CRC OBST EVID-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's 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 over 20 years practicing obstetrics, I know now that while 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, requires 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 literature and data. It is increasingly difficult to read and acquire as knowledge all that is published, certainly in obstetrics, with about 3000 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. 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 over 400 Cochrane reviews, with hundreds of other meta-analyses also published in obstetrical topics (Table 1). All of the Cochrane reviews, 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 evidencebased 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. Like all pilots fly planes under similar rules to maximize safety, all obstetricians should manage all aspects of pregnancy with similar, evidence-based rules. Indeed only interventions that have been proven to provide benefit should be used routinely. However, 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.