What are the American College of Obstetricians and Gynecologists (ACOG) guidelines?

American College of Obstetricians and Gynecologists (ACOG) Guidelines

The American College of Obstetricians and Gynecologists (ACOG) develops clinical practice guidelines that provide evidence-based recommendations for obstetric and gynecologic care, with approximately one-third of their recommendations based on good and consistent scientific evidence (Level A). 1, 2

Overview of ACOG Guidelines

• ACOG guidelines are published as Practice Bulletins, Committee Opinions, Obstetric Care Consensus documents, and other formats to guide clinical practice in obstetrics and gynecology 1, 3
• ACOG uses a three-tier grading system for recommendations: Level A (good and consistent evidence), Level B (limited or inconsistent evidence), and Level C (consensus and expert opinion) 1, 2
• Research shows that approximately 30% of ACOG recommendations are Level A, 38% are Level B, and 32% are Level C 1
• Gynecologic recommendations are more likely to be based on Level A evidence (34.7%) compared to obstetric recommendations (25.5%) 1

Key ACOG Guidelines by Topic

Fetal Macrosomia

• ACOG defines fetal macrosomia as an estimated fetal weight greater than 4,500g and recommends against induction of labor for suspected macrosomia as it does not improve maternal or fetal outcomes 4
• Labor and vaginal delivery are not contraindicated for women with estimated fetal weights up to 5,000g in the absence of maternal diabetes 4
• Prophylactic cesarean delivery may be considered for suspected fetal macrosomia with estimated weights >5,000g in non-diabetic women and >4,500g in diabetic women 4
• Suspected fetal macrosomia is not a contraindication to attempted vaginal birth after previous cesarean delivery 4

Preterm Birth Risk Assessment

• ACOG does not recommend routine screening for risk of preterm labor in the general obstetric population beyond historical risk factors 4
• Home uterine activity monitoring (HUAM) is not recommended for preventing preterm birth due to insufficient supporting data 4
• Transvaginal cervical ultrasonography can reliably assess cervical length, but is not recommended for routine screening due to lack of effective treatments 4
• Fetal fibronectin testing may be useful in women with symptoms of preterm labor to identify those with negative values and reduced risk of preterm birth 4

Abnormal Uterine Bleeding

• ACOG recommends using the PALM-COEIN classification system for abnormal uterine bleeding, which categorizes causes as structural (polyp, adenomyosis, leiomyoma, malignancy) or non-structural (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not classified) 4
• For abnormal uterine bleeding associated with ovulatory dysfunction, medical treatments include progestin-only contraception and combined hormonal contraception 4
• If medical treatment fails or is contraindicated, surgical options including endometrial ablation and hysterectomy may be considered 4
• Endometrial biopsy is preferred over dilation and curettage for diagnosing endometrial hyperplasia or cancer due to being less invasive, safer, and lower cost 4

Adnexal Masses During Pregnancy

• ACOG provides specific recommendations for laparoscopic management of adnexal masses during pregnancy, including left lateral decubitus positioning after the first trimester 4
• CO2 insufflation pressure should be 10-15 mmHg during surgery, with operating pressure maintained at 12 mmHg 4
• Fetal heart rate monitoring is recommended before and after surgery for viable fetuses, though recommendations for intraoperative monitoring vary 4
• Routine prophylactic use of tocolytics is not recommended during surgical management of adnexal masses in pregnancy 4

Informed Consent for Labor Induction

• ACOG recommends providing information about labor induction as early as possible in the prenatal period, not immediately before the procedure 5
• Patients should be informed about methods to be used for induction (mechanical methods, prostaglandins, oxytocin) and their specific risks 5
• Additional counseling is required for patients with previous cesarean delivery due to increased risks, particularly the contraindication of misoprostol due to high risk of uterine rupture 5
• Healthcare providers should help patients identify which risks and benefits matter most to them, respecting patient autonomy 5

Implementation of ACOG Guidelines

• ACOG guidelines are narrative documents that don't easily translate into computable clinical decision support, requiring translation into implementable formats for electronic health records 3
• Studies comparing ACOG guidelines with other international guidelines (such as RCOG) show significant differences in recommendations for common obstetric topics 6
• ACOG guidelines perform well in predicting advanced-stage conditions but may perform poorly in identifying early-stage disease, as demonstrated in studies of adnexal mass referral guidelines 7

Limitations of ACOG Guidelines

• Only about one-third of ACOG recommendations are based on good and consistent scientific evidence (Level A) 1, 2
• The majority of recommendations rely on limited or inconsistent evidence (Level B) or expert consensus (Level C) 1
• Guidelines for obstetrics are less likely to be based on high-quality evidence compared to gynecologic guidelines 1
• ACOG guidelines may not be directly comparable to international guidelines on the same topics 6