MFM Referrals
MFM Referral Form
Indications for Referral
Prior PregnancyComplications |
| History consistent with possible cervical incompetence |
| Cerclage in prior pregnancy |
| Preterm birth less than 34 weeks |
| Severe Preeclampsia |
| Abruption less than 37 weeks |
| History of abnormal placental implantation |
| IUGR less than 3% requiring delivery less than 36 weeks |
| IUFD/Stillbirth without a normal term pregnancy since |
| Second trimester spontaneous loss without a known genetic anomaly |
Current MaternalCondition |
| Type 1 diabetes |
| Type 2 diabetes with other complications (add details in comments) |
| pre-pregnancy BMI greater than 40 |
| Cardiac disease |
| Renal disease |
| Essential Hypertension with one or more risk factors for placental insufficiency |
| Graves Disease with thyroid antibodies |
| Chemotherapy in current pregnancy |
| HIV |
| Epilepsy with seizures in pregnancy |
| Severe mental health concern requiring antipsychotic/mood stabilizing medication(s) |
| Rheumatological condition (eg. SLE, APLA) |
| Syphilis – active |
| Active TB |
Current PregnancyComplications |
| Cervical length less than 2.5cm and with progressive shortening at less than 24 weeks |
| Preeclampsia with potential need for delivery less than 35 weeks |
| Growth US – less than 10% with abnormal dopplers, asymmetry and/or low AFI at less than 36 weeks |
| Mono/Di twins |
| Di/Di twins with progressive growth discordance >20% |
| Triplets or higher order multiples |
| Significant fetal anomaly |
| Placenta or cord abnormality (eg. Chorioangioma, large cord varices) |
| Persistent polyhydramnios – greater than 95% |
| Persistent oligohydramnios – less than 5% without PPROM (2x1cm pocket) |
| PPROM less than 32 weeks |
| Significant risk factors for placental insufficiency |
| ICP with BA >100 |
