Evaluacion de Sangrado Uterino

CLINICAL PRACTICE GUIDELINES
FOR
PRACTITIONERS
FOR PRACTITIONERS
This combined reference has been developed as an educational tool by a statewide, interdisciplinary
panel of providers, in collaboration with Blue Cross and Blue Shield of Missouri.
It is intended to identify leading best practices and help practitioners reduce variation in practice
patterns. It is not intended to include all possible methods of care for a particular condition, to identify
all criteria for recommending a specific procedure, or to be a required treatment of a particular
condition.
The practitioner, at his/her discretion, is expected to exercise reasonable clinical judgment regarding
the care each patient needs. Individual patient circumstances should always be taken into account.
These guidelines are intended to serve as a foundation for a continuous process of collaboration with
physicians and allied health providers to maintain and advance the knowledge base associated with
best practices.
Each of the Guidelines is based on recommendations from recognized specialty societies (i.e.,
ACOG, ACOG, AAFP, ACC, AAP, ACP-ASIM), national organizations (i.e., American Cancer
Society, American Heart Association, March of Dimes), and governmental entities (i.e., U.S.
Department of Health and Human Services, the Centers for Disease Control and Prevention). An
external panel of BCBSMo physicians and the BCBSMo Quality Improvement and Physician Review
Committee (QIPRC) reviewed the revised guidelines on the basis of content, clarity and
appropriateness.
We hope you will find this manual useful in your practice. Information regarding current issues will be
provided from time to time through guideline updates and periodic mailings. We invite your
comments and suggestions. Please direct your communications to:
Sharon Hoffarth, MD, MPH, FACPM
Medical Director, Quality Management
Blue Cross and Blue Shield of Missouri
1831 Chestnut Street
St. Louis, MO 63103-2275
Fax: (314) 923-8542
John J. Seidenfeld, MD, MSHA, FACP
Senior Vice President and Corporate Medical Director
CONTENTS
! Evaluation of Abnormal Uterine Bleeding Premenopausal Patients
! Evaluation of Abnormal Uterine Bleeding Perimenopausal Patients
! Evaluation of Abnormal Uterine Bleeding Postmenopausal Patients
! Management of Vaginal Vault Prolapse
! Management of Uterine Leiomyomas
! Treatment of Endometriosis
! Dysfunctional Labor
! Induction of Labor
! Breech Presentation
! Non-Reassuring Fetal Status
! Fetal Macrosomia
! Vaginal Birth after Cesarean (VBAC)
! Pregnancy-Associated Hypertensive Disease
! Hypertension
! Hyperlipidemia
! Stable Angina
! Unstable Angina
! Congestive Heart Failure (CHF)
! Peptic Ulcer Disease
! GERD
! Diverticulosis and Diverticulitis
! Low Back Pain
! Carpal Tunnel Syndrome
! Uncomplicated Acute Bronchitis
! Community-Acquired Pneumonia (CAP)
! Asthma
! Depression
! Diabetes
Evaluation of Abnormal Uterine Bleeding
PREMENOPAUSAL PATI ENTS
Abnormal excessive
uterine bleeding
Differential Diagnosis Includes:
Complications of pregnancy
Infections - uterus, cervix, vagina
Trauma - laceration, abrasion, foreign body
Cancer - gynecologic malignancy
Benign lesions - uterus, cervix, vagina
Systemic disease - thyroid, liver, coagulopathy, von Willebrands disease
Iatrogenic - hormones, anticoagulants, intrauterine contraceptive devices
Includes:
Gynecological and Obstetrical history
Medication history
Pelvic exam with Papanicolaou smear
Diagnostic aids, to consider, as appropriate:
Liver function tests
Thyroid function tests
Coagulation profile
Pregnancy test
CBC
Is cause of
bleeding due to
pelvic pathology,
medication,
systemic disease?
Is
pregnancy
test
positive?
Pregnancy
evaluation
Address cause of bleeding, such as:
Treat infection
Follow-up malignancy work-up:
- Risk Factors:
>35 years old
<30 years old with a long-term history of
oligoovulation or anovulation with
exposure to unopposed estrogen.
Obesity
Evaluate for leiomyoma.
