1 Placenta Previa : Diagnosis And Management 1. Aim and introduction Maternal and fetal morbidity and mortality from placenta praevia are considerable1-4 and are associated with high demands on health resources. Consensus views as to how we should manage and audit these cases, especially in the face of a rising incidence of placenta praevia and its complications5,6 are therefore considered important. The purpose of this guideline is to address the methods of diagnosing of placenta praevia and the clinical management of it in both the antenatal and peripartum periods. Placenta praevia exists when the placenta is inserted wholly or in part into the lower segment of the uterus. If it encroaches on the cervical os it is considered a major or complete praevia if not then minor or partial praevia exists. This diagnosis has evolved from the original clinical I-IV grading system and is determined by ultrasonic imaging techniques relating the leading edge of the placenta to the cervical os and the leading fetal pole. Management decisions for women with placenta praevia are based on clinical and ultrasound findings. 2. Identification and assessment of evidence The Cochrane library and the Cochrane register of controlled trials were searched for relevant RCTs, systematic reviews and meta-analyses relating to placenta praevia. A search was also carried out of MEDLINE and PUBMED. Last search was done April 2000. The searches were performed using the relevant MeSH terms including all subheadings and this was combined with a key-word search using - human; female; placenta praevia; placenta accreta; placenta percreta; placental diseases; pregnancy complications; uterine haemorrhage; caesarean section; hysterectomy; embolisation. The majority of publications on placenta praevia are retrospective studies, case reports and reviews, with a paucity of prospective studies and randomised trials or meta-analyses. 3. Diagnosis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agnetic resonance imaging has been reported in the diagnosis of placenta praevia where TAS images have been unsatisfactory,14 and has the advantage of being possible without a full bladder, and is an objective test 2 14 removing operator error. It is particularly useful in imaging posterior placentae, but has not been subject to comparison with TVS and can only be recommended for use in a research context at this stage. 4. Antenatal management 8$92#,(0$,*5#$#'050$,*(%*%,())*#22"-2"(#,0*/-"*:-50$*:(,1*5#;-"*2)#30$,#*2"#0&(#*($*,10*,1(". ,"(50%,0"7*<$=*1-50*6#%0.*3#"0*/-"*%+31*:-50$*%1-+).*60*3-$.+3,0.*:(,1($*#*"0%0#"31 3-$,0>,7 @O E(C&*2%/0$(';'+$#/+,*(%$-,$G(51/'+(")3/+$3(E"4"'+(@QQQ9 ($:)1&%$3(BC6'(&<(,0+$%-$0+,&0'(<&% @J )1/*$0+/()%/$-,/I(+2$%$(G$%$(&01;(+2%$$(+%,/1'I(&0$(*&#)/%$3(2&'),+/1(-$%'"'(2&#$(*/%$N (/03(+G& @>N@M @J ,0-$'+,4/+$3(+2$("'$(&<(*$%-,*/1(*$%*1/4$= (62$(+%,/1(.;(S,04($+(/1 (*&#)/%$3(DJ(G&#$0 /11&G$3(2&#$(G,+2(D>(G&#$0(T$)+(,0(2&'),+/1(/03(+2$(&01;(',40,<,*/0+(3,<<$%$0*$(G/'(/(%$3"*+,&0(,0 2&'),+/1('+/;=(S,+2('"*2(/('#/11('+"3;("03$%?)