USPSTF final recommendation statement favor screening for preeclampsia throughout pregnancy.

The US Preventive Services Task Force (USPSTF) today issued its final recommendations for preeclampsia screening by monitoring the blood pressure throughout pregnancy with grade B, meaning there exists substantial net benefit for the mother and infant because of screening.

The recommendations, accompanying editorial and systematic review evidence was published online 25 April 2017 in JAMA.

USPSTF has earlier released a draft recommendation on September 27, 2016 which was open to public comments till October 2017.

The task force last full review of this topic was in 1996. The topic was again reviewed recently in light of new evidence and change in definition of preeclampsia.

The current recommendation states that Blood Pressure measurement should be done at each antenatal visit. No timing interval is mentioned.

The screening applies to all pregnant women without a known diagnosis of preeclampsia or being at high risk for the disease.

Conditions associated with increased risks are previous history of eclampsia or preeclampsia (particularly early-onset preeclampsia), medical morbidities associated includes DM 1 or 2, GDM, chronic hypertension, renal disease, and autoimmune diseases), previous history of adverse pregnancy outcome and multifetal gestation.

Other risk factors include nulliparity, obesity, African American race, low socioeconomic status, and advanced maternal age.

Evidence did not suggest point of care urine testing when screening for preeclampsia because it alone could not predict the health outcome.

Recently revised criteria for the diagnosis of preeclampsia include:

• elevated blood pressure (≥140/90 mm Hg on 2 occasions 4 hours apart, after 20 weeks of gestation)
• and either proteinuria (≥300 mg/dL on a 24-hour urine protein test, protein to creatinine ratio of ≥0.3 mg/mmol, or urine protein dipstick reading >1 if quantitative analysis is not available)
• or, in the absence of proteinuria, thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms.

The USPSTF further recommends low dose aspirin (81 mg/d) after 12 weeks of gestation for all women at high risk for preeclampsia.

Other Obstetrics and Gynecology societies like The Society of Obstetricians and Gynecologists of Canada, The National Institute for Health(NIH) and Care Excellence recommends urinalysis for proteinuria at each antenatal visit.

The ACOG only recommends B.P. measurements at every visit with detailed history to evaluate the risk.

“Preeclampsia and CVDs including hypertension are bound not only by common pathophysiology but also epidemiology” said Nisha I. Parikh, MD, and Juan Gonzalez, MD, PhD, from the University of California, San Francisco, in an accompanying editorial published simultaneously in JAMA Internal Medicine.

"Pregnancy is essentially a cardiovascular stress test, and the development of preeclampsia among other pregnancy complications is the earliest marker of patients at risk for future [cardiovascular disease].” They further added.

The full text of recommendation statement in JAMA can be assessed here.

The accompanying editorial in JAMA can be accessed here.

The accompanying editorial in JAMA cardiology can be accessed here.

The accompanying editorial in JAMA Internal Medicine can be accessed here.

U.S. Preventive Services Task Force issues important update on annual pelvic exams!

Courtesy: NBC.news.

The U.S. Preventive Services Task Force (USPSTF) today released final recommendation statement and evidence summary for performing pelvic examination for screening asymptomatic adult women who are not at increased risk of any specific gynecological conditions.

The recommendations and evidence summary published online on March 7,2017 in online edition of JAMA.

The USPSTF recommends that the current evidence is insufficient to endorse or refute for routine pelvic screening in asymptomatic adult women. (I statement). This is not a recommendation against performing a routine pelvic examination, but an acknowledgement that more research is needed.   

This statement does not hold good for specific conditions like screening for cervical cancer with a “Pap” test and screening for gonorrhea and chlamydia for which screening is already advocated.

The recent recommendations are based on a systematic review conducted by USPSTF to focus on benefits, harms and accuracy of screening pelvic examination for four major conditions like ovarian cancer; bacterial vaginosis; genital herpes; and trichomoniasis.

Pelvic examination is a routine part of physical examination and in 2012 an estimated 44.2 million pelvic examinations were performed in USA. Many gynecological conditions like pelvic malignancy, infections of the genital tract and benign conditions like polyps, endometriosis and uterine fibroid are detected by pelvic examination. No studies evaluated the effectiveness of early diagnosis and treatment of screen-detected, asymptomatic gynecologic conditions compared with the diagnosis and treatment of symptomatic gynecologic conditions.

 But evidence does not favor performing a screening pelvic examination in asymptomatic women to reduce morbidity and mortality. USPSTF could find few studies that supported performing pelvic examination to reduce all-cause mortality, disease-specific morbidity or mortality, or improve quality of life.

Similarly, USPSTF found very few studies that documented the harm of screening pelvic examination. Studies reported false-positive rates for ovarian cancer, between 1.2% to 8.6%, and false-negative rates, between 0% to 100%.

The USPSTF does recognize that research gap exists in areas evaluating benefits and harms of screening pelvic examination. Future research is needed to develop risk assessment tools to identify women that can benefit from pelvic examination. These studies when done may influence the future recommendation by USPSTF.

The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) concluded that performing screening pelvic examinations in asymptomatic, nonpregnant adult women is not recommended.

The American College of Obstetricians and Gynecologists ( ACOG)  is reviewing the USPSTF  recommendations and evidence to issue its take on the matter. It has  issued a practice advisory for screening pelvic exams today. 

Currently  ACOG recommends performing pelvic examinations annually in all patients 21 years and older.

ACOG further quotes" The Task Force recommendation does NOT apply to pregnant women, and it does NOT apply to women who present to their obstetrician-gynecologists with signs or symptoms. This recommendation applies only to asymptomatic, non-pregnant women. It is critically important for obstetrician-gynecologists to elicit accurate and complete medical, surgical, and family histories and to conduct thorough reviews of systems as part of the well-woman visit. Some women may not recognize that certain signs or symptoms are truly abnormal; these signs and symptoms may be interpreted as "normal" for them, when, in fact, they should prompt evaluation, which may include a pelvic examination."

 ACOG concluded that “the decision to perform a complete examination at the time of the periodic health examination should be a shared decision between the patient and clinician.”

USPSTF also further recognizes that the decision should be individualized according to each patient and clinical situation. The policy and insurance coverage is also taken into consideration when making a decision.  

Full text of the recommendations can be accessed here.

Full text of the evidence summary can be accessed here.