Evaluate for Dysfunctional Uterine Bleeding
(DUB - bleeding not controlled by hormones , D&C
or nonsteroidal anti-inflammatory agents)
Determine ovulatory status
Ovulatory
Anovulatory
Determine bleeding pattern
Menorrhagia Polymenorrhea Oligomenorrhea Intermenstrual
bleeding
Evaluate for
bleeding disorder
Consider
evaluation for
luteal phase
defect
Progesterone
withdrawal every
3 months, OCPs
or clomiphene
induction.
Remove IUD or begin a
period of observation
Treat
OCPs
Begin
period of
observation
Determine TSH
and prolactin
levels
Reassure the patient or
initiate Oral
Contraceptive Pills
(OCPs)
Normal Abnormal
Treat the
disorder
Consider evaluation for polycystic
ovarian syndrome versus chronic anovulation
(examination, consider determination of LH, FSH,
DHEA-s and free testosterone on day 3 of cycle)
Treat with
OCPS or
clomiphene
OCPs, progesterone withdrawal
every 3 months, or clomiphene
for ovulation induction
Perform biopsy or
ultrasonography to
exclude uterine
pathology
OCPs or
domiphene
(serophene)
Yes Yes No
No
No
Yes
Yes
No
No
Yes
Yes No
No Yes
Adolescent?
IUD?
Cervical
pathology?
Bleeding
at
ovulation?
Risk for
hypothalamic disorder
(stress, eating disorder,
high level of
exercise)?
Focused History &
Physical Exam
DHEA-S - dihydroepiandrosterone sulfate
DUB - dysfunctional uterine bleeding
FSH - follicle - stimulating hormone
IUD - intrauterine device
LH - luteinizing hormone
OCP - oral contraceptive pills
TSH - thyroid-stimulating hormone
Legend:
Physician focus for managing patients with abnormal uterine bleeding:
!
As initial approach, to pre- and perimenopausal patients without genital tract lesions, uterine
enlargement, IUDs, and not pregnant, treat conservatively.
Indicator
For those patients with DUB, and no other documented abnormal findings, the percentage of patients
treated pharmacologically.
References:
Oriel KA, Schrager S. Abnormal uterine bleeding. American Family Physician. 1999;10(5);1371-1380.
Available online: http://www.aafp.org/afp/991001ap/1371.html. Accessed May 23, 2001.
New Zealand Guidelines Group. Guidelines for the management of heavy menstrual bleeding.
(1999, May) Available online: National Guideline Clearinghouse, http://www.guidelines.gov. Accessed
May 21, 2001.
Chuong CJ, Brenner PF. Management of abnormal uterine bleeding. American Journal of Obstetrics
and Gynecology. 1996;175(3);787-792.
Long C. Evaluation of patients with abnormal uterine bleeding. American Journal of Obstetrics and
Gynecology. 1996;175(3);784-786.
PERI MENOPAUSAL PATI ENTS
Abnormal uterine
bleeding
Perform history and physical exam, including:
Medication history
Laboratory tests to consider, as appropriate:
Follicle-stimulating hormone (FSH)
Coagulation profile
Pregnancy test (If positive, evaluate for complication of pregnancy)
CBC
Genital tract lesion present Uterine enlargement present
Treat, perform biopsy or refer as
appropriate
Consider transvaginal
ultrasonography or
sonohysterography
Determine beta
human chorionic
gonadotropin
("-HCG)
Perform transvaginal
ultrasonography,
sonohysterography or
hysteroscopy, or dilation and
curettage
Positive
Negative
Evaluate for pregnancy
Perform endometrial biopsy Biopsy not possible
Etiology still
unclear
Etiology
identified
Perform
hysteroscopy
Treat
Normal pathology or atrophy Hyperplasia Atypia or carcinoma
Cyclic hormonal regulation or
begin a period of observation
Cyclic progesterone
therapy; hyperplasia that
persists requires D&C
Refer patient for
treatment
!
As initial approach, to pre- and perimenopausal patients without genital tract lesions, uterine
enlargement, IUDs, and not pregnant, treat conservatively.
Indicator
References:
May 21, 2001.
and Gynecology. 1996;175(3);787-792.
Gynecology. 1996;175(3);784-786.