&G$%$3(+&(/0'G$%(/0;(U"$'+,&0'(&0('/<$+;(*"%%$0+1; '+/03/%3(*&0'$%-/+,-$(,0?)/+,$0+(#/0/4$#$0+(&<(G&#$0(G,+2(#/V&%()1/*$0+/()%/$-,/(*/00&+(.$ *%,+,*,'$3= B$+%&')$*+,-$(%$-,$G'(2/-$(.$$0()$%<&%#$3(3$#&0'+%/+,04(+2/+(+2$(&"+*&#$'(&<(G&#$0(G,+2 )1/*$0+/()%/$-,/(/%$(-$%;(-/%,/.1$(/03(0&+(/1G/;'()%$3,*+$3(.;(/0+$0/+/1($-$0+'@QNDK(/1+2&"42 G&#$0(G,+2()1/*$0+/()%/$-,/(G2&(2/-$(.1$3(+$03(+&(3$1,-$%($/%1,$%=@QND@(6G&(&+2$%(%$+%&')$*+,-$ */'$(0&+$(%$-,$G'(2/-$(/''$''$3(+2$(&"+*&#$(&<(/(+&+/1(&<(MJ(G&#$0(#/0/4$3($:)$*+/0+1;(/+ 2&#$(*&#)/%$3(+&(QK(#/0/4$3(/'(,0)/+,$0+'=DDNDH(F0(.&+2('+"3,$'(3$*,',&0(<&%(*/%$(,0(+2$ *&##"0,+;(G$%$(#/3$(&0(*1,0,*/1(4%&"03'(5"0')$*,<,$39(/03(0$,+2$%('+"3;('2&G$3(/(',40,<,*/0+ 3,<<$%$0*$(,0(*1,0,*/1(&"+*&#$'(/1+2&"42(&"+?)/+,$0+(*/%$(G/'(/''&*,/+$3(G,+2(%$3"*$3 2&'),+/1,'/+,&0(/03(*&'+= R-, 3$ 0* $ P$ -$1 1. R-, 3$ 0* $ P$ -$1 111 3 !10*+%0*-/*30"&(3#)*30"3)#'0*,-*"0.+30*6)00.($'*#$.*2"-)-$'*2"0'$#$3=*(%*$-,*6#3?0.*+2*6= %+//(3(0$,*0&(.0$30*,-*"03-550$.*,1(%*2"#3,(30*-+,%(.0*-/*#*3)($(3#)*,"(#)7 62$(+G&('+"3,$'(&0(*$%-,*/1(*$%*1/4$(%/03&#,'$3(JW(G&#$0(.$+G$$0(+2$#(/03(&01;(&0$(&<(+2$'$ R-, @> '2&G$3(/()&'',.1$(.$0$<,+= (E%,/'(3$#&0'+%/+$3(/(%$3"*+,&0(,0(+2$(0"#.$%(&<(./.,$'(.&%0(.$<&%$ 3$ HW(G$$T'(&%(1$''(+2/0(DT4(/1+2&"42(%/03&#,'/+,&0(G/'(.;(.,%+2(3/+$N(/03(/0/1;','(G/'(.; 0* @> +%$/+#$0+(%$*$,-$3N(0&+(,0+$0+,&0(+&(+%$/+= $ P$ -$1 1. !-3-)=%(%*/-"*,"0#,50$,*-/*+,0"($0*#3,(&(,=*($*,10*2"0%0$30*-/*6)00.($'*.+0*,-*2)#30$,# 2"#0&(#*3#$*60*+%0/+)*($*%0)03,0.*3#%0%7 62$(/$+,&1&4;(&<(.1$$3,04(,0()1/*$0+/()%/$-,/(,'(+2&"42+(+&(.$(3"$(+&(+2$(3;0/#,*'(&<(+2$ 3$-$1&)#$0+(&<(+2$(1&G$%("+$%,0$('$4#$0+N(."+(#/;(/1'&(.$(+%,44$%$3(.;("+$%,0$(/*+,-,+;=(62,'(G/' +$'+$3(&0(DD(G&#$0(G,+2(*$0+%/1()1/*$0+/()%/$-,/(,0(/(*&##"0,+;('$++,04(,0(E"'+%/1,/(G2$%$(+2$; DW "03$%G$0+(&0$(2&"%(&<("+$%,0$(#&0,+&%,04(+G,*$(3/,1;= (62$%$(G/'(0&(',40,<,*/0+(*2/04$(,0("+$%,0$ /*+,-,+;()%,&%(+&(-/4,0/1(.1$$3,04(/03()%&)2;1/*+,*(+$%."+/1,0$(/))$/%$3(+&(&<<$%(0&()%&+$*+,&0= X&G$-$%(+2$'$(0"#.$%'(/%$('#/11(/03('$1$*+,-$("'$(&<(+&*&1;','(<&%#'()/%+(&<()%$-,&"'1;('+/03/%3 DONDJ Y*&0'$%-/+,-$(/44%$'',-$(#/0/4$#$0+(&<()1/*$0+/()%/$-,/Y= (Z&%$(%$*$0+1;N([$',04$%($+(/1D> *&03"*+$3(/()%&')$*+,-$('+"3;(&0(@@D(G&#$0(G,+2(/*"+$(-/4,0/1(.1$$3,04(/03(T0&G0()1/*$0+/ )%/$-,/(/03(4/-$(+&*&1;','(+&(>D(G2&(2/3(',40,<,*/0+("+$%,0$(/*+,-,+;(5MOL9=(62,'(4%&")(&<()/+,$0+' 2/3(/()%&1&04/+,&0(<%&#(/3#,'',&0(+&(3$1,-$%;(,0+$%-/1(5HQ=D(-'(DJ=Q(3/;'N()\K=KD9(/03(/0(,0*%$/'$ ,0(.,%+2G$,42+(5D=ODK(-'(D=@DWT4N()\K=KH9(*&#)/%$3(+&(+2$(WK(G&#$0(G2&(G$%$(0&+(4,-$0 +&*&1;','=(62$(1/%4$'+('$%,$'(&<(*/'$'(G2$%$(+&*&1;','(2/'(.