Management of pregnancy - VA/DoD Clinical Practice Guidelines ...

VA/DoD Clinical Practice Guideline
For Pregnancy Management
Table 5. Indications for Ultrasonography During Pregnancy
A. Evaluation Of Known Or Suspected
Complications Of Pregnancy:
- confirm intrauterine pregnancy
- suspected ectopic pregnancy
- vaginal bleeding
- abdominal and pelvic pain
- maternal pelvic or adnexal masses
- uterine abnormalities
- cervical insufficiency
- suspected amniotic fluid abnormalities
- suspected placental abruption
- premature rupture of membranes
- premature labor
- suspected placenta previa
- suspected hydatidiform mole
- evaluate abdominal / pelvic pain or mass
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B. Pregnancy Dating:
- uncertain gestational age
- assigned gestational age and clinical size
discrepancy
- evaluation of suspected multiples
C. As Component of Screening For Fetal
Aneuploidy:
- abnormal biochemical markers
- history of previous congenital anomaly
- to assess findings that may increase or
decrease the risk of aneuploidy
- family, environmental or maternal history
increasing the risk for fetal anomalies
- to screen for fetal anomalies
D. Evaluation of Fetal Growth and Well Being:
- confirm cardiac activity
- suspected fetal death
- determine fetal presentation
- fetal condition in late registrants for
prenatal care
- medical conditions posing high risk of
fetal growth abnormalities
- signs of fetal growth abnormality
- follow up of known fetal anomaly
E. As adjunct For Procedures:
- amniocentesis, chorionic villus sampling
or fetal surgery
- external cephalic version
- cervical cerclage placement/evaluation
- embryo transfer, or localization and
removal of an intrauterine device
RATIONALE
Neither early, late, nor serial ultrasound examination in low risk pregnancy has been proven to improve
perinatal morbidity or mortality. Clinical trials show that a single mid‐trimester ultrasound examination
detects multiple gestations and congenital malformations earlier in pregnancy, but there is currently
insufficient evidence that early detection results in improved short term perinatal outcomes.
Routine second‐trimester ultrasound can lower the rate of induction for presumed post‐term pregnancy, a
benefit likely to accrue primarily to women with unreliable dates, among whom ultrasound is more accurate
than the unreliable dates for predicting actual date of delivery. It is also unclear whether the likeliest
potential benefits of routine second‐trimester ultrasound (reduced induction of labor for postterm pregnancy
and increased induced abortions for fetal anomalies) would justify widespread testing from a cost
effectiveness standpoint.
No benefits of routine ultrasound examination of the fetus in the third trimester have been demonstrated
despite multiple randomized controlled trials. Additional trials of third‐trimester placental grading are
needed to adequately evaluate the potential benefits of screening for placental appearance.
DISCUSSION
One meta-analysis of controlled trials of routine versus selective ultrasound evaluation before 24 weeks’ gestation
found that routine screening provided better gestational age assessment (with subsequent lower incidence of
induction for post-term pregnancy), earlier detection of multiple gestations, and greater detection of unsuspected
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