Tool
Monitoring
Frequency
Committee to review
the results and
receive the reports
Acting on
recommendations
Implementation of
practice changes and
lessons learned.
Sharing best practice
specific time frame, at
the
Delivery
Suite
Forum. A lead member
will be identified to take
each change forward.
Lessons will be shared
with the relevant
staff groups
This guideline will be monitored as part of the 3 yearly audit cycle, is maybe as part of other audit topic’s for example Multiple Pregnancy, preexisting diabetes. Actions from these audits will be monitored through maternity and gynaecology audit committee.
Page 21 of 23
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17
REFERENCES
Bhide A, Prefumo F, Moore J, Hollis B, Thilaganathan B. (2003) Placental edge to
internal os distance in the late third trimester and mode of delivery in placenta praevia.
BJOG : an international journal of obstetrics and gynaecology. 2003 Sep;110(9):860-4.
PubMed PMID: 14511970.
Kirwan D. (2010)18+0 to 20+6 Weeks Fetal Anomaly Scan National Standards and
Guidance for England. National Anomaly Screening Programme, 2010.
Loughna P, Chitty L, Evans T, Chudleigh T. (2009) Fetal size and dating charts
recommended for clinical obstetric practice. Ultrasound. 2009, 17(3)
NICE (2008) Antenatal care (NICE clinical guidelines 62) London: NICE Press.
NICE (2011) Multiple Pregnancy (NICE Clinical Guidelines 129). London: NICE Press.
RCOG. (2011) Placenta Praevia, Placenta Praevia Accreta and Vasa Praevia: Diagnosis
and Management (Green-top 27), . RCOG Press.
RCOG.(2011) Cervical Cerclage (Green Top Guideline 60). London: RCOG Press,.
RCOG. (2011) Reduced Fetal Movements (Green-top 57), RCOG Press.
RCOG. (2012) Small-for-Gestational-Age Fetus, Investigation and Management (Greentop 31) RCOG Press
Spencer K, Spencer CE, Stamatopoulou A, Staboulidou I, Nicolaides KH. (2010) Early
vaginal bleeding has no impact on markers used in first trimester aneuploidy screening.
Prenatal diagnosis. 2010 June; 30(6):547-50. PubMed PMID: 20509154
Spencer K, Staboulidou I, Nicolaides KH. (2010) First trimester aneuploidy screening in
the presence of a vanishing twin: implications for maternal serum markers. Prenatal
diagnosis. 2010 Mar;30(3):235-40. PubMed PMID: 20066674.
Yu CK, Khouri O, Onwudiwe N, Spiliopoulos Y, Nicolaides KH, (2008) Fetal Medicine
Foundation Second-Trimester Screening G. Prediction of pre-eclampsia by uterine artery
Doppler imaging: relationship to gestational age at delivery and small-for-gestational
age. Ultrasound in obstetrics & gynecology : the official journal of the International
Society of Ultrasound in Obstetrics and Gynecology;31(3):310-3. PubMed PMID:
18241089.
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WOM/MAT/CLI/GUI/V1/2014/04
Appendix 1: Change Log
Change Log – Obstetric Ultrasound
Substantive changes since
previous version
Reason for Change
Author & Group(s)
approving
change(s)
New guideline
Merger of 3 guidelines
Consultant
Obstetricians and
Gynaecologists
Maternity
Improvement Board
Appendix 2 – Impact assessments
Equalities impact checklist - must be completed for all new policies
Microsoft Word 97 2003 Document
Organisational impact checklist - must be completed for all new policies
Organisational
impact assessment
Page 23 of 23

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