2020年日本产科实践指南.pdf

Guidelines for obstetrical practice in Japan:Japan Society ofObstetrics and Gynecology and Japan Association ofObstetricians and Gynecologists 2020 editionItakura Atsuo1,Satoh Shoji2,Aoki Shigeru3,Fukushima Kotaro4,Hasegawa Junichi5,Hyodo Hironobu6,Yoshimasa Kamei7,Kondoh Eiji8,Makino Shintaro9,Matsuoka Ryu10,Morikawa Mamoru11,Nagamatsu Ttakeshi12,Nakata Masahiko13,Katsuhiko Naruse14,Nishigori Hidekazu15,Nishiguchi Tomizo16,Obata-Yasuoka Mana17,Ohno Yasumasa18,Oura Kuniaki19,Shimoya Koichiro20,Shiozaki Arihiro21,Suzuki Shunji22,Tanaka Kanji23,Yoshida Shiro24,Kudo Yoshiki25,Maeda Tsugio26and Shozu Makio271Department of Obstetrics and Gynecology,Juntendo University,Graduate School of Medicine,Tokyo,Japan2Oita Prefectural Hospital,Oita,Japan3Yokohama City University Medical Center,Yokohama,Japan4Fukushima Clinic,Fukushima,Japan5St.Marianna University School of Medicine,Kawasaki,Japan6Tokyo Metropolitan Bokutoh Hospital,Tokyo,Japan7Saitama Medical University Hospital,Saitama,Japan8Kumamoto University Graduate School of Medicine,Kumamoto,Japan9Juntendo University Urayasu Hospital,Urayasu,Japan10Showa University School of Medicine,Tokyo,Japan11Kansai Medical University,Osaka,Japan12Graduate School of Medicine,University of Tokyo,Tokyo,Japan13Toho University Omori Medical Center,Tokyo,Japan14Dokkyo Medical University,Mibu,Japan15Fukushima Medical University,Fukushima,Japan16Shizuoka Childrens Hospital,Shizuoka,Japan17Faculty of Medicine,University of Tsukuba,Tsukuba,Japan18Ohno Womens Clinic,Iwakura,Japan19Minami Nagareyama Ladies Clinic,Nagareyama,Japan20Kawasaki Medical School,Okayama,Japan21University of Toyama,Toyama,Japan22Nihon Medical University,Tokyo,Japan23Hirosaki University Hospital,Hirosaki,Japan24Nagano Childrens Hospital,Azumino,Japan25Hiroshima University,Graduate School of Medicine,Hiroshima,Japan26Maeda Womens Clinic,Shizuoka,Japan27Graduate School of Medicine,Chiba University,Chiba,JapanAbstractThe 2017 clinical guidelines for obstetrical practice by the Japan Society of Obstetrics and Gynecology andthe Japan Association of Obstetricians and Gynecologists were revised and published as the 2020 editionReceived:August 22 2022.Accepted:September 11 2022.Correspondence:Atsuo Itakura,Department of Obstetrics and Gynecology,Juntendo University,Graduate School of Medicine,2-1-1Hongo,Bunkyo-ku,Tokyo 113-8421,Japan.Email:a-itakurjuntendo.ac.jp1 2022 Japan Society of Obstetrics and Gynecology.doi:10.1111/jog.15438J.Obstet.Gynaecol.Res.2022 14470756,0,Downloaded from https:/ by Donghua University,Wiley Online Library on 17/10/2022.See the Terms and Conditions(https:/ Wiley Online Library for rules of use;OA articles are governed by the applicable Creative Commons License(in Japanese).The aim of these guidelines is to present appropriate standard obstetric diagnosis and manage-ment procedures that have reached consensus among Japanese obstetricians.The 2020 guidelines include113 clinical questions and an appendix,followed by answers(CQ&A;originally 112 in the 2017 edition),a discussion,list of references,and some tables and figures presenting common problems and questionsencountered in obstetrical practice.Each answer comes with a recommendation level of A,B,or C andhas been prepared based principally on evidence or a consensus among Japanese obstetricians in situa-tions where“evidence”is weak or lacking.Answers with a recommendation level of A or B representcurrent standard care practices in Japan.All 113 CQ&As and the appendix are presented here to pro-mote a better understanding of the current standard care practices for pregnant and lactating women inJapan.Key words:clinical questions,complicated pregnancy,guidelines,obstetrical practice,recommendations,standard care practices.IntroductionIn Japan,approximately 840 000 women give birthannually.Because guidelines for obstetrical practicewere not previously available in Japan,remarkablediversity exists among facilities,particularly in thescreening and treatment of fetal/pregnancy abnor-malities.This diversity in practices may partly explainthe increased number of malpractice lawsuits in thecountry.The Japan Society of Obstetrics and Gynecol-ogy(JSOG)and the Japan Association of ObstetriciansandGynecologists(JAOG)publishedguidelinesdescribingstandardcarepracticesforpregnantwomen for the first time in 2008 and have revisedthem every 3 years since.The latest version is the2020 edition,which is published in Japanese.Theseguidelines describe appropriate standard obstetricdiagnosis and management procedures that havereached consensus among Japanese obstetricians atthe time of the revision.The dissemination of theseguidelines is expected to:(1)enable the provision ofappropriatestandardmedicalcaretopregnantwomen and newborns managed at any obstetric carefacility;(2)improve obstetric care safety;(3)reducehuman and financial burden;and(4)promote mutualunderstanding among healthcare providers and preg-nant women.As these guidelines were originally writ-ten