POSTMENOPAUSAL PATI ENTS
Abnormal uterine
bleeding
Medication history
Laboratory tests to consider, as appropriate:
Coagulation profile
Pregnancy test
CBC
Genital tract lesion present Uterine enlargement present
Treat, perform biopsy or refer as
appropriate
Consider performing transvaginal
ultrasonography or
sonohysterography
Determine which HRT regimen (continuous-
combined or sequential) and duration of HRT
Duration > 6 months
Duration < 6 months
If early withdrawal bleeding,
increase progesterone dosage
Begin a period of
observation
Perform endometrial biopsy or transvaginal ultrasonography to
exclude endometrial carcinoma
Heavy or prolonged bleeding or
breakthrough bleeding in > 2 cycles
Endometrial biopsy performed
Transvaginal ultrasonography performed
Abnormal findings Normal findings
Refer patient for
treatment
Endometrial
stripe < 5 mm
Endometrial
stripe > 5 mm
Uterine pathology
identified
Atrophic
endometrium
Perform
endometrial
biopsy or
hysteroscopy
with biopsy
Refer patient for
treatment
Perform transvaginal
ultrasonography,
sonohysterography or
hysteroscopy, depending on
clinical suspicion
Begin period of
observation
Yes
No
No Yes
Normal
findings,
receiving
HRT?
Bleeding
stopped?
!
As initial approach, to postmenopausal patients without genital tract lesions, or uterine enlargement,
treat conservatively.
Indicator
References:
May 21, 2001.
and Gynecology. 1996;175(3);787-792.
Gynecology. 1996;175(3);784-786.
Management of Vaginal Vault Prolapse
Symptoms of
Vaginal Prolapse
Symptoms may include:
Asymptomatic
Pelvic Pressure
Pulling, aching sensation
Urinary symptoms
Bowel symptoms
Sexual dysfunction
Protrusion of uterus or vagina through introitus
Vaginal/cervical ulceration with discharge/odor
Asymptomatic
Pelvic Pressure
Pulling, aching sensation
Urinary symptoms
Bowel symptoms
Sexual dysfunction
Protrusion of uterus or vagina through introitus
Vaginal/cervical ulceration with discharge/odor
History:
Family
Pregnancy
Occupation
Physical activity
Medication
Physical Exam:
Gynecological exam
Assess degree of prolapse (supine and standing)
Evaluate incontinence, and post-void residual urine
Lab and diagnostic tests:
If clinically indicated:
Cervical cytology
Urinalysis and culture
Urodynamics
Cystoscopy/urethroscopy
History:
Family
Pregnancy
Occupation
Physical activity
Medication
Physical Exam:
Gynecological exam
Assess degree of prolapse (supine and standing)
Evaluate incontinence, and post-void residual urine
If clinically indicated:
Cervical cytology
Urinalysis and culture
Urodynamics
Cystoscopy/urethroscopy
Focused History and
Physical Exam
Postmenopausal?
Consider hormone treatment:
Hormone Replacement Therapy (HRT)
Estrogen Replacement Therapy (ERT)
Pills, patch, cream
Estrodial vaginal ring (e.g., Estring)
Good response?
Follow up office visit in 6 months.
Clinical observation with lifestyle modifications:
Diet/weight control
Increase fiber, fruit juice
Decrease caffeine
Avoid heavy lifting
Quit smoking
Medication
Pelvic floor exercise (e.g. Kegel)
Mechanical vault support (e.g. tampon, diaphragm, pessary)
Indications for Pessary use:
Stress urinary incontinence
Vaginal vault prolapse
Cystocele
Enterocele
Rectocele
Uterine prolapse
Preoperative preparation
Indications for Pessary use:
Stress urinary incontinence
Vaginal vault prolapse
Cystocele
Enterocele
Rectocele
Uterine prolapse
Preoperative preparation
Good response?
Follow up office visit in 6
months or based on treatment
option.
Counsel patient and consider surgical options:
Reconstruction of pelvic anatomy with/without hysterectomy
Vaginal obliterative procedures
(e.g. colpocleisis, sacrospinous ligament fixation)
Preoperative estrogen replacement therapy:
associated with reducing duration of
postoperative bladder catheterization in women
undergoing reconstructive surgery for pelvic
organ prolapse.
Preoperative estrogen replacement therapy:
associated with reducing duration of
postoperative bladder catheterization in women
undergoing reconstructive surgery for pelvic
organ prolapse.
Yes
No
Yes
No
No
Yes
Management of Vaginal Vault Prolapse
References:
Margolis MT. Surgical options for treatment of vaginal vault prolapse procidentia and vaginal
reconstruction. Contemporary OB-GYN. March 1999. Available
online:http://obgyn.pdr.net/obgyn/public.htm?path=content/journals/g/data/1999/g3a/g3a023.html
Accessed May 15, 2001.
