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ACOG Clinical Highlights
The following are highlights from ACOG Practice Bulletins, Committee Opinions,
and Technical Assessments which are provided to let you know which topics have
been updated by ACOG recently.
These highlights are not meant to replace the full text documents, nor are
they meant to replace clinical consultation with the appropriate health professionals.
If you have any questions, please contact the IHS OB/GYN Chief Clinical Consultant,
Jean Howe.
Practice Bulletins
Topics On This Page 
Other Clinical Highlights
January 2010
Noncontraceptive Uses of Hormonal Contraceptives,
ACOG Practice Bulletin No. 110, January 2010
More than 80% of U.S. women will use hormonal contraception during their reproductive
years. Many of these women use hormonal contraception for its noncontraceptive
benefits. Hormonal contraceptives can correct menstrual irregularities resulting
from oligo-ovulation or anovulation and make menstruation more predictable.
The purpose of this document is to describe noncontraceptive uses for hormonal
contraceptives and examine the evidence evaluating the effectiveness of contraceptives
for these applications. For many of the conditions, experts suggest that effects
of contraceptives are class effects and that all formulations may provide similar
therapy. Evidence will be given for specific routes and formulations of hormonal
contraception when available, although there are few data on newer methods and
formulations.
Summary of Recommendations and Conclusions
The following recommendations are based on good and consistent scientific
evidence (Level A):
- Combined OCs should not be used to treat existing functional ovarian cysts.
- Use of combined hormonal contraception has been shown to decrease the risk
of endometrial and ovarian cancer.
- Combined OCs have been shown to regulate and reduce menstrual bleeding, treat
dysmenorrhea, reduce premenstrual dysphoric disorder symptoms, and ameliorate
acne.
- Continuous combined hormonal contraception, DMPA, and the levonorgestrel
intrauterine system may be considered for long-term menstrual suppression.
The following recommendations are based on limited or inconsistent scientific
evidence (Level B):
- Based on the limited data available it appears overall that combined OCs
do not increase the risk of development of uterine leiomyomas.
- Hormonal contraception should be considered for the treatment of menorrhagia
in women who may desire further pregnancies.
Proposed Performance Measure
Percentage of women using hormonal contraception for symptomatic relief of menorrhagia
or dysmenorrhea or both who have no contraindications and wish to preserve reproductive
function
Noncontraceptive Uses of Hormonal Contraceptives. ACOG Practice Bulletin No.
110. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;115:206–18.
December 2009
Cervical Cytology Screening, ACOG Practice Bulletin
No. 109, December 2009
The incidence of cervical cancer has decreased more than 50% in the past 30
years because of widespread screening with cervical cytology. In 1975, the rate
was 14.8 per 100,000 women in the United States; by 2006, it had been reduced
to 6.5 per 100,000 women. Mortality from the disease has undergone a similar
decrease. The American Cancer Society estimates 11,270 new cases of cervical
cancer in the United States in 2009, with 4,070 deaths from the disease. Recent
estimates worldwide, however, are of almost 500,000 new cases and 240,000 deaths
from the disease per year. When cervical cytology screening programs have been
introduced into communities, marked reductions in cervical cancer incidence have
followed.
New technology for performing cervical cancer screening is evolving rapidly,
as are recommendations for classifying and interpreting the results. The purpose
of this document is to provide a review of the best available evidence on screening
for cervical cancer. Specific equipment and techniques for performing cervical
cytology and interpretation of the results are not discussed.
Summary of Recommendations and Conclusions
The following recommendations are based on good and consistent scientific
evidence (Level A):
- Cervical cancer screening should begin at age 21 years. Screening before
age 21 should be avoided because it may lead to unnecessary and harmful evaluation
and treatment in women at very low risk of cancer.
- Cervical cytology screening is recommended every 2 years for women between
the ages of 21 years and 29 years.
- Women aged 30 years and older who have had three consecutive negative cervical
cytology screening test results and who have no history of CIN 2 or CIN 3, are
not HIV infected, are not immunocompromised, and were not exposed to diethylstilbestrol
in utero may extend the interval between cervical cytology examinations to every
3 years.
- Both liquid-based and conventional methods of cervical cytology are acceptable
for screening.
- In women who have had a total hysterectomy for benign indications and have
no prior history of high-grade CIN, routine cytology testing should be discontinued.
- Co-testing using the combination of cytology plus HPV DNA testing is an appropriate
screening test for women older than 30 years. Any low-risk woman aged 30 years
or older who receives negative test results on both cervical cytology screening
and HPV DNA testing should be rescreened no sooner than 3 years subsequently.