$$0("'$3(<&%(.1$$3,04(,0(+2$(+2,%3 +%,#$'+$%(,0*1"3,04(>J(&<(@KO(G&#$0(G,+2()1/*$0+/()%/$-,/(,'(%$)&%+$3(,0(/(%$+%&')$*+,-$(%$-,$G(.; DM 6&G$%'($+(/1 (/03(2/'('"44$'+$3(0&(,0*%$/'$3(#&%.,3,+;(&%(#&%+/1,+;(/''&*,/+$3(G,+2('"*2("'$(,0 /(+$%+,/%;('$++,04= R-, 3$ 0* $ P$ -$1 11. 5. Delivery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lacenta accreta, increta and percreta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`1+%/'&"03(,#/4,04N (*&1&"% HO 3&))1$%(/03()&G$%(/#)1,+"3$("1+%/'&0,*(/04,&4%/)2;HW(/03(#/40$+,*(%$'&0/0*$(,#/4,04 (2/-$ /11(.$$0('2&G0(+&(.$(-/1"/.1$(,0(+2$(3,/40&','(&<()1/*$0+/(/**%$+/N(,0*%$+/(/03()$%*%$+/= R-, 3$ 0* $ P$ -$1 11. 7. Common sense issues: suggestions for good practice recommendations in this guideline The Confidential Enquiries into Maternal Deaths have, over many years, highlighted the dangers associated with massive haemorrhage in general, and placenta praevia in particular.1,36,37 Many points are made concerning what constitutes both substandard care and good practice. The following recommendations are by no means exhaustive: C"(-"*,-*.0)(&0"=*#))*:-50$*:(,1*2)#30$,#*2"#0&(#4*#$.*,10("*2#",$0"%4*%1-+).*1#&0*1#. #$,0$#,#)*.(%3+%%(-$%*"0'#".($'*.0)(&0"=*#$.*2-%%(6)0*6)--.*,"#$%/+%(-$*"0B+("050$,%*#$. #$=*-6;03,(-$%*-"*B+0"(0%*.0#),*:(,1*0//03,(&0)=7 D)--.*%1-+).*60*#&#()#6)0*/-"*,10*20"(2#",+5*20"(-.*9*,10*#5-+$,*"0B+("0.*:())*.020$.*-$*,10 3)($(3#)*/0#,+"0%*-/*0#31*($.(&(.+#)*3#%07 8$*#$=*3#%0*:10"0*#*:-5#$*:(,1*2)#30$,#*2"#0&(#*(%*60($'*.0)(&0"0.*,10*3-$%+),#$,*-$93#))*/-" ,10*.0)(&0"=*%+(,0*%1-+).*60*($&-)&0.7 <$=*:-5#$*'-($'*,-*,10#,"0*:(,1*?$-:$*2)#30$,#*2"#0&(#*%1-+).*60*#,,0$.0.*6=*#$ 0>20"(0$30.*-6%,0,"(3(#$*#$.*#$#0%,10,(%,4*:(,1*3-$%+),#$,*2"0%0$30*"0#.()=*#&#()#6)07*<$ ($0>20"(0$30.*-6%,0,"(3(#$*%1-+).*$-,*60*)0/,*+$%+20"&(%0.*:10$*3#"($'*/-"*,10%0*:-50$7 !1(%*(%*0%203(#))=*(52-",#$,*($*,1-%0*:-50$*:(,1*1('10"*"(%?%*-/*3-52)(3#,(-$%4*$#50)= 2"0&(-+%*+,0"($0*%3#"%4*#$,0"(-"*2)#30$,#*2"#0&(#*-"*#%%-3(#,0.*2)#30$,#*#33"0,#7 E#%%(&0*1#05-""1#'0*%1-+).*60*.0#),*:(,1*($*#33-".#$30*:(,1*,10*"03-550$.#,(-$%*-/*,10 IJ4IK F-$/(.0$,(#)*G$B+("(0%*($,-*E#,0"$#)*H0#,1%*"02-",%7 !10*%+"'(3#)*5#$-0+&"0%*"0B+("0.*($*,10*/#30*-/*5#%%(&0*1#05-""1#'0*#%%-3(#,0.*:(,1 2)#30$,#*2"#0&(#*3#0%#"0#$*%03,(-$%*%1-+).*60*20"/-"50.*6=*#22"-2"(#,0)=*0>20"(0$30. %+"'0-$%*#$.*3#))($'*/-"*0>,"#*10)2*0#")=*%1-+).*60*0$3-+"#'0.*#$.*$-,*%00$*#%*L)-%($'*/#30L7 Uterotonic agents may help in reducing the blood loss associated with bleeding from the relatively atonic lower uterine segment,38 together with bimanual compression, packing39 or even aortic compression, can buy time while senior help arrives. Additional surgical manoeuvres which may be considered include the B-Lynch suture,40 uterine41 or internal iliac artery ligation,42 or hysterectomy. Arterial embolisation has been reported43 and is useful in selected cases as long as the iliac vessels have not been tied off. !10*31-(30*-/*#$#0%,10,(3*,031$(B+0*/-"*3#0%#"0#$*%03,(-$%*/-"*2)#30$,#*2"#0&(#*5+%,*60 5#.0*6=*,10*#$#0%,10,(%,*3-$.