What are the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines for managing women's health conditions?

RCOG Guidelines Overview

The Royal College of Obstetricians and Gynaecologists (RCOG) publishes comprehensive clinical guidance through their "Green Top Guidelines" (GTGs), which serve as the primary evidence-based framework for managing obstetric and gynecological conditions in the UK, though notably 43% of their recommendations rely on expert opinion rather than high-quality randomized controlled trial data. 1

Core Structure and Evidence Quality

• RCOG GTGs use a levels-based approach (Levels I-IV) for obstetric care stratification, with recommendations graded by evidence strength 2
• Only 9% of RCOG recommendations achieve Grade A status (based on high-quality evidence), with just 5% classified as Evidence Level 1++ (highest quality) and 7% derived from RCTs 1
• Of 1,861 total obstetrical recommendations across 37 GTGs, 69% cite identifiable references, while 43% are based on consensus and expert opinion 1
• The evidence grading system ranges from 1++ (highest quality meta-analyses and RCTs) down to Level 4 (expert opinion), which should guide your prioritization when studying 2

Key Clinical Areas Covered by RCOG Guidelines

Venous Thromboembolism in Pregnancy

• RCOG 2015 guidelines mandate risk assessment at specific time-points during pregnancy and postnatally, using a scoring system based on preexisting, obstetric, and transient risk factors 3, 4
• Risk stratification assigns points for factors including: personal/family history of VTE (3 points for high-risk thrombophilia), age >35, BMI >30 (2 points if >40), parity >3, smoking, varicose veins, multiple pregnancy, preeclampsia, cesarean section (2 points), hyperemesis/dehydration (3 points), immobility >3 days, and surgical procedures (3 points) 3
• For early pregnancy loss (<10 weeks), VTE risk is significantly lower than continuing pregnancy (1.3 vs 7.8 per 10,000), suggesting routine thromboprophylaxis may not be warranted in uncomplicated early losses 3

Management of Pregnancy in High-Risk Cardiac Patients

• High-risk patients (including those with pulmonary hypertension, severe aortic stenosis, or ascending aorta dilatation >45mm) require management in specialized centers with on-site cardiac surgery 3
• Vaginal delivery with epidural analgesia and elective instrumental delivery is the preferred approach for most cardiac patients, with cesarean section reserved for obstetric indications or specific cardiac conditions: aortic dilatation >45mm, severe aortic stenosis, Eisenmenger syndrome, or severe heart failure 3
• Endocarditis prophylaxis during delivery is not routinely recommended, though treatment should be individualized 3

Pregnancy Termination Procedures

• Dilatation and evacuation is the safest procedure for pregnancy termination in both first and second trimesters (up to 24 weeks gestation), with significantly lower complication rates than medical methods: hemorrhage 9.1% vs 28.3%, infection 1.3% vs 23.9%, and retained tissue 1.3% vs 17.4% 3, 5
• Mifepristone can be used up to 7 weeks gestation as an alternative to surgery, but requires hospital setting with close monitoring in high-risk patients 3, 6
• Prostaglandin E1 or E2 (or misoprostol) can be used for second-trimester evacuation when surgery is not feasible, but requires systemic oxygen saturation monitoring and norepinephrine support for blood pressure maintenance 3
• Prostaglandin F compounds must be avoided as they significantly increase pulmonary artery pressure and may decrease coronary perfusion 3
• Saline abortion should be avoided due to risks of intravascular volume expansion, heart failure, and clotting abnormalities 3

Obesity in Pregnancy

• Women with BMI ≥30 should receive 5mg folic acid supplementation daily starting at least 1 month before conception and continuing through first trimester 3
• Preconception counseling should address risks of miscarriage, preeclampsia, gestational diabetes, and long-term health complications including hypertension, sleep apnea, and cardiac disease 3
• Anesthesia consultation is recommended if BMI >35, ideally in first trimester 3
• Early pregnancy screening for gestational diabetes should be performed in women with obesity 3
• VTE risk assessment and thromboprophylaxis consideration are essential components of care 3

Practical Application for MRCOG Preparation

• RCOG official guidelines form the essential foundation for MRCOG Part 2 examination preparation and should be the primary study resource 2
• NICE guidelines relating to obstetrics and gynecology must be thoroughly reviewed as they are essential for examination success 2
• Focus on high-yield topics including VTE in pregnancy, hypertensive disorders, and management of obstetric emergencies 2
• The RCOG StratOG eLearning platform provides interactive modules specifically designed for MRCOG preparation 2
• Practice applying guidelines to clinical scenarios rather than memorizing isolated facts 2

Important Caveats

• RCOG and ACOG guidelines often differ substantially—only 28% of ACOG recommendations are confirmed by RCOG, with 16% showing direct disagreement 7
• RCOG guidelines typically contain almost twice as many recommendations per topic compared to ACOG (median 15 vs 7) 7
• The heavy reliance on expert opinion (43% of recommendations) means clinical judgment remains crucial when evidence is limited 1
• Guidelines undergo regular updates through audit cycles, so always verify you are using the most current version 8