New ‘Evolve’ recommendations to improve obstetric and paediatric care

pregnancyThe Royal Australasian College of Physicians (RACP) has today released a series of new recommendations to help avoid unnecessary and potentially harmful tests and procedures carried out with pregnant women and children.

Discussing the latest recommendations from the Society of Obstetric Medicine of Australia and New Zealand, Dr Helen Robinson said the latest evidence shows the D-dimer test is unreliable when it comes to detecting venous thromboembolism in pregnant women.

“Venous thromboembolism is a condition that includes deep vein thrombosis and pulmonary embolism,” Dr Robinson said. “The D-dimer test is often used to assist diagnosis of venous thromboembolism if a patient presents with symptoms, such as leg pain, swelling, oedema or lung-related chest pain.

“A higher than normal D-dimer level could mean the patient has venous thromboembolism. However, D-dimer concentrations rise during pregnancy so the test is incredibly unreliable if a doctor is trying to rule out venous thromboembolism.

“Women are five times more likely to develop venous thromboembolism during pregnancy, so it’s incredibly important that it’s successfully detected and treated.

“If venous thromboembolism is suspected, our advice is that clinicians use compression ultrasonography to rule out arm or leg thrombosis. For pulmonary embolism we recommend clinicians use appropriate imaging, as the foetal radiation exposure with these tests is within safe limits.”

The Australasian Paediatric Endocrine Group has also made a number of recommendations for paediatric care. Professor Fergus Cameron said that a review of current clinical evidence highlighted limitations in some growth-promoting strategies such as gonadotropin releasing hormone and aromatase inhibition hormone therapies.

“Gonadotropin releasing hormone therapy is very effective at treating precocious puberty in children but appears to have little benefit in increasing height in children with normally-timed puberty,” Professor Cameron said.

“There also appears to be an association between gonadotropin hormone therapy in girls with early (not precocious) puberty and subsequent risk of polycystic ovarian syndrome. “Our advice is that doctors should not be using this drug to treat children with height problems unless they are specifically treating central precocious puberty. The potential side effects of the treatment can’t be justified.” 

Other recommendations from the Australasian Paediatric Endocrine Group include:

 Don’t prescribe aromatase inhibitor hormone therapy for height promotion.
 Don’t rely on random measures of circadian hormones (hormones that fluctuate across the time of the day) for diagnostic purposes.
 Don’t rely solely on radiologic measures of bone age for assessing growth in young children with short stature under two years of age.

Other recommendations from the Society of Obstetric Medicine of Australia and New Zealand include:  Don’t test for inherited clotting disorders when women have pregnancy complications due to the placenta.
 Don’t repeatedly test for protein in the urine in established pre-eclampsia.
 Avoid measuring erythrocyte sedimentation rate in pregnancy. This is a general marker of inflammation in the body and is normally elevated in pregnancy. These lists are part of the Evolve physician-led initiative.

There are now 17 Evolve lists published, with a further 15 in development.​

“The Evolve initiative is all about doctors and patients discussing the potential harms and benefits of conducting a test or procedure,” RACP President Dr Catherine Yelland explained. “Even if tests and treatments are available to diagnose and treat a condition, doctors and patients should be questioning if they are necessary, do they carry risk, or will they make any difference to a clinical outcome.”
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