+3,($'*,10*2"-30.+"07 The data available on choice of technique for these cases demonstrate differing opinions from the UK obstetric anaesthetists.44 While evidence from the USA suggests that regional anaesthesia is safe,6 the decision and responsibility must remain with the anaesthetist. 8. Related issues Risk factors for placenta praevia include previous uterine infection and/or surgery. This opportunity is taken to reiterate previous recommendations: •( screening for infection before termination of pregnancy and antibiotic prophylaxis to minimise the risk of post abortion infective morbidity;45 •( prophylactic antibiotics should be used for emergency caesarean section and considered for elective procedures46 and manual removal of the placenta; 5 •( use of antenatal corticosteroids in threatened preterm delivery; •( anti D immunoglobulin for rhesus negative women who bleed;48 •( thromboprophylaxis for any woman at increased risk of thromboembolism.49 9. Auditable standards Surgical support at caesarean sections on women with placenta praevia has been addressed in the reports of the Confidential Enquiries into Maternal Deaths.36,37 The substandard care associated with all cases of major haemorrhage in these reports focuses us onto areas which may be suitable for audit in everyday working practice. All women with massive haemorrhages with or without placenta praevia should be subjected to clinical audit: 47 !"#$%$&'#$(")(*)#+,)+',-(..+'/,)0$#+)'1,23'#,)0(.4)3& !&&.(&.$'#,)&,.5("",6)$"7(67,-,"# 83$%4)'"1),**,%#$7,).,535%$#'#$(" !&&.(&.$'#,)*63$1)$5)$"*35,1 !&&.(&.$'#,)-("$#(.$"/)$"5#$#3#,1 93-:,.)(*)0(-,")#.'"5*35,1)(")#+,)&(5#"'#'6)0'.15);53//,5#$"/)$"'1,23'#,):6((1 ,5#$-'#$(")(")1,6$7,.<)53$#,= >$5%+'./,)+',-(/6(:$" In addition, care of woman with placenta praevia can be assessed in terms of the accuracy of antenatal diagnosis. 10. Risk management As in all cases of high risk, particular attention should be paid to careful documentation of all issues surrounding clinical discussion and decisions. Names of all clinical staff involved should be recorded legibly and signed in the notes, together with the content of any discussions, advanced directives and decisions. References 1.( Department of Health. Why mothers die. Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1994-1996. Department of Health. London; 1998:48-55. 2.( Iyasu S, Saftlas AK, Rowley DL, Koonin LM, Lawson HW, Atrash HK. The epidemiology of placenta praevia in the United States, 1979 through 1987. Am J Obstet Gynecol 1993;168:1424-9. 3.( Rossiter CE. Maternal mortality. Br J Obstet Gynaecol 1985; Supple 5: 100-115. 4.( McShane PM, Heyl PS, Epstein MF. Maternal and perinatal morbidity resulting from placenta praevia. Obstet Gynecol 1985;65:176-82. 5.