in Japanese,this English version has been draftedto benefit non-Japanese speakers.The draft wasrepeatedly revised after frequent audits and opinionsgathered since the publication of the draft in the offi-cial JSOG journal and on the JSOG and JAOG websites.Dinoprostone vaginal inserts became availablein 2020,and since CQ&As on their use have not fullygone through these processes through other CQ&As,its discussion was designated as“Appendix 1.”Theoriginal version of“Guidelines for Obstetrical Practicein Japan 2020”contains a discussion,a list of refer-ences,and some tables and figures.However,thesesections have been omitted here because of spacelimitations.Implications of A,B,and C recommendationlevelsSeveral tests and/or treatments for pregnant womenare presented as answers with a recommendationlevel of A,B,or C for each clinical question.Theanswers and recommendation levels are principallybased on evidence or a consensus among Japaneseobstetricians when the evidence is considered weakor lacking.The answers usually begin with a verband may promote changes in outlook and practicesamong maternity medical providers.Answers with arecommendation level of A or B are current standardcare practices in Japan.Level A indicates a strongerrecommendationthanLevelB.Consequently,informed consent is required when maternity healthproviders do not provide care based on an answerwith a Level A or B recommendation.Answers with arecommendation level of C are possible options thatmay favorably affect the outcome but for which someuncertainty remains on whether the possible benefitsoutweigh the possible risks.Thus,care based onanswers with a Level C recommendation does notnecessarily need to be provided.Some answers with aLevel A or B recommendation include examinationsand treatments that may be difficult for generalmaternity health providers to perform.In such cases,the maternity health providers must refer the womanto an appropriate institution.2 2022 Japan Society of Obstetrics and Gynecology.Atsuo et al.14470756,0,Downloaded from https:/ by Donghua University,Wiley Online Library on 17/10/2022.See the Terms and Conditions(https:/ Wiley Online Library for rules of use;OA articles are governed by the applicable Creative Commons LicenseChapter A:General PracticeCQ001:How should singleton pregnant womenwithout remarkable risk be cared for antenatally?Answers:1.Provide health checkup for pregnant woman andtry to monitor for the following:early premature labor,gestational diabetes,hypertensive disorders of preg-nancy,fetal dysfunction,fetal growth restriction(FGR),abnormalfetalposition,oligohydramnios,hydramnios,low-lyingplacenta,and placenta previa.(A)2.Measure or evaluate the following items at each ante-natal health checkup:maternal weight,blood pres-sure,uterine fundus height(generally 16 weeks ofgestation),urine glucose and protein concentrations,fetal heart rate(FHR),and maternal edema.(B)3.Providehealthcheckupforpregnantwomanaccording to the following intervals:approximatelythree times from the initial visit to 11 weeks of ges-tation,every 4 weeks at 1223 weeks of gestation,every 2 weeks at 2435 weeks of gestation,andevery week at 3640 weeks of gestation.(C)4.Provide health checkup,including fetal well-beingassessment,at least twice a week after 41 weeks ofgestation(see CQ409).(B)CQ002:What information should be collectedfrom women in the early stage of pregnancy?Answers:1.Request women to complete the medical question-naire(to be filled out by the woman herself)to obtainnecessary information for pregnancy management.(B)2.Collect or measure the following information:height,weight,body mass index(BMI),blood pressure,andurine dipstick test protein and glucose.(B)3.Perform cervical cytology test.(B)CQ003:What kind of blood tests should be per-formed in early pregnancy?Answer:1.The following blood tests are recommended:bloodtyping,including ABO and Rh(A);irregular anti-body screening(A);blood count(A);epatitis B sur-face(HBs)antigen(A);hepatitis C virus(HCV)antibody(A),rubella antibody(HI)(A);syphilisscreening(A);human T cell leukemia 1(HTLV-1)antibody,until 30 weeks gestation(A);humanimmunodeficiency virus(HIV)screening(A);bloodglucose(B);and toxoplasma antibody(C).CQ004-1:How should pregnant women with ahigh risk of deep vein thrombosis(DVT)orpulmonary thromboembolism(PTE)be screenedand managed?Answers:1.Assess the risk of developing venous thromboem-bolism(VTE)in early pregnancy and considerapplicable preventive measures.Revisit preven-tive measures if new risk factors arise duringpregnancy.(C)2.Offer prophylactic anticoagulation for pregnanciesdescribed below:(1)For the first group in Table 1,provide prophylac-tic anticoagulation throughout pregnancy.(B)(2)For the second group in Table 1,consider pro-phylacticanticoagulationthroughoutpreg-nancy.(B)(3)For the second group in Table 1,provide prophy-lactic anticoagulation after surgery during pregnancy.(B)(4)For women with three or more risk factors in thethird group in Table 1,consider prophylacticanticoagulation throughout pregnancy(or for acertain period).