Cardiotocography/EFM Part II: Management

Today we are back with our midwifery colleagues Linda Steinhardt and Liz Kettyle, who shepherd us through the management of cardiotocography in labor.

We start this episode by quickly reviewing definitions, and defining categories of tracings, reviewed below:

Copyright UpToDate

Recall that category I tracings virtually exclude fetal acidemia, while category III tracings are associated with acidemia 25% of the time, but also have higher risk of cerebral palsy, neurologic injury, or fetal death. That said, the positive predictive value for bad outcomes of CTG is overall poor.

We review a number of scenarios and resuscitative measures for category II and III tracings. However, much of this episode draws on the 2013 Clark et al. article to describe the management of category II tracings. The algorithm is below:

Clark et al. (AJOG 2013)

Hypertension and Pregnancy Trio

We’ve had an overwhelming response to our Espresso episode on acute treatment of severe hypertension in pregnancy, so today we have a special triple episode release on pregnancy and hypertension! We dive into ACOG PB 202 on Preeclampsia and Gestational Hypertension, and ACOG PB 203 on Chronic Hypertension in Pregnancy (membership required for both).

In our first episode, we dive into risk factors and definitions to set the stage. Recall several risk factors that may raise your suspicion for these disorders:
- Nulliparity
- Multiple gestation
- Chronic hypertension
- History of hypertensive disorder of pregnancy in previous pregnancy
- Pregestational or gestational diabetes mellitus
- Thrombophilia, Anti-phospholipid syndrome, or SLE
- Chronic kidney disease
- Advanced maternal age > 35 years
- Obesity (BMI > 30) or obstructive sleep apnea
- Conception via assisted reproductive technology

In episodes 2 and 3, we dive into the specific definitions and management for each hypertensive disorder. Here are our show notes in table format; we hope that this helps you with your own review!

And in closing, a few postpartum/future health pearls to consider:
- With a history of any of these hypertensive disorders, baby aspirin is indicated in future pregnancies beginning at 12 weeks gestation to reduce risk or delay onset of preeclampsia.
- Women with a history of preeclampsia have 3-4x higher lifetime risk of hypertension, and 2x lifetime risk of heart disease and stroke, thus its important to ask about these even with just the annual physical.
- Best available evidence suggest NSAIDs are OK to use postpartum for patients with hypertensive disorders of pregnancy.
- Best available evidence also supports use of parenteral magnesium for seizure prophylaxis in patients who develop any of these disorders during the postpartum period (generally onsets within first week, but has been reported up to 8 weeks after delivery!).

Further reading from the OBG Project:
And get updates on this and more content, as well as other awesome features for FREE if you’re a PGY-4 — sign up for OBG First!
Diagnosing Preeclampsia: Key Definitions and ACOG Guidelines
ACOG Preeclampsia Guidelines: Antenatal Management and Timing of Delivery
Aspirin Treatment for Women at Risk for Preeclampsia: ACOG and USPSTF Guidelines
Chronic Hypertension in Pregnancy: Diagnosis and BP Measurement
Chronic Hypertension in Pregnancy: Evaluation and Management
The 2017 AHA/ACC Blood Pressure Guidelines
#GrandRounds: Does Hypertension in Pregnancy Predict Hypertension in Later Life?

Espresso: Treatment of Acute Hypertension in Pregnancy and Postpartum

Our second espresso episode focuses on the acute treatment of severe-range BPs in the pregnant and postpartum patient. More or less, we let the freshly released ACOG CO 767 speak for itself.

Below you’ll find the algorithms we describe in the podcast, which are present in ACOG CO 767. In addition to the below, always remember:

-Obtain IV access and labs (CBC, Creatinine, AST, ALT, urine protein:creatinine ratio) for any newly diagnosed patient with severe-range pressures.
-Avoid labetalol in patients with known asthma, as the beta-blockade effect can trigger respiratory issues, as well as those with CHF or pre-existing cardiac disease. Labetalol may also cause neonatal bradycardia due to beta-blockade.
-Immediate-release nifedipine should not be administered sublingually due to possibility of developing precipitous hypotension. Similarly, parenteral hydralazine may also cause precipitous maternal hypotension.
-IV magnesium sulfate should be given at a 4g or 6g bolus initially, followed by 2g/hr drip for the prevention of eclamptic seizures, if not previously given. Adjusted dosing may be required if renal insufficiency is noted on laboratories. Magnesium sulfate is not an antihypertensive agent.

Espresso: Medical Management of Postpartum Hemorrhage

Welcome to our first Espresso Episode! Just like an espresso, this should be a short, sweet, but highly caffeinated review of more familiar topics. These are intended for rapid-fire review — perfect for while you’re running up to that postpartum hemorrhage!

In today’s episode, we really just stick to the medication management for postpartum hemorrhage, though as anyone with experience with these might remember, there are a lot more components than just these medicines to make hemorrhage management successful. That said, an exam, bimanual massage, and uterotonic agents will resolve many of the cases you’ll see on the floor. More important for CREOGs are likely the dosing and side effects of these medicines, which we also review today. The ACOG PB 183 table on these medicines is also below for visual learners.

For when you have a bit more time to sit and breathe after the run up the stairs, check out ACOG PB 183 to review postpartum hemorrhage in full (ACOG membership required).

ACOG PB 183


Prenatal Genetic Screening and Testing

This topic can be a source of confusion and anxiety to many providers of OB care, and we hope that we can at least provide some of the basics in today’s episode. For in depth review, see ACOG PB 163 for screening tests, and PB 162 for prenatal testing (ACOG membership required).

One of the most useful and high yield tables on this subject is Table 2 from PB 163 (below). Knowing the differences between these tests, their components, and advantages/disadvantages can be useful for exams as well as your clinical practice.

PB 163 also reviews what the workup should be after a positive screen or after a sonographic finding of aneuploidy, which we did not cover in totality on today’s episode but may also be of use to you.

Just remember — are you screening, or are you testing?