( Ananth CV, Smulian JC, Vintzileos AM. The association of placenta praevia with history of caesarean delivery and abortion: a metaanalysis. Am J Obstet Gynecol 1997;177:1071-8. 6.( Frederiksen MC, Glassenberg R, Stika CS. Placenta praevia: a 22 year analysis. Am J Obstet Gynecol 1999;180:1432-7. 7.( Oyelese KO, Holden D, Awadh A, Coates S, Campbell S. Placenta praevia: the case for transvaginal sonography. Cont Rev Obstet Gynaecol 1999;257-261. 6 8.( Smith RS, Lauria MR, Comstock CH, Treadwell MC, Kirk JS, Lee W, Borroms SF. Transvaginal ultrasonography for all placentas that appear to be low-lying or over the internal cervical os. Ultrasound Obstet Gynecol 1997;9:22-4. 9.( Leerentveld RA, Gilberts ECAM, Arnold MJC, Wladimiroff JW. Accuracy and safety of transvaginal sonographic placental localisation Obstet gynecol 1990;76:759-62. 10.(Lauria MR, Smith RS, Treadwell MC, Comstock CH, Kirk JS, Lee W, Borroms SF. The use of secondtrimester transvaginal sonography to predict placenta praevia. Ultrasound Obstet Gynecol 1996;8:33740. 11.(Oppemheimer LW, Farine D, Knox Ritchie JW, Lewinsky RM, Telford J, Fairbanks LA. What is a low-lying placenta? Am J Obstet Gynecol 1991;165:1036-8. 12.(Sherman SJ, Carlson DE, Platt LD, Mediaris AL. Transvaginal ultrasound: does it help in the diagnosis of placenta praevia? Ultrasound Obstet Gynecol 1992; 256-60. 13.(McClure N, Dorman JC. Early identification of placenta praevia. Br J Obstet Gynaecol 1990;97:959-61. 14.(Powell MC, Buckley J, Price H, Worthington BS, Symonds EM. Magnetic resonance imaging and placenta praevia. Am J Obstet Gynecol 1986;154:656-9. 15.(Nelson JP. Interventions for suspected placenta praevia (Cochrane review). In The Cochrane Library, Issue 1,2000. Oxford: Update software. 16.(Wing DA, Paul RH, Millar LK. Management of the symptomatic placenta praevia: a randomised, controlled trial of inpatient versus outpatient expectant management. Am J Obstet Gynecol 1996;175:806-11. 17.(Arias F. Cervical cerclage for the temporary treatment of patients with placenta praevia. Obstet Gynecol 1988;71:545-8. 18.(Cobo E, Conde-Agudelo A, Delgado J, Canaval H, Congote A. Cervical cerclage: an alternative for the management of placenta praevia. Am J Obstet Gynecol 1998;179:122-5. 19.(Love CDB, Wallace EM. Pregnancies complicated by placenta praevia: what is appropriate management? Br J Obstet Gynaecol 1996;103:864-7. 20.(Groom KM, Woo YL, Paterson-Brown S. Management of placenta praevia. J Obstet Gynaecol 2000 (in press). 21.(Lam CS, Wong SF, Chow KM, Ho LC. Women with placenta praevia and antepartum haemorrhage have a worse outcome than those who do not bleed before delivery. J Obstet Gynaecol 2000;20:27-31. 22.(Droste S, Keil K. Expectant management of placenta praevia: cost benefit analysis of outpatient treatment. Am J Obstet Gynecol 1994;170:1254-7. 23.