The following recommendations are based on limited and inconsistent scientific
evidence (Level B):
- Sexually active adolescents (ie, females younger than age 21 years) should
be counseled and tested for sexually transmitted infections, and should be counseled
regarding safe sex and contraception. These measures may be carried out without
cervical cytology and, in the asymptomatic patient without the introduction of
a speculum.
- Because cervical cancer develops slowly and risk factors decrease with age,
it is reasonable to discontinue cervical cancer screening between 65 years and
70 years of age in women who have three or more negative cytology test results
in a row and no abnormal test results in the past 10 years.
- Women treated in the past for CIN 2, CIN 3, or cancer remain at risk for
persistent or recurrent disease for at least 20 years after treatment and after
initial posttreatment surveillance, and should continue to have annual screening
for at least 20 years.
- Women who have had a hysterectomy with removal of the cervix and have a history
of CIN 2 or CIN 3—or in whom a negative history cannot be documented—should
continue to be screened even after their period of posttreatment surveillance.
Whereas the screening interval may then be extended, there are no good data to
support or refute discontinuing screening in this population.
The following recommendations are based primarily on consensus and expert
opinion (Level C):
- Regardless of the frequency of cervical cytology screening, physicians also
should inform their patients that annual gynecologic examinations may still be
appropriate even if cervical cytology is not performed at each visit.
- Women who have been immunized against HPV-16 and HPV-18 should be screened
by the same regimen as nonimmunized women.
Proposed Performance Measure
Percentage of women between the ages 21 years and 29 years who have received
a Pap test within the past 2 years
Cervical Cytology Screening. ACOG Practice Bulletin No. 109. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2009; 114:1409–20.
October 2009
Polycystic Ovary Syndrome, ACOG Practice Bulletin
No. 108, October 2009
Polycystic ovary syndrome (PCOS) is a disorder characterized by hyperandrogenism,
ovulatory dysfunction, and polycystic ovaries. Its etiology remains unknown,
and treatment is largely symptom based and empirical. PCOS has the potential
to cause substantial metabolic sequelae, including an increased risk of diabetes
and cardiovascular disease, and these factors should be considered when determining
long-term treatment. The purpose of this document is to examine the best available
evidence for the diagnosis and clinical management of PCOS.
The following recommendations and conclusions are based on good and consistent
scientific evidence (Level A):
- An increase in exercise combined with dietary change has consistently been
shown to reduce diabetes risk comparable to or better than medication.
- Improving insulin sensitivity with insulin-sensitizing agents is associated
with a decrease in circulating androgen levels, improved ovulation rate, and
improved glucose tolerance.
- The recommended first-line treatment for ovulation induction remains the
antiestrogen clomiphene citrate.
- The addition of eflornithine to laser treatment is superior in the treatment
of hirsutism than laser alone.
The following recommendations and conclusions are based on limited and inconsistent
scientific evidence (Level B):
- Women with a diagnosis of PCOS should be screened for type 2 diabetes and
impaired glucose tolerance with a fasting glucose level followed by a 2-hour
glucose level after a 75-g glucose load.
- Women with PCOS should be screened for cardiovascular risk by determination
of BMI, fasting lipid and lipoprotein levels, and metabolic syndrome risk factors.
- Reduction in body weight has been associated with improved pregnancy rates
and decreased hirsutism, as well as improvements in glucose tolerance and lipid
levels.
- There may be an increase in pregnancy rates by adding clomiphene to metformin,
particularly in obese women with PCOS.
- If clomiphene citrate use fails to result in pregnancy, the recommended second-line
intervention is either exogenous gonadotropins or laparoscopic ovarian surgery.
The following recommendations and conclusions are based primarily on consensus
and expert opinion (Level C):
- Combination low-dose hormonal contraceptives are most frequently used for
long-term management and are recommended as the primary treatment of menstrual
disorders.
- Women in groups at higher risk for nonclassical congenital adrenal hyperplasia
and a suspected diagnosis of PCOS should be screened to assess the 17- hydroxyprogesterone
value.
- A low-dose regimen is recommended when using gonadotropins in women with
PCOS.
- There is no clear primary treatment for hirsutism in PCOS.
Polycystic ovary syndrome. ACOG Practice Bulletin No. 108. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2009; 114:936–49.
