Choosing Wisely

ACOG's list of "Five More Things Physicians and Patients Should Question" in obstetrics-gynecology (published March 2016) was released as part of the Choosing Wisely® campaign, led by the American Board of Internal Medicine (ABIM) Foundation. The list builds on the original "Five Things Physicians and Patients Should Question" (published February 2013).

The combined list includes ten evidence-based recommendations to support ob-gyns and their patients in making wise choices about their care. The list of ten tests or procedures to avoid as part of the Choosing Wisely® initiative includes:

1. Don’t schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks 0 days gestational age.
   
   Delivery prior to 39 weeks 0 days has been shown to be associated with an increased risk of learning disabilities and a potential increase in morbidity and mortality. There are clear medical indications for delivery prior to 39 weeks 0 days based on maternal and/or fetal conditions. A mature fetal lung test, in the absence of appropriate clinical criteria, is not an indication for delivery.

 

2. Due to recently-published evidence related to induction of labor between 39 and 41 weeks gestation, the ACOG has withdrawn this recommendation.

 

3. Don’t perform routine annual cervical cytology screening (Pap tests) in women 30 – 65 years of age.
   
   In average risk women, annual cervical cytology screening has been shown to offer no advantage over screening performed at 3-year intervals. However, a well-woman visit should occur annually for patients with their health care practitioner to discuss concerns and problems, and have appropriate screening with consideration of a pelvic examination.

 

4. Don’t treat patients who have mild dysplasia of less than two years in duration.
   
   Mild dysplasia (Cervical Intraepithelial Neoplasia [CIN 1]) is associated with the presence of the human papillomavirus (HPV), which does not require treatment in average risk women. Most women with CIN 1 on biopsy have a transient HPV infection that will usually clear in less than 12 months and, therefore, does not require treatment.

 

5. Don’t screen for ovarian cancer in asymptomatic women at average risk.
   
   In population studies, there is only fair evidence that screening of asymptomatic women with serum CA-125 level and/or transvaginal ultrasound can detect ovarian cancer at an earlier stage than it can be detected in the absence of screening. Because of the low prevalence of ovarian cancer and the invasive nature of the interventions required after a positive screening test, the potential harms of screening outweigh the potential benefits.

 

6. Avoid using robotic assisted laparoscopic surgery for benign gynecologic disease when it is feasible to use a conventional laparoscopic or vaginal approach.
   
   Robotic-assisted and conventional laparoscopic techniques are comparable with respect to perioperative outcomes, intraoperative complications, length of hospital stay and rate of conversion to open surgery. However, evidence shows that robotic-assisted laparoscopic surgery has similar or longer operating times and higher associated costs.

 

7. Don’t perform prenatal ultrasounds for non-medical purposes, for example, solely to create keepsake videos or photographs.
   
   Prenatal ultrasounds are an integral part of a woman’s prenatal care. While obstetric ultrasound has an excellent safety record, the U.S. Food and Drug Administration considers keepsake imaging as an unapproved use of a medical device. The American Institute of Ultrasound in Medicine also discourages the non-medical use of ultrasound for entertainment purposes. Keepsake ultrasounds are not medical tests and should not replace a clinically performed sonogram.

 

8. Don’t routinely transfuse stable, asymptomatic hospitalized patients with a hemoglobin level greater than 7–8 grams.
   
   Multiple factors need to be considered in transfusion decisions, including the patient’s clinical status and oxygen delivery ability. Arbitrary hemoglobin or hematocrit thresholds should not be used as the only criterion for transfusions of packed red blood cells.

 

9. Don’t perform pelvic ultrasound in average risk women to screen for ovarian cancer.
   
   Although the mortality rate associated with ovarian cancer is high, the disease occurs infrequently in the general U.S. population, with an age-adjusted incidence of 13 cases per 100,000 women. As a result, the positive predictive value of screening for ovarian cancer is low, and most women with a positive screening test result will have a false-positive result. Annual screening with transvaginal ultrasonography in women does not reduce the number of ovarian cancer deaths.

 

10. Don’t routinely recommend activity restriction or bed rest during pregnancy for any indication.
    
    Bed rest or activity restriction has been commonly recommended for a variety of conditions in pregnancy including multiple gestation, intrauterine growth restriction, preterm labor, premature rupture of membranes, vaginal bleeding and hypertensive disorders in pregnancy. However, information to date does not show an improvement in birth outcome with the use of bed rest or activity restriction, but does show an increase in loss of muscle conditioning and thromboembolic disease.

 

Additional details about these items, including the evidence to support them, can be found here (PDF).