(Mouer JR. Placenta praevia: antepartum conservative management, inpatient versus outpatient. Am J Obstet Gynecol 1994;170:1683-6. 7 24.(Magann EF, Johnson CA, Gookin KS, Roberts WE, Martin RW, Morrison JC. Placenta praevia: does uterine activity cause bleeding? Aust NZ J Obstet Gynecol 1993;33(1): 22-4 25.(Cotton DB, Read JA, Paul RH, Quilligan EJ. The conservative aggressive management of placenta praevia. Am J Obstet Gynecol 1980;137:687-95. 26.(Silver R, Depp R, Sabbagha RE, Dooley SL, Socol ML, Tamura RK. Placenta praevia: aggressive expectant management. Am J Obstet Gynecol 1984;150:15-22. 27.(Besinger RE, Moniak CW, Paskiewicz LS, Fishes SG, Tomich PG. The effect of tocolytic use in the management of symptomatic placenta praevia. Am J Obstet Gynecol 1995;172:1770-8. 28.(Towers CV, Pircon RA, Heppard M. Is tocolysis safe in the management of third trimester bleeding? Am J Obstet Gynecol 1999;180:1572-8. 29.(Dinsmoor MJ, Hogg BB. Autologous blood donation with placenta praevia: is it feasible? Am J Perinatol 1995;12:382-4. 30.(Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta praevia -placenta accreta. Am J Obstet Gynecol 1997;177:210-4. 31.(Clark SL, Koonings PP, Phelan JP. Placenta praevia / accreta and prior caesarean section. Obstet gynecol 1985;66:89-92. 32.(Zaki ZMS, Bahar AM, Ali ME, Albar HAM, Gerias MA. Risk factors and morbidity in patients with placenta praevia accreta compared to placenta praevia non-accreta. Acta Obstet gynecol scand 1998;77:391-4. 33.(Finberg HJ, Williams JW. Placenta accreta: prospective sonographic diagnosis in patients with placenta previa and prior caesarean section. J Ultrasound Med 1992;11:333-43. 34.(Chou MM, Ho ESC. Prenatal diagnosis of placenta praevia accreta with power amplitede ultrasonic angiography. Am J Obstet Gynecol 1997;177:1523-5. 35.(Thorp JM, Wells SR, Wiest HH, Jeffries L, Lyles E. First trimester diagnosis of placentapraevia percreta by magnetic resonance imaging. Am J Obstet Gynecol 1998;178:616-8. 36.(Department of Health. Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1991-1993. Department of Health. London; 1998:32-47. 37.(Department of Health. Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1988-1990. Department of Health. London; 1998:34-44. 38.(Merrikay AO, Mariano JP. Controlling refractory atonic postpartum haemorrhage with Hemabate sterile solution. Am J Obstet Gynecol 1990;162:205-8. 39.(Maier RC. Control of postpartum haemorrhage with uterine packing. Am J Obstet gynecol 1993;169:31723. 40.(B-Lynch C, Coker A, Lawal AH, Abu I, Cowen MJ. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. Br J Obstet Gynaecol 1997;104:372-5. 8 41.(O'Leary JA. Uterine artery ligation in the control of post caesarean haemorrhage. J Reprod Med 1990;40:189-93. 42.(Clark SL, Phelan JP, Yeh SY, Bruce SR, Paul RH. Hypogastric artery ligation for obstetric haemorrhage. Obstet Gynecol 1985;66:353-6. 