August 2009
Induction of Labor ACOG Practice Bulletin
Number 107 August 2009
More than 22% of all gravid women undergo induction of labor in the United States,
and the overall rate of induction of labor in the United States has more than
doubled since 1990 to 225 per 1,000 live births in 2006. The goal of induction
of labor is to achieve vaginal delivery by stimulating uterine contractions before
the spontaneous onset of labor. Generally, induction of labor has merit as a
therapeutic option when the benefits of expeditious delivery outweigh the risks
of continuing the pregnancy. The benefits of labor induction must be weighed
against the potential maternal and fetal risks associated with this procedure.
The purpose of this document is to review current methods for cervical ripening
and induction of labor and to summarize the effectiveness of these approaches
based on appropriately conducted outcomes-based research. These practice guidelines
classify the indications for and contraindications to induction of labor, describe
the various agents used for cervical ripening, cite methods used to induce labor,
and outline the requirements for the safe clinical use of the various methods
of inducing labor.
The following recommendations and conclusions are based on good and consistent
scientific evidence
(Level A):
- Prostaglandin E analogues are effective for cervical ripening and inducing
labor.
- Low- or high-dose oxytocin regimens are appropriate for women in whom induction
of labor is indicated.
- Before 28 weeks of gestation, vaginal misoprostol appears to be the most
efficient method of labor induction regardless of Bishop score, although high
dose oxytocin infusion also is an acceptable choice.
- Approximately 25 mcg of misoprostol should be considered as the initial dose
for cervical ripening and labor induction. The frequency of administration should
not be more than every 3–6 hours.
- Intravaginal PGE2 for induction of labor in women with premature rupture
of membranes appears to be safe and effective.
- The use of misoprostol in women with prior cesarean delivery or major uterine
surgery has been associated with an increase in uterine rupture and, therefore,
should be avoided in the third trimester.
- The Foley catheter is a reasonable and effective alternative for cervical
ripening and inducing labor.
The following recommendation is based on evidence that may be limited or inconsistent
(Level B):
- Misoprostol (50 mcg every 6 hours) to induce labor may be appropriate in
some situations, although higher doses are associated with an increased risk
of complications, including uterine tachysystole with FHR decelerations.
Proposed Performance Measure:
Percentage of patients in whom gestational age is established by clinical criteria
when labor is being induced for logistic or psychosocial indications.
Induction of labor. ACOG Practice Bulletin No. 107. American College of Obstetricians
and Gynecologists. Obstet Gynecol 2009;114:386–97.
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July 2009
Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation,
and General Management Principles ACOG Practice Bulletin Number 106 July
2009
In the most recent year for which data are available, approximately 3.4 million
fetuses (85% of approximately 4 million live births) in the United States were
assessed with electronic fetal monitoring (EFM), making it the most common obstetric
procedure. Despite its widespread use, there is controversy about the efficacy
of EFM, interobserver and intraobserver variability, nomenclature, systems for
interpretation, and management algorithms. Moreover, there is evidence that the
use of EFM increases the rate of cesarean deliveries and operative vaginal deliveries.
The purpose of this document is to review nomenclature for fetal heart rate assessment,
review the data on the efficacy of EFM, delineate the strengths and shortcomings
of EFM, and describe a system for EFM classification.
The following recommendations and conclusions are based on good and consistent
scientific evidence (Level A):
- The false-positive rate of EFM for predicting cerebral palsy is high, at
greater than 99%.
- The use of EFM is associated with an increased rate of both vacuum and forceps
operative vaginal delivery, and cesarean delivery for abnormal FHR patterns or
acidosis or both.
- When the FHR tracing includes recurrent variable decelerations, amnioinfusion
to relieve umbilical cord compression should be considered.
- Pulse oximetry has not been demonstrated to be a clinically useful test in
evaluating fetal status.
The following conclusions are based on limited or inconsistent scientific
evidence (Level B):
- There is high interobserver and intraobserver variability in interpretation
of FHR tracing.
- Reinterpretation of the FHR tracing, especially if the neonatal outcome is
known, may not be reliable.
- The use of EFM does not result in a reduction of cerebral palsy.
The following recommendations are based on expert opinion (Level C):
- A three-tiered system for the categorization of FHR patterns is recommended.
- The labor of women with high-risk conditions should be monitored with continuous
FHR monitoring.
- The terms hyperstimulation and hypercontractility should be abandoned.
Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and
General Management Principles. ACOG Practice Bulletin No. 106. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:192–202. http://www.ncbi.nlm.nih.gov/pubmed/19546798
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June 2009
Bariatric Surgery and Pregnancy ACOG Practice Bulletin
Number 105 June 2009
As the rate of obesity increases, it is becoming more common for providers of
women’s health care to encounter patients who are either contemplating
or have had operative procedures for weight loss, also known as bariatric surgery.
The counseling and management of patients who become pregnant after bariatric
surgery can be complex. Although pregnancy outcomes generally have been favorable
after bariatric surgery, nutritional and surgical complications can occur and
some of these complications can result in adverse perinatal outcomes. The purpose
of this Practice Bulletin is to provide a summary of the risks of obesity in
pregnancy, review the available literature regarding outcomes of pregnancy after
bariatric surgery, and provide recommendations for the care of the patient during
her pregnancy and delivery after bariatric surgery.
The following conclusions and recommendations are based on limited or inconsistent
scientific evidence (Level B:)
- Contraceptive counseling is important for adolescents because pregnancy rates
after bariatric surgery are double the rate in the general adolescent population.
- Because there is an increased risk of oral contraception failure after bariatric
surgery with a significant malabsorption component, nonoral administration of
hormonal contraception should be considered in these patients.
- In using medications in which a therapeutic drug level is critical, testing
drug levels may be necessary to ensure a therapeutic effect.
The following conclusions and recommendations are based primarily on consensus
and expert opinion (Level C):
- There should be a high index of suspicion for gastro-intestinal surgical
complications when pregnant women who have had these procedures present with
significant abdominal symptoms.
- Bariatric surgery should not be considered a treatment for infertility.
- Bariatric surgery should not be considered an indication for cesarean delivery.
- There is no consensus on the management of patients during pregnancy who
have had an adjustable gastric banding procedure, but early consultation with
a bariatric surgeon is recommended.
- Alternative testing for gestational diabetes should be considered for those
patients with a malabsorptive-type surgery.
- Consultation with a nutritionist after conception may help the patient adhere
to dietary regimens and cope with the physiologic changes of pregnancy.
- A broad evaluation for micronutrient deficiencies at the beginning of pregnancy
for women who have had bariatric surgery should be considered.
Proposed Performance Measure:
Documentation of counseling about weight gain and nutrition in pregnancy
Bariatric Surgery and Pregnancy. ACOG Practice Bulletin No. 105. American
College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:1405–13. http://www.ncbi.nlm.nih.gov/pubmed/19461456
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May 2009
Antibiotic Prophylaxis for Gynecologic Procedures ACOG
Practice Bulletin Number 104 May 2009
Surgical site infection remains the most common surgical complication. Up to
5% of patients undergoing operative procedures will develop a surgical site infection
leading to a longer hospital stay and increased cost (1). One of the advances
in infection control practices has been the selective use of antibiotic prophylaxis.
However, indiscriminate antibiotic use has been associated with the selection
of antibiotic-resistant bacteria, which have acknowledged consequences for institutions
as well as for individual patients. It is important for clinicians to understand
when antibiotic prophylaxis is indicated and when it is inappropriate. The purpose
of this document is to review the evidence for surgical site infection prevention
and appropriate antibiotic prophylaxis for gynecologic procedures.
The following recommendations and conclusions are based on good and consistent
scientific evidence (Level A):
- Patients undergoing hysterectomy should receive single-dose antimicrobial
prophylaxis preoperatively.
- Pelvic inflammatory disease occurs uncommonly with or without the use of
antibiotic prophylaxis and so prophylaxis is not indicated at the time of IUD
insertion.
- Antibiotic prophylaxis is indicated for elective suction curettage abortion.
- Antibiotic prophylaxis is not recommended in patients undergoing diagnostic
laparoscopy.
The following recommendations and conclusions are based on limited or inconsistent
scientific evidence (Level B):
- In patients with no history of pelvic infection, HSG can be performed without
prophylactic antibiotics. If HSG demonstrates dilated fallopian tubes, antibiotic
prophylaxis should be given to reduce the incidence of post-HSG PID.
- Routine antibiotic prophylaxis is not recommended for the general patient
population undergoing Hysteroscopic surgery.
- Cephalosporin prophylaxis is acceptable in those patients with a history
of penicillin allergy not felt to be immunoglobulin E mediated (immediate hypersensitivity).
- Patients found to have preoperative bacterial vaginosis should be treated
before hysterectomy.
The following recommendations and conclusions are based primarily on consensus
and expert opinion (Level C):
- Antibiotic prophylaxis is not recommended in patients undergoing exploratory
laparotomy.
