ACOG recommendations for management of suboptimally dated pregnancies.

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The American College of Obstetricians and Gynecologists (ACOG) recently published its recommendations regarding management and delivery of pregnancies in whom the best clinical estimation of gestational dates is not confirmed in forthcoming March 2017 issue of Obstetrics and Gynecology Journal. 

ACOG has always strived to curb elective deliveries before 39 weeks of pregnancy and spread awareness among obstetricians about the negative effects of elective delivery before 39 weeks, which increases neonatal respiratory and nonrespiratory morbidities.[1] 

The article can be accessed here.

This topic was also debated at the ACOG Annual Clinical and Scientific Meeting 2016.[2]

The most accurate method of gestational dating is a first trimester sonography. As the woman advances into second and third trimester the reliability of USG for the purpose of dating decreases linearly.  Pregnancies without an USG performed to confirm or revise the gestational dating before 22 0/7 weeks are labeled as suboptimally dated.

The guidelines for management are:

1. The decision about timing the delivery in a suboptimally dated pregnancy should be based on the best clinical estimate of the gestational age.
2. There is no role for elective delivery in suboptimally dated pregnancies to avoid the neonatal morbidity because the pregnancy may be earlier in gestation than believed to be. Decision to administer antenatal corticosteroids should be based on the best clinical judgement if a woman with suboptimally dated pregnancy is identified to be at risk for preterm delivery.
3. Amniocentesis to determine fetal lung maturity should not be used to decide the time of delivery in suboptimally dated pregnancies because  it is not reliable in predicting pulmonary maturity and other non-respiratory outcomes.
4. A follow-up sonography after 3-4 weeks of the initial one is always advisable in women with suboptimally dated pregnancies. It helps to support the prediction of gestational dating as well as fetal well-being in terms of weight gain. If IUGR is suspected, a close surveillance with umbilical cord Doppler should be considered.
5. It is always difficult to manage a presumably late-term pregnancy that lacks accurate dating because of the risk of overlooking post maturity and associated fetal morbidity and mortality. Therefore, is advised to begin antepartum fetal surveillance at 39–40 weeks of gestation and to deliver at 41 weeks using the best clinical judgement because it could be more postdated than it is believed to be.
6. In women with suboptimally dated pregnancy with a previous history of low transverse C-section incision a trial of labor can be given based on the clinical assessment of gestational age. If a woman requests a repeat elective C-section, it should be planned around 39 weeks based on best clinical judgement.
7. Women with suboptimally dated pregnancy should be well informed about the risks of neonatal morbidity and mortality because of inaccurate dating.

The full text of the  journal article can be accessed here.  

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[1] https://obgynupdated.blogspot.com/2017/01/choosing-wisely-and-acog-advises.html

[2] https://obgynupdated.blogspot.com/2016/05/elective-induction-of-labor-iol-at-39.html