Prenatal ultrasounds for nonmedical purposes and routine use of robotic assisted laparoscopic surgery for benign gynecologic disease are among the interventions physicians and patients should question, according to the American College of Obstetricians and Gynecologists.
The organization produced the list of five interventions to be questioned as part of the ABIM (American Board of Internal Medicine) Foundation’s Choosing Wisely initiative, which “aims to promote conversations between clinicians and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary,” according to the Choosing Wisely website .
ACOG released its first Choosing Wisely list in 2003, advising clinicians to avoid elective labor inductions before 39 weeks as well as annual pap tests in women aged 30-65.
“These are good topics to bring up in discussion with patients,” said Dr. Gerardo Bustillo , an ob.gyn. at Orange Coast Memorial Medical Center in Fountain Valley, Calif. “Patients may ask for inappropriate interventions such as early induction of labor, and these recommendations will equip physicians and other healthcare providers in explaining the dangers of certain interventions.”
The five new items include:
1. Avoid using robotic assisted laparoscopic surgery for benign gynecologic disease when it is feasible to use a conventional laparoscopic or vaginal approach.
ACOG states that comparable perioperative outcomes, intraoperative complications, length of hospital stay, and rate of conversion to open surgery result from both robotic-assisted and conventional laparoscopic surgeries but that robotic-assisted techniques cost more and can take longer. But Dr. Bustillo questioned this item’s addition to the list in light of new evidence that “robotic-assisted hysterectomies resulted in fewer postoperative complications than conventional laparoscopic and vaginal hysterectomies, when performed by high-volume robotic gynecologic surgeons,” he said.
The patients undergoing robotic-assisted hysterectomy, he added, experienced the same or decreased intraoperative and postoperative complications compared with those undergoing conventional techniques despite being more complex patients. They were older with higher rates of adhesive disease, large uteri, and morbid obesity.
2. Don’t perform prenatal ultrasounds for nonmedical purposes, for example, solely to create keepsake videos or photographs.
Keepsake imaging is not an approved use of a medical device by the Food and Drug Administration and is also discouraged by the American Institute of Ultrasound in Medicine. These “comfort ultrasounds” are often performed by the request of the patient and are done without true medical indications,” said Dr. Sherry Ross , an ob.gyn. at Providence Saint John’s Health Center in Santa Monica, Calif.
“Not only are these types of ultrasounds excessive, but they are costly as well,” she said. “Counseling the pregnant woman is the best way to reduce unnecessary ultrasounds, especially those performed at the local mall.”
3. Don’t routinely transfuse stable, asymptomatic hospitalized patients with a hemoglobin level greater than 7-8 grams.
“Arbitrary hemoglobin or hematocrit thresholds should not be used as the only criterion for transfusions of packed red blood cells,” ACOG advises. The potential risks of transfusion make this item the most important of the additions, according to Dr. Bustillo. “These risks include infection with certain pathogens, allergic and immune transfusion reactions, volume overload, hyperkalemia, and iron overload,” he said.
4. Don’t perform pelvic ultrasound in average risk women to screen for ovarian cancer.
With an age-adjusted incidence of just 13 ovarian cancer cases per 100,000 women annually, the positive predictive value is low for screening for ovarian cancer, leading to a high rate of false positives, ACOG notes.
“The tools that are currently available for screening women who are high risk include transvaginal pelvic ultrasound and CA 125 blood tests done every 6 months to 1 year along with pelvic examinations,” Dr. Ross said. “Those at high risk include those with a family history or who test positive for BRCA1 and 2 mutations and Ashkenazi women with a single family member with breast cancer before age 50 or with ovarian cancer.” Without a family history or other risk factors, a CA 125 or pelvic ultrasound in asymptomatic women does not reduce deaths, she added.
5. Don’t routinely recommend activity restriction or bed rest during pregnancy for any indication.
Historically, physicians have recommended bed rest for a range of pregnancy conditions, including multiple gestation, intrauterine growth restriction, preterm labor, premature rupture of membranes, vaginal bleeding, and hypertensive disorders in pregnancy, ACOG notes. “The negative financial and psychosocial implications of putting women on activity restriction, specifically bed rest, are well documented,” said Dr. Anthony C. Sciscione , director of Maternal-Fetal Medicine at Christiana Care Health System and program director for Christiana Care’s ob.gyn. residency program in Wilmington, Del. “However, no study has demonstrated a benefit to activity restriction during pregnancy for any diagnosis.”
The only clinical benefit resulting from bed rest has been a modest decrease in blood pressure that does not translate to improved outcomes, Dr. Sciscione said. Additional risks of activity restriction include an increase in maternal anxiety and depression, significant financial impact on the family, physical deconditioning, bone loss, and a potential increase in blood clots. Being active in pregnancy, however, is linked to a decrease in preterm birth, he added.
The 2013 list
Among the previous five items included in the 2013 list are not scheduling elective, nonmedically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days of gestational age and not scheduling elective, non-medically indicated labor inductions between 39 weeks 0 days and 41 weeks 0 days unless the cervix is favorable.
ACOG also recommended that asymptomatic women of average risk do not receive screenings for ovarian cancer, that patients with mild dysplasia for less than 2 years do not receive treatment, and that women aged 30-65 years do not receive routine annual cervical cytology screenings.