CRC MATRNL-FETAL EVIDNC BAS GUD PDF

Introduction

To me, pregnancy has always been the most fascinating and exciting area of interest, as care involves not one, but at least two persons—the mother and the fetus—and leads to the miracle of a new life. I was a third-year medical student, when, during a lecture, a resident said: ‘‘I went into obstetrics because this is the easiest medical field. Pregnancy is a physiologic process, and there isn't much to know. It is simple.'' I knew from my ‘‘classic'' background that ‘‘obstetrics'' means to ‘‘stand by, stay near,'' and that indeed pregnancy used to receive no medical support at all.

After almost 20 years practicing obstetrics, I now know that although physiologic and at times simple, obstetrics and maternal-fetal medicine can be the most complex of the medical fields: pregnancy is based on a different physiology than for nonpregnant women, can include any medical disease, require surgery, etc. It is not so simple. In fact, ignorance can kill, in this case with the health of the woman and her baby both at risk. Too often, I have gone to a lecture, journal club, rounds, or other didactic event to hear presented only one or a few articles regarding the subject, without the presenter reviewing the pertinent best review of the total literature and data. It is increasingly difficult to read and acquire knowledge of all that is published, even just in obstetrics, with about 3,000 scientific manuscripts published monthly on this subject. Some residents or even authorities would state at times that ‘‘there is no evidence'' on a topic. We indeed used to be the field with the worst use of randomized trials (1). As the best way to find something is to look for it, my coauthors and I searched for the best evidence. On careful investigation, indeed there are data on almost everything we do in obstetrics, especially on our interventions. Indeed, our field is now the pioneer for numbers of meta-analysis and extension of work for evidence-based reviews (2). Obstetricians are now blessed with lots of data, and should make the best use of it.

The aims of this book are to summarize the best evidence available in the obstetrics and maternal-fetal medicine literature, and make the results of randomized trials and meta-analyses easily accessible to guide clinical care. The intent is to bridge the gap between knowledge (the evidence) and its easy application. To reach these goals, we reviewed all trials on effectiveness of interventions in obstetrics. Millions of pregnant women have participated in thousands of properly conducted randomized controlled trials (RCT). The efforts and sacrifice of mothers and their fetuses for science should be recognized at least by the physicians' awareness and understanding of these studies. Some of the trials have been summarized in almost 400 Cochrane reviews, with hundreds of other meta-analyses also published in obstetrical topics (Table 1). All of the Cochrane reviews, as well as other meta-analyses and trials in obstetrics and maternal-fetal medicine, were reviewed and referenced. The material presented in single trials or meta-analyses is too detailed to be readily translated to advice for the busy clinician who needs to make dozens of clinical decisions a day. Even the Cochrane Library, the undiscussed leader for evidence-based medicine efforts, has been criticized for its lack of flexibility and relevance in failing to be more easily understandable and clinically readily usable (3). It is the gap between research and clinicians that needed to be filled, making sure that proven interventions are clearly highlighted, and are included in today's care. Just as all pilots fly planes under similar rules to maximize safety, all obstetricians should manage all aspects of pregnancy with similar, evidenced-based rules. Indeed, only interventions that have been proven to provide benefit should be used routinely. On the other hand, primum non nocere: interventions that have clearly been shown to be not helpful or indeed harmful to mother and/or baby should be avoided. Another aim of the book is to make sure the pregnant woman and her unborn child are not penalized by the medical community. In most circumstances, medical disorders of pregnant women can be treated as in nonpregnant adults. Moreover, there are several effective interventions for preventing or treating specific pregnancy disorders.

Evidence-based medicine is the concept of treating patients according to the best available evidence. While George Bernard Shaw said: ‘‘I have my own opinion, do not confuse me with the facts,'' this can be a deadly approach, especially in medicine, and compromise two or more lives at the same time in obstetrics and maternal-fetal medicine. What should be the basis for our interventions in medicine? Meta-analyses provide a comprehensive summary of the best research data available. As such, they provide the best guidance for ‘‘effective'' clinical care (4). It is unscientific and unethical to practice medicine, teach, or conduct research without first knowing all that has already been proven (4). In the absence of trials or metaanalyses, lower level evidence is reviewed. This book aims at providing a current systematic review of the evidence, so that current practice and education, as well as future research can be based on the full story from the best-conducted research, not just the latest data or someone's opinion (Table 2). These evidence-based guidelines cannot be used as a ‘‘cookbook,'' or a document dictating the best care. The knowledge from the best evidence presented in the guidelines needs to be integrated with other knowledge gained from clinical judgment, individual patient circumstances, and patient preferences, to lead to best medical practice. These are guidelines, not rules. Even the best scientific studies are not always perfectly related to any given individual, and clinical judgment must still be applied to allow the best ‘‘particularization'' of the best knowledge for the individual, unique patient. Evidence- based medicine informs clinical judgment, but does not substitute it. It is important to understand though that greater clinical experience by the physician actually correlates with inferior quality of care, if not integrated with knowledge of the best evidence (5). The appropriate treatment is given in only 50% of visits to general physicians (5). At times, limitations in resources may also limit the applicability of the guidelines, but should not limit the physician's knowledge. Guidelines and clinical pathways based on evidence not only point to the right management, but also can decrease medicolegal risk (6).

We aimed for brevity and clarity. Suggested management of the healthy or sick mother and child is stated as straightforwardly as possible, for everyone to easily understand and implement (Table 3). If you find the Cochrane reviews, scientific manuscripts, and other publications difficult to ‘‘translate'' into care of your patients, this book is for you. We wanted to prevent information overload.

On the other hand, ‘‘everything should be made as simple as possible, but not simpler'' (A. Einstein). Key management points are highlighted at the beginning of each guideline, and in bold in the text. The chapters are divided in two volumes, one on obstetrics and one on maternal-fetal medicine; cross-references to chapters in Obstetric Evidence Based Guidelines have been noted in the text where applicable. Please contact us ([email protected]) for any comments, criticisms, corrections, missing evidence, etc.

I have the most fun discovering the best ways to alleviate discomfort and disease. The search for the best evidence for these guidelines has been a wonderful, stimulating journey. Keeping up with evidence-based medicine is exciting. The most rewarding part, as a teacher, is the dissemination of knowledge. I hope, truly, that this effort will be helpful to you, too.