Clinical practice guidelines in obstetric medicine

In their introduction to a “Report on Clinical Practice Guidelines We Can Trust”, The Institute of Medicine of the National Academies (IOM) website states:

When treating patients, doctors and other healthcare providers often are faced with difficult decisions and considerable uncertainty. They rely on the scientific literature, in addition to their knowledge, experience, and patient preferences, to inform their decisions. Clinical practice guidelines are statements that include recommendations intended to optimize patient care. They are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.¹

The review identified the importance of the quality of the process of guideline development, as well as the associated requirements of promoting adoption and evaluation.

In Obstetric Medicine, there are a multitude of clinic practice guidelines produced by the professional Colleges, Societies of Obstetric Medicine, National Institutes and International Collaborations. These cover a range of subjects from common to rare. The problem for the clinician is which guideline do we follow? In some countries, this is mandated by government or the professional colleges, but in many cases the clinician is left to review a variety of expert opinions based on the same literature. In many cases, there is consensus, e.g. the level of blood pressure requiring urgent antihypertensive therapy, the timely management of acute sepsis. However, in many situations there are grey areas and the clinical practise guideline reflects the opinion of the experts in the absence of high-quality evidence. This can be extremely helpful but at other times confusing. In some guidelines, this is reflected as a “show of hands” by the authors regarding the degree of consensus.

There are many examples of dissenting guidelines including diagnostic criteria for gestational diabetes, thyroxine treatment for mild subclinical hypothyroidism and antenatal prophylaxis for venous thromboembolism. Ultimately, it is not the accuracy of the guideline, which is critical but the impact its implementation has on patient outcomes and the quality, efficiency and consistency of our clinical care. This will invariably reflect the local health environment, resources and the patients themselves.

To assist you in this process, the International Society of Obstetric Medicine (ISOM) website will be creating a repository of current clinic practice guidelines of relevance to the practise of Obstetric Medicine. Hopefully, this will lead to more collaboration and less replication of this important but expensive, time-consuming process.

Again quoting from the IOM Report:

Rather than dictating a one-size-fits-all approach to patient care, clinical practice guidelines offer an evaluation of the quality of the relevant scientific literature and an assessment of the likely benefits and harms of a particular treatment. This information enables healthcare providers to proceed accordingly, selecting the best care for a unique patient based on his or her preferences.

In this month’s issue are two original articles that will inform future guidelines in their field. The first is a systematic review and meta-analysis of randomised trials in the prevention of gestational diabetes in pregnant women with risk factors for gestational diabetes. Analysing results from 14 trials including almost two and half thousand women Madhuvrata et al. show that dietary intervention was associated with a statistically significantly lower incidence of gestational diabetes (Odds ratio 0.33, 95% CI 0.14 to 0.76) and gestational hypertension (Odds ratio 0.28, 95% CI 0.09, 0.86) compared to standard care. Exercise, lifestyle changes and metformin had no significant effect.

The second is a 10-year-cohort study from Oxford of the pregnancy outcome of women with cystic fibrosis. Renton and colleagues found baseline lung function was predictive of gestational age at delivery and that a decline in lung function at delivery was a marker for further decline in function following pregnancy. They also highlight a new finding of a high incidence of haemoptysis.

Also in this issue, Dasari et al. examine 104 maternal deaths in a single tertiary care hospital in South India over a five-year period and describe an increasing proportion of indirect deaths. Davidson and colleagues describe pregnancy and renal outcomes in 55 women with chronic kidney disease in a tertiary unit in Brisbane. Their findings are similar to other studies demonstrating two-thirds of women having pre-eclampsia, caesarean delivery and preterm delivery and women with CKD 3-5 exhibiting post partum deterioration in renal function.

As we write, we are at the regional ISOM meeting and maternal medicine course in Singapore where delegates have gathered from Australia, New Zealand, Indonesia, Malaysia, Brunei, Philippines, Abu Dhabi, Saudi Arabia, India and Hong Kong with many keen physicians and obstetricians from Singapore. Many clinical problems in obstetric medicine are the same all over the globe, yet there are regional differences related in part to genetic susceptibility. So we learnt today that not only is Factor V Leiden extremely rare in Chinese but so too is obstetric cholestasis.

We hope that you will learn much from the review and other articles in the following pages.

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