43.(Hansch E, Chitkara U, McAlpine J, El-Sayed Y, Dake MD, Razavi MK. Pelvic arterial embolisation for control of obstetric haemorrhage: a five year experience. Am J Obstet Gynecol 1999;180:1454-60. 44.(Bonner SM, Haynes SR, Ryall D. The anaesthetic management of caesarean section for placenta praevia: a questionnaire survey. Anaesthesia 1995;50:992-4. 45.(Royal College of Obstetricians and Gynaecologists. The Care of Women Requesting Induced Abortion. London: RCOG Press, 2000. 46.(Royal College of Obstetricians and Gynaecologists. Effective Procedures in Maternity Care : Suitable for Audit. London. RCOG Press, 1997. 47.(Royal College of Obstetricians and Gynaecologists. Green-top guideline no 7. Antenatal corticosteroids to prevent respiratory distress syndrome. London. RCOG, 1999. 48.(Royal College of Obstetricians and Gynaecologists. Green-top guideline no 22. Use of anti-D immunoglobulin for rh prophylaxis. London. RCOG, 1999. 49.(Royal College of Obstetricians and Gynaecologists. Report of the RCOG Working Party on Prophylaxis Against Thromboembolism in Gynaecology and Obstetrics. London, 1995. APPENDIX Clinical guidelines are: 'systematically developed statements which assist clinicians and patients in making decisions about appropriate treatment for specific conditions'. Each guideline is systematically developed using a standardised methodology. Exact details of this process can be found in 'Guidance for the development of RCOG green-top guidelines' (available on the RCOG website). These recommendations are not intended to dictate an exclusive course of management or treatment. They must be evaluated with reference to individual patient needs, resources and limitations unique to the institution and variations in local populations. It is hoped that this process of local ownership will help to incorporate these guidelines into routine practice. Attention is drawn to areas of clinical uncertainty where further research may be indicated. The evidence used in this guideline was graded using the scheme below and the recommendations formulated in a similar fashion with a standardised grading scheme. Classification of evidence levels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rades of recommendations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ood Practice Point !"0,//"-.".(3"'*(1&)0*%0"(3)'".(,-(*7"(0+%-%0)+("?1"&%"-0"(,2(*7"(6$%."+%-"(."5"+,1/"-* 6&,$18 @9%4*A8%&'2%('*6"4*:/+&8)'&*+(*,'9"2.*+.*-9'*A8%&'2%('4*"(&*B8&%-*C8,1D+00%--''*+.*-9'*E+3"2*D+22'7' +.*F,4-'-/%)%"(4*"(&*A3("')+2+7%4-4*,3G H%44*C*I"-'/4+(1J/+6(*HEDFA=*K+(&+( C8,0%--'&*.+/*:''/*/'$%'6*-+G L/*A*D++:'/*MB("'4-9'-%4-N=*J%/0%(79"0 L/*A*K'6%4*MD+(.%&'(-%"2*#(;8%/%'4*%(-+*H"-'/("2*L'"-94N L/*C*H"):9"%2*HEDFA=*O'6)"4-2'18:+(1@3(' I/+.'44+/*P*I*O'%24+(*QEDFA=*K%$'/:++2 I/+.'44+/*I*P*C-''/*QEDFA=*K+(&+( H/*C*B*R"2S%(49"6*HEDFA=*K%$'/:++2