- For transcervical procedures such as HSG, chromotubation, and hysteroscopy,
prophylaxis may be considered in those patients with a history of PID or tubal
damage noted at the time of the procedure.
- Patients with a history of an immediate hypersensitivity reaction to penicillin
should not receive cephalosporin antibiotics.
- Pretest screening for bacteriuria or urinary tract infection by urine culture
or urinalysis, or both, is recommended in women undergoing urodynamic testing.
Those with positive test results should be given antibiotic treatment.
Proposed Performance Measure:
The percentage of women undergoing hysterectomy who received preoperative antibiotic
prophylaxis.
American College of Obstetricians and Gynecologists. Antibiotic prophylaxis
for gynecologic procedures. ACOG Practice Bulletin No. 104. Obstet Gynecol 2009;113:1180–9.
http://www.ncbi.nlm.nih.gov/pubmed/19384149
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April 2009
Hereditary Breast and Ovarian Cancer Syndrome ACOG
Practice Bulletin Number 103 April 2009
Hereditary breast and ovarian cancer syndrome is an inherited cancer-susceptibility
syndrome. The hallmarks of this syndrome are multiple family members with breast
cancer or ovarian cancer or both, the presence of both breast cancer and ovarian
cancer in a single individual, and early age of breast cancer onset. Clinical
genetic testing for gene mutations allows physicians to more precisely identify
women who are at substantial risk of breast cancer and ovarian cancer. For these
individuals, screening and prevention strategies can be instituted to reduce
their risks. Obstetricians and gynecologists play an important role in the identification
and management of women with hereditary breast and ovarian cancer syndrome.
The following recommendations are based on good and consistent scientific
evidence (Level A):
- Women with BRCA1 or BRCA2 mutations should be offered risk-reducing
salpingo-oophorectomy by age 40 years or when child-bearing is complete.
- For a risk-reducing bilateral salpingo-oophorectomy, all tissue from the
ovaries and fallopian tubes should be removed. Thorough visualization of the
peritoneal surfaces with pelvic washings should be performed. Complete, serial
sectioning of the ovaries and fallopian tubes is necessary, with microscopic
examination for occult cancer.
- A genetic risk assessment is recommended for patients with a greater than
an approximate 20–25% chance of having an inherited predisposition to breast
cancer and ovarian cancer.
Proposed Performance Measure:
Percentage of patients identified as having greater than a 20–25% risk
of having a BRCA mutation (high risk) who are referred for genetic counseling
American College of Obstetricians and Gynecologists. Hereditary breast and
ovarian cancer syndrome. ACOG Practice Bulletin No. 103. Obstet Gynecol 2009;113:957–66.
http://www.ncbi.nlm.nih.gov/pubmed/19305347
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March 2009
Management of Stillbirth ACOG Practice Bulletin Number
102 March 2009
Stillbirth is one of the most common adverse pregnancy outcomes, complicating
1 in 160 deliveries in the United States. Approximately 25,000 stillbirths at
20 weeks or greater of gestation are reported annually (1). The purpose of this
bulletin is to review the current information on stillbirth, including definitions
and management, the evaluation of a stillbirth, and strategies for prevention.
The following recommendations and conclusions are based on good and consistent
scientific evidence. (Level A)
- In low-risk women with unexplained stillbirth the risk of recurrence stillbirth
after 20 weeks of gestation is estimated at 7.8–10.5/1,000 with most of
this risk occurring before 37 weeks of gestation.
- The most prevalent risk factors associated with stillbirth are non-Hispanic
black race, nulliparity, advanced maternal age, and obesity (Table 1).
- The risk of subsequent still birth is twice as high for women with a prior
live born, growth restricted infant delivered before 32 weeks of gestation than
for women with a prior stillbirth.
- Amniocentesis for fetal karyotyping has the highest yield and is particularly
valuable if delivery is not expected imminently.
The following recommendations and conclusions are based primarily on limited
or inconsistent scientific evidence (Level B):
- In the second trimester, dilation and evacuation can be offered. Labor induction
also is appropriate at later gestational ages, if second trimester dilation and
evacuation is unavailable, or based on patient preference.
- Induction of labor with vaginal misoprostol is safe and effective in patients
with a prior cesarean delivery with a low transverse uterine scar before 28 weeks
of gestation.
The following recommendations and conclusions are based primarily on consensus
and expert opinion (Level C):
- The most important tests in the evaluation of a stillbirth are fetal autopsy;
examination of the placenta, cord, and membranes; and karyotype evaluation.
