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SMFM and Choosing Wisely: The Latest 5 Practices That Doctors and Patients Should Question

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Learning Objectives and CME/Disclosure Information

SUMMARY:

The purpose of the Choosing Wisely campaign is to promote discussion between patients and clinicians with the goal of preventing unnecessary medical interventions. SMFM augmented the previous ten Choosing Wisely campaign questions with five additional practices that “Physicians and Patients Should Question” (May 2019). We summarize this most recent set of five practices, and also provide ‘Related ObG Topics’ below. All 15 practices can be found in the ‘Learn More – Primary Sources’ section below, along with related references.

KEY POINTS:

  • In women with low risk aneuploidy screening results and isolated ‘soft markers’, such as echogenic intracardiac focus (EIF) or isolated choroid plexus cyst (CPC)
    • Do not recommend invasive testing
    • Describe ‘soft marker’ finding as ‘not clinically significant’ or ‘normal variant’
  • Following cerclage placement
    • Do not perform serial cervical length measurement
    • There is no evidence that cervical length monitoring following a cerclage improves outcomes, despite cervical shortening being associated with increased risk for preterm birth
  • In the clinical evaluation for thrombophilia, recurrent pregnancy loss, or for at-risk family members
    • Do not order MTHFR polymorphism genotyping
    • Two polymorphic variants are known to decrease enzyme activity: 677C>T and 1298A>C 
    • Older studies suggested that MTHFR genotype status may be related to increased risk of venous thrombosis, coronary heart disease, recurrent pregnancy loss and adverse pregnancy outcomes but more recent analyses have not demonstrated consistent associations  
  • In pregnant women who are asymptomatic
    • Do not screen for subclinical hypothyroidism
    • RCTs have not demonstrated treatment benefit for subclinical hypothyroidism
    • A recent secondary analysis of a large RCT did not identify a difference between prepregnancy TSH < 2.5 vs ≥5 mIU/L and preterm delivery, GDM or preeclampsia
  • When making the diagnosis of oligohydramnios in the third trimester
    • Do not use AFI | Deepest vertical pocket of <2 is preferred
    • AFI is associated with more women being identified with oligohydramnios, but without any significant benefit in perinatal outcome

Learn More – Primary Sources:

SMFM Choosing Wisely: Things Physicians and Patients Should Question

Choosing Wisely®: Promoting conversations between patients and clinicians

SMFM Consult Series 42: The role of ultrasound in women who undergo cell-free DNA screening

SMFM: Cervical cerclage for the woman with prior adverse pregnancy outcome

ACOG Committee Opinion 197: Inherited Thrombophilias in Pregnancy

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Related ObG Topics:

SMFM Guidance – The Role of Prenatal Ultrasound and NIPT 
Cervical Cerclage – Professional Recommendations
MTHFR Polymorphism Testing – The Evidence Isn’t There
Subclinical Hypothyroidism and Pregnancy Outcome – Is There a Relationship?
Deepest Pocket or AFI When Performing Prenatal Ultrasound?  

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