(C)3.For women with the risk factors listed in Table 1,explain the risk of developing the disease and rec-ommend exercises such as lifting the lower limbs,bending the knees,bending the back of the legs,and wearing elastic stockings(C)4.Useunfractionated heparinforanticoagulationduring pregnancy(low-molecular-weight heparincan be used after abdominal surgery for womenwith a high risk of VTE).(C)5.Switch to unfractionated heparin as soon as possi-ble,with an exception for women receiving warfa-rin before conception.(A)6.Obtain written informed consent when administer-ing low-molecular-weight heparin other than aftersurgery.(B)7.Discontinue anticoagulation treatment with unfractio-nated heparin after the onset of labor or at least 36 h(intravenously)or 12 h(subcutaneously)prior toscheduled surgical procedures.(B)8.Perform the following steps when administeringheparin(unfractionated/low-molecular weight):3 2022 Japan Society of Obstetrics and Gynecology.Guidelines for obstetrical practice in Japan 2020 14470756,0,Downloaded from https:/ by Donghua University,Wiley Online Library on 17/10/2022.See the Terms and Conditions(https:/ Wiley Online Library for rules of use;OA articles are governed by the applicable Creative Commons License(1)Monitor and assess PT,APTT,platelet count,and liver function.(B)(2)Pay attention to the development of heparin-induced thrombocytopenia.(B)(3)Consider appropriate time intervals for theinsertion and removal of catheters,such as forepidural anesthesia.(B).CQ004-2:How should postpartum women with ahigh risk of DVT or pulmonary PTE be screenedand managed?Answers:1.Improve dehydration and promote early initiationof usual daily activities.(B)2.When performing cesarean section,place thewomen in the open-legged(supine)or lithotomyposition,ensuring no strong pressure is placed onthe knee socket.(C)3.In women undergoing a cesarean section,useintermittent pulse-pressure treatment or prescribethe use of elastic stockings.(C)4.For women with the risk factors listed in Table 1,recommend the habitual elevation of their lowerlimbs,exercise of their ankles,and wearing ofelastic stockings.(C)5.Regarding prophylactic anticoagulation and inter-mittent pulse-pressure treatment(or wearing ofelastic stockings)in the postpartum period,followthe instructions below:(1)For the first group in Table 2,provide prophy-lactic anticoagulation or anticoagulation com-binedwithintermittentpulse-pressuretreatment.(B)(2)For the second group in Table 2,provide pro-phylacticanticoagulationorintermittentpulse-pressure treatment.(B)(3)For the third group in Table 2,consider pro-phylacticanticoagulationorintermittentpulse-pressure treatment.(C)6.Use either unfractionated heparin or low-molecular-weight heparin for anticoagulation.When switchingfrom heparin to warfarin,continue overlap treat-ment until the effect of warfarin is achieved.(B)TABLE 1 VTE risk during pregnancyGroup 1:High riskWomen who meet the following conditions should be offered with anticoagulation or anticoagulation combined withintermittent pneumatic compression during postpartum period.(1)History of two or more VTEs(2)History of VTE and one of the following(a)Thrombotic predispositionais present.(b)Preexisting VTEs developed either(i)during pregnancy or(ii)while taking estrogen.(c)Preexisting VTEs developed without transient risk factors such as rest,dehydration,or surgery.(d)A first-degree close relative has a history of VTE.(3)Anticoagulation for VTE treatment(prophylaxis)has been administered since before pregnancy.Group 2:Intermediate riskWomen who meet the following conditions should be advised with anticoagulation during pregnancy.Women who meet the following conditions should be treated with anticoagulation after surgery during pregnancy.(1)History of VTE,depending on temporary risk factors such as rest,dehydration,or surgery.(2)No history of VTE but meet the following conditions.(a)Thrombotic predispositionais present.(b)The following diseases(conditions)are present during the pregnancy.Heart disease,lung disease,SLE(with immunosuppressive drugs),malignancy,inflammatory bowel disease,inflammatory multiple arthropathy,tetraplegia,hemiplegia,nephrotic syndrome,sickle cell disease(rare amongJapanese)Group 3:Low risk(higher risk than pregnancies with no risk factors)Women with three or more of the following factors should be considered for anticoagulation therapy during pregnancy.Women with one to two of the following factors should be aware of the incidence of VTE during pregnancy.Thirty-five years of age or older,prepregnancy BMI 25 kg/m2,smoker,history of VTE in first-degree relative,bed rest,long trip,dehydration,prominent superficial varicose veins,systemic infection,surgery during pregnancy,ovarianhyperstimulation syndrome,hyperemesis,multiple pregnancies,preeclampsia.Abbreviations:BMI,body mass index;SLE,systemic lupus erythematosus;VTE,venous thromboembolism.andaThrombo