- Patient support should include emotional support and clear communication
of test results. Referral to a bereavement counselor, religious leader, peer
support group, or mental health professional may be advisable for management
of grief and depression.
Performance Measure:
The percentage of stillbirths for which placental evaluation was performed and
autopsy was offered
Management of Stillbirth. ACOG Practice Bulletin No. 98. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2009; 113:748–61. http://www.ncbi.nlm.nih.gov/pubmed/19300347
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February 2009
Ultrasonography in Pregnancy ACOG Practice Bulletin Number
101 February 2009
Most women have at least one ultrasound examination during pregnancy. The purpose
of this document is to present evidence regarding the methodology of, indications
for, benefits of, and risks associated with obstetric ultrasonography in specific
clinical situations. Portions of this document were developed collaboratively
with the American College of Radiology and the American Institute of Ultrasound
in Medicine. The sections that address physician qualifications and responsibilities,
documentation, quality control, infection control, and patient safety contain
recommendations from the American College of Obstetricians and Gynecologists.
The following conclusions are based on good and consistent evidence (Level
A):
- Ultrasound examination is an accurate method of determining gestational age,
fetal number, viability, and placental location.
- Gestational age is most accurately determined in the first half of pregnancy.
- Ultrasonography can be used in the diagnosis of many major fetal anomalies.
- Ultrasonography is safe for the fetus when used appropriately.
The following conclusions are based on limited or inconsistent evidence (Level
B):
- Ultrasonography is helpful in detecting fetal growth disturbances.
- Ultrasonography can detect abnormalities in amniotic fluid volume.
The following conclusion and recommendation are based primarily on consensus
and expert opinion (Level C):
- The optimal timing for a single ultrasound examination in the absence of
specific indications for a first-trimester examination is at 18 20 weeks
of gestation.
- The benefits and limitations of ultrasonography should be discussed with
all patients.
Proposed Performance Measure:
Documentation of the discussion of the benefits and limitations of ultrasonography.
Ultrasonography in Pregnancy. ACOG Practice Bulletin No. 101. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2009;113: 451–61. http://www.ncbi.nlm.nih.gov/pubmed/19155920
Critical
Care in Pregnancy ACOG Practice Bulletin Number
100 February 2009
Critical care in pregnancy is a field that remains unevenly researched. Although
there is a body of evidence to guide many recommendations in critical care, limited
research specifically addresses obstetric critical care. The purpose of this
document is to review the available evidence, propose strategies for care, and
highlight the need for additional research. Much of the review will, of necessity,
focus on general principles of critical care, extrapolating where possible to
obstetric critical care.
The following conclusions are based on good and consistent scientific evidence
(Level A):
- Pregnancy changes normal laboratory values and physiologic parameters.
- Approximately 75% of obstetric ICU patients are admitted to the unit postpartum.
- Hemorrhage and hypertension are the most common causes of admission from
obstetric services to intensive care.
The following recommendations are based on limited or inconsistent scientific
evidence (Level B):
- Cesarean delivery in the ICU should be restricted to cases in which transport
to the operating room or delivery room cannot be achieved safely or expeditiously,
or to a perimortem procedure.
- Treatment of sepsis should not await admission to an ICU but should begin
as soon as septic shock is diagnosed.
The following recommendations and conclusions are based primarily on consensus
and expert opinion (Level C):
- High-intensity ICU physician staffing is associated with lower ICU mortality
rates, lower hospital mortality rates, and decreased length of stay in both the
ICU and a hospital, compared with models in which intensivist consultation is
optional.
- Decisions about care for a pregnant patient in the ICU should be made collaboratively
with the intensivist, obstetrician, specialty nurses, and neonatologist.
- The care of any pregnant woman requiring ICU services should be managed in
a facility with obstetric adult ICU and neonatal ICU capability.
- Necessary medications should not be withheld from a pregnant woman because
of fetal concerns.
- Necessary imaging studies should not be withheld out of potential concern
for fetal status, although attempts should be made to limit fetal radiation exposure
during diagnostic testing.
Proposed Performance Measure:
Percentage of pregnant or postpartum patients in the ICU who have documented
involvement of an obstetrician– gynecologist.
Critical Care in Pregnancy. ACOG Practice Bulletin No. 100. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2009;113: 433–50. http://www.ncbi.nlm.nih.gov/pubmed/19155919
 Committee Opinions
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