Viera AJ, Larkins-Pettigrew M. Practical use of the pessary. American Family Physician. May 1,
2000. Available online: http://www.aafp.org/afp/20000501/2719.html. Accessed May 21, 2001.
Theofrastous JP, Addison WA, Timmins MC. Voiding function following prolapse surgery. Impact
of estrogen replacement. Journal of Reproductive Medicine. December 1996; 41(12):881-4.
Eriksen B. A randomized, open parallel-group study on the preventive effect of an estradiol-
releasing vaginal ring (Estring) on recurrent urinary tract infections in postmenopausal women.
American Journal of Obstetrics and Gynecology. 1999;180:1072-1079.
ACOG. Pelvic Support Problems. (ACOG Patient Education). Washington, DC. 1995.
Management of Uterine Leiomyomas
Fibroids - benign smooth muscle
tumors found in the submucous,
intramural and/or subserosal
regions of the uterus.
Differential diagnosis:
Fibroma
Leiomyosarcoma
Endometrial hyperplasia
Adnexal mass
Differential diagnosis:
Fibroma
Leiomyosarcoma
Endometrial hyperplasia
Adnexal mass
Risk factors:
Increasing age prior to
menopause
Family history
African and Caribbean
American ethnicity
Obesity
Nulliparity/infertility
Risk factors:
Increasing age prior to
menopause
Family history
African and Caribbean
American ethnicity
Obesity
Nulliparity/infertility
Medical therapy may improve
hematologic profile or reduce
mass in preparation for
surgery, but should not be
used for more than six
months, or on an ongoing or
repeated basis.
Medical therapy may improve
hematologic profile or reduce
mass in preparation for
surgery, but should not be
used for more than six
months, or on an ongoing or
repeated basis.
Asymptomatic
Excessive uterine bleeding
Pelvic discomfort:
Pain/pressure
Low back pain
Abdominal swelling
Dyspareunia
Urinary
urgency/frequency
Recurrent miscarriage
Preterm labor
Infertility
Asymptomatic
Excessive uterine bleeding
Pelvic discomfort:
Pain/pressure
Low back pain
Abdominal swelling
Dyspareunia
Urinary
urgency/frequency
Recurrent miscarriage
Preterm labor
Infertility
Suspected Uterine Fibroids
Medication history
Laboratory tests to consider, as appropriate
Coagulation profile
Pregnancy test
CBC
Endometrial sampling
Confirm by:
Transvaginal ultrasound,
Transvaginal sonohysterogram (TVSH)
Transabdominal ultrasound or
Magnetic Resonance Imaging (MRI) (if
location or nature of fibroid is uncertain
or patient refuses TVSH)
Symptomatic?
Asymptomatic
with fibroids
>14 weeks
size?
Follow-up in office in
6 months unless
symptoms change.
Discuss options,
including observation
with patients.
Offer medical management:
Iron supplementation
Non-steroidal anti-inflamatory drugs (NSAIDS)
Hormone therapy
Progestins
Oral contraceptives
GnRH - agonists: (+ add back therapy as indicated)
Successful
treatment of
symptoms?
Continue
therapy 4-6
months.
Review
at 6
months.
Discuss surgical options:
Endometrial ablation to arrest bleeding.
Myomectomy
Hysteroscopic
Laparascopic
Abdominal
Hysterectomy indicators:
Bleeding causing anemia, lifestyle or hygiene problems
Intractable pelvic pain + progressive dysmenorrhea
Rapidly enlarging size
Enlargement postmenopausal (R/O sarcoma)
Pressure symptoms
Consider preoperative therapy with GnRH in women with large
uteri (>18 weeks size) for reduction in operative blood loss
Consider preoperative therapy with GnRH in women with large
uteri (>18 weeks size) for reduction in operative blood loss
With pre/peri-menoapausal patients, discuss options of Salpingo-
oophorectomy or sparing ovaries
With pre/peri-menoapausal patients, discuss options of Salpingo-
oophorectomy or sparing ovaries
Yes
No
Yes No
Yes
No
Physician focus for Management of Uterine Leiomyomas:
!
For symptomatic women with first time diagnosis of leiomyomata, consider initial medical management.
Indicator: Percentage of women with first time diagnosis receiving conservative medical