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Title:
Management of Uncomplicated Pregnancy
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Citation
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Management
of Uncomplicated Pregnancy in the Primary Care Setting. Washington, DC: VA/DoD Evidence Based
Clinical Practice Guideline Working Group, Veterans Health Administration,
Department of Veterans Affairs, and Health Affairs, Department of Defense,
September 2002. Office of Quality
and Performance publication 10Q CPG/UCP-02
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Completion Date:
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November 2002
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Release Date:
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December 2002
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Source(s):
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The
Uncomplicated Pregnancy Guideline (UCP) was developed and written for
clinicians by the Department of Veterans Affairs (VA) and the Department of
Defense (DoD).
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Adaptation:
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The guideline
draws heavily from the Institute for Clinical Systems Improvement (ICSI) – Health
Care Guideline: Routine Prenatal Care, July 2000 and the Guide to
Clinical Preventive Services (CPS) Second Edition, Report of the U.S.
Preventive Services Task Force, 1996.
Additionally, the American College of Obstetricians and
Gynecologists (ACOG) technical bulletins and guidelines were used as a
respected source for expert opinion.
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Guideline Status:
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This is an
initial release of the guideline.
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Developer(s):
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Veterans Health
Administration (VA), Department of Veterans Affairs (VA) - Federal
Government Agency [U.S.]
Department of Defense (DoD) - Federal Government Agency [US]
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Funding Source:
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U.S. Government
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Committee:
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The Management
of Uncomplicated Pregnancy Working Group
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Group Composition:
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The list
of contributors to the guideline includes obstetricians, midwives,
internists, family practitioners, physician’s assistants, nurses, and
pharmacists, as well as consultants in the field of guideline and algorithm
development. Individuals are from
diverse geographic regions and both VA and DoD health care systems and
include civilian practitioners.
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Disease/Condition:
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Uncomplicated
Pregnancy (UCP)
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Category:
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Screening,
Diagnosis, Treatment, and Management
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Intended Users:
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Clinicians in
the primary care setting and OB specialty clinics
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Target Population:
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Pregnant females
eligible for care in the VA or DoD health care delivery system.
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Contact Person(s):
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VA:
Carole Turner , RN
Women’s Health
Veteran’s Affairs
810 Vermont Avenue, NW
Washington, DC 20320
Phone: (202) 273-8577
Email: carole.turner@hq.med.va.gov
DoD:
Jay Carlson, LTC, MC, USA
OB/GYN Consultant to Army TSG
Walter Reed Army Medical Center
6900 Georgia Avenue
Bldg 2, Rm. 6764Washington, DC 20307-5001
Phone: (202) 782-8432
Email: jay.carlson@na.amedd.army.mil
USAF:
Christopher Zahn, Lt Col (P), MC, USAF
USUHS
Obstetrics and Gynecology
4301 Jones Bridge Road
Bethesda, MD 20814
Phone: (301)295-8262
Email: czahn@usuhs.mil
USN:
Terry A. Harrison, CDR, MC, USN
Obstetrics and Gynecology
Naval Medical Center
34730 Bob Wilson Drive
San Diego, CA 92134
Phone: (619) 532-7004
Email: taharrison@nmcsd.med.navy.mil
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GOALS/OBJECTIVES
- Provide a scientific evidence-base for practice interventions
and evaluations.
- Enhance patient education so that pregnant women
and their providers will each be aware of the specific expectations
for every visit, thus promoting a partnership with a common goal of a
healthy infant and mother.
- Improve patient and provider satisfaction with
antenatal care from initial encounter in the clinic through
parturition by providing an overview of screening and monitoring
options as well as discussion about general clinical approaches to
uncomplicated pregnancy.
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INTERVENTIONS AND
PRACTICES
The Guideline consists of two parts addressing Management of UCP in the
primary care settings.
- Algorithm
and Annotations – To be used for prenatal management of an
uncomplicated pregnancy.
- Prenatal
Care Interventions – Includes evidence-based interventions to be
performed at all prenatal visits and prenatal visits at 6-8 weeks,
10-12 weeks, 16-27 weeks, 28-36 weeks and 38-41 weeks. Interventions not recommended are
included.
The guideline
also contains the following appendices that provide screening instruments
and more detailed information about a condition or treatment option to
inform the provider of the spectrum of treatment options.
- Appendix
A-1: Screening Items for Self-Administered Questionnaire – First Visit
- Appendix
A-2: Standard for Performance of Antepartum Obstetrical Ultrasound
Examination
- Appendix
B-1: Guideline Development Process
- Appendix
B-2: Acronym List
- Appendix
B-3: Participant List
- Appendix
B-4: Bibliography
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OUTCOMES CONSIDERED
Standardized prenatal care and education for uncomplicated pregnant
patients resulting in improved outcomes as measured by gestation at
delivery and incidence of infants with Group B Streptococcus sepsis;
improved patient and provider satisfaction; and reduced cost.
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MAJOR RECOMMENDATIONS
The Uncomplicated Pregnancy (UCP) Guideline is presented in an algorithmic
format for the practitioner to follow at specific intervals during
pregnancy. Interventions and
contraindications are provided in an effort to reduce variation in the
delivery of prenatal care.
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CLINICAL ALGORITHM(S) ARE
PROVIDED FOR:
- UCP
in the clinical out-patient setting
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TYPE OF EVIDENCE
The process of developing this guideline was evidence-based whenever
possible. Evidence-based practice
integrates clinical expertise with the best available clinical evidence
derived from systematic research.
Where evidence is ambiguous or conflicting, or where scientific data
are lacking, the clinical experience of the multidisciplinary Working Group
was used to guide the development of consensus-based recommendations. The guideline contains a discussion of
the evidence supporting each recommendation and includes a bibliography.
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DESCRIPTION OF METHODS TO COLLECT EVIDENCE
The review of the literature, the evaluation of evidence, and the
development of the guideline proceeded in sequential steps. The ICSI – Health Care
Guideline: Routine Prenatal Care
(2000) served as the starting point for the development of questions and
key terms.
Fifty-six researchable questions and associated key
terms were developed after orientation to the ICSI document and to
identified goals. The questions
specified population (characteristics of the target population),
intervention (diagnostic, screening, therapy, and assessment), control (the
type of control used for comparison), and outcome (outcome measures being
morbidity, mortality, patient satisfaction, and cost). A systematic search of the literature
was conducted. It was found that
ICSI, Cochrane or other meta-analyses addressed 32 of the questions. Three questions were not researched
because legal mandates preclude debate.
The focus shifted to the remaining 21 questions that required
further study. The search used
well-known and widely available databases that were appropriate for the
clinical subject. The results of
the search were organized and reported using reference manager
software. Evidence Appraisal
Reports for the 21 unanswered questions were prepared by the Center for
Evidence-based Practice at the State University of New York, Upstate
Medical University, Department of Family Medicine.
See Guideline
Development Process (Appendix B-1) Pages B-1 and B-2
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| METHODS TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE
Practicing clinicians thoroughly evaluated the evidence-based
recommendations. The clinical
experts and research team evaluated the evidence according to criteria
proposed by the U.S. Preventive Services Task Force (USPSTF) (2001). The experts themselves, after an
orientation and tutorial on the evidence grading process, formulated
Quality of Evidence ratings, a rating of Overall Quality, a rating of the
Net Effect of the Intervention, and an overall Recommendation.
See Guideline
Development Process (Appendix B-1), page s B-2 and B-3
The Grading Scheme Used for the Guideline
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TABLE
1: Quality of Evidence (QE)
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I
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At least one
properly done RCT.
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II-1
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Well-designed
controlled trial without randomization.
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II-2
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Well-designed
cohort or case-control analytic study.
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II-3
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Multiple time
series, dramatic results of uncontrolled experiment.
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III
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Opinion of
respected authorities, case reports, and expert committees.
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TABLE
2: Overall Quality
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Good
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High-grade
evidence (I or II-1) directly linked to health outcome.
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Fair
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High-grade
evidence (I or II-1) linked to intermediate outcome; or
Moderate-grade
evidence (II-2 or II-3) directly linked to health outcome.
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Poor
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Level III
evidence or no linkage of evidence to health outcome.
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TABLE
3: Net Effect of the Intervention
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Substantial
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More than a
small relative impact on a frequent condition with a substantial burden
of suffering; or
A large
impact on an infrequent condition with a significant impact on the
individual patient level.
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Moderate
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A small
relative impact on a frequent condition with a substantial burden of
suffering; or
A moderate
impact on an infrequent condition with a significant impact on the
individual patient level.
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Small
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A negligible
relative impact on a frequent condition with a substantial burden of
suffering; or
A small
impact on an infrequent condition with a significant impact on the
individual patient level.
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Zero or
Negative
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Negative
impact on patients; or
No relative
impact on either a frequent condition with a substantial burden of
suffering; or
An infrequent
condition with a significant impact on the individual patient level.
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TABLE
4: Grade the Recommendation
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A
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A strong recommendation
that the intervention is always indicated and acceptable.
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B
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A
recommendation that the intervention may be useful/effective.
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C
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A
recommendation that the intervention may be considered.
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D
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A
recommendation that a procedure may be considered not useful/effective,
or may be harmful.
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I
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Insufficient
evidence to recommend for or against – the clinician will use clinical
judgment.
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REVIEW METHODS
The
final draft of the guideline is distributed for review by an at large audience
across VA and DoD. Patient Care Services and the Network-appointed Guideline
Champions solicit feedback from a broader group of end users. Members of
related QUERI groups are also asked to comment. Network designated staff
will be asked to use the guideline in the direct care setting and provide
feedback to the Network Guideline Champions. This portion of the field test
is intended to provide feedback regarding the format and usability. At this
time, the peer review of the guideline is also being completed by at least
three VA /DoD staff, including primary care clinicians, who have been trained
and previously assigned to perform the independent review. Within 3 weeks,
the rating tool containing the reviewer’s comments and recommendation will
be forwarded to the Office of Quality and Performance and the Vice Chairperson
of the NCPG Council. The Vice Chairperson of the NCPG Council will forward
a summary of the recommendations from the peer reviewers to the National
Champions. Final editing incorporates feedback as appropriate. The National
Senior Champions along with the Evidence Chaperone and the NCGPC Representative
will integrate comments and suggestions into the final document as appropriate.
Discussion of serious controversies regarding interpretation of the evidence
will be included in the introduction to the guideline and may be the subject
of discussion at the time of review with the Council. Provider tools will
also be finalized and submitted to Employee Education System for final formatting.
Prior to delivery to the NCPG Council, the champions group will re-convene
by conference call to approve the final draft and tools.
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QUALIFYING STATEMENTS
Clinical practice guidelines, which are
increasingly being used in health care, are seen by many as a potential
solution to inefficiency and inappropriate variations in care. Guidelines
should be evidenced-based as well as based upon explicit criteria to ensure
consensus regarding their internal validity. However, it must be remembered
that the use of guidelines must always be in the context of a health care
provider's clinical judgment in the care of a particular patient. For that
reason, the guidelines may be viewed as an educational tool analogous to
textbooks and journals, but in a more user-friendly format.
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GUIDELINE AVAILABILITY
Electronic copies available from:
U.S. Army Medical Command Quality Management web site.
www.qmo.amedd.army.mil
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Copy
Statement: No copyright restrictions apply
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