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

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VA/DoD Clinical Practice Guideline For Pregnancy Management Interventions Not Recommended in Prenatal Care (All Weeks) I 52. Routine Screening with Fetal Fibronectin: Not Recommended BACKGROUND Fetal fibronectin levels can identify pregnant women at risk for preterm delivery. Routine fetal fibronectin screening of cervical vaginal fluid has been suggested by some experts as a means of reducing preterm delivery among low-risk/asymptomatic pregnancies. However, there is insufficient data to support fetal fibronectin screening in all pregnant women. RECOMMENDATIONS 1. 2. Recommend against routine screening for preterm birth with fetal fibronectin (fFN) test. [D] Utilization of fFN testing in symptomatic women between 24 and 34 6/7 weeks’ gestation may be useful in guiding management of women with signs and symptoms of preterm labor. [B] DISCUSSION In a large meta-analysis, the accuracy for predicting spontaneous preterm birth using the fFN test varied considerably with no significant differences in estimates of accuracy in studies with high/low quality (Honest et al, 2002). Several prospective cohort studies have shown no improvement in outcomes for either mother or baby (Leitech et al., 1999; Ramsey & Andrews, 2003). The routine use of this expensive technology is not justified in light of the low predictive value of either a positive or negative test, along with absence of an effective intervention. The potential value of fFN testing in the setting of questionable preterm labor is to more precisely discriminate between the subset of women who have true preterm labor versus false labor. A negative test in women with preterm contractions may provide information sufficient to avoid the use of tocolytics and corticosteroids in an individual at low risk for preterm birth (Ramsey & Andrews, 2003). The following was noted in a memorandum reporting the findings and recommendations of a multidisciplinary and multi-service national Department of Defense (DoD) committee regarding the use of fFN testing as an adjunct to the assessment of suspected preterm labor: the primary benefit [of using the fFN test] is in patients presenting with preterm contractions where [one is] clinically uncertain if the patient will be delivering within one to two weeks. The fFN specimen should only be sent if the result would potentially change the patient’s management. It should not be used if it will not alter care (DoD Committee Consensus on Fetal Fibronectin Testing in Pregnancy (2007). EVIDENCE TABLE Recommendations Sources of Evidence LE QE SR 1 Routine fetal fibronectin screening at 24 weeks’ estimated gestational age (EGA) for prevention of preterm labor (not recommended) Ramsey & Andrews, 2003 Goldenberg et al., 1996 Honest, 2002 Leitech et al., 1999 Revah et al., 1998 Tekeskin, 2005 I Good D 2 Utilization of the fFN test in symptomatic women between 24 and 34 weeks’ gestation may be useful in guiding management of women with preterm contractions ACOG, 2003 Honest, 2002 Tekeskin, 2005 II-2 Fair B LE = Level of Evidence; QE = Quality of Evidence; SR = Strength of Recommendation (See Appendix A) Interventions Page - 99
VA/DoD Clinical Practice Guideline For Pregnancy Management I 53. Routine Cervical Examination: Not Recommended BACKGROUND Digital cervical examination can identify pregnant women at risk for preterm delivery. Universal screening of cervical dilation and effacement has been suggested as a means of reducing preterm delivery among lowrisk/asymptomatic pregnancies. However, there is insufficient data to justify routine digital cervical examination in all pregnant women. RECOMMENDATIONS 1. Recommend against performing cervical examination to screen for preterm birth prevention in low-risk asymptomatic pregnant women. [D] DISCUSSION A large RCT of routine cervical examinations during pregnancy failed to show a statistically or clinically significant difference in rates of low birth weight, delivery at less than 37 weeks’ EGA, and preterm premature rupture of membranes between pregnant women randomized to routine cervical examinations versus avoidance of cervical examination (unless clinically indicated) (Buekens et al., 1994). The median number of cervical examinations in the control group was one versus six in the experimental arm of the study. EVIDENCE TABLE Recommendations Sources of Evidence LE QE SR 1 Routine cervical examination at 28 weeks’ gestation for prevention of preterm labor (not recommended) Buekens et al., 1994 I Good D LE = Level of Evidence; QE = Quality of Evidence; SR = Strength of Recommendation (See Appendix A) I 54. Routine Antenatal Pelvimetry: Not Recommended BACKGROUND Traditionally, all pregnant women underwent clinical pelvimetry during the course of their pregnancy to detect pelvic diameters that would preclude a trial of labor or place a woman at increased risk of dystocia. RECOMMENDATIONS 1. Recommend against the use of antenatal pelvimetry (clinical or radiographic) in routine prenatal care. [D] 2. There is fair evidence that clinical pelvimetry is not effective in predicting the actual occurrence of cephalopelvic disproportion (CPD), and its performance is associated with significant increase in cesarean section rates. [D] DISCUSSION Only two randomized trials have evaluated pelvimetry for pregnant women experiencing normal pregnancy. Two additional trials have involved pregnant women with a previous cesarean section. These four trials are summarized in a Cochrane review (Pattinson, 2001). The performance of X-ray pelvimetry may be harmful and is associated with a significant increase in cesarean section rate (odds ratio=2.17) and radiographic exposure to the fetus (Parsons & Spellacy, 1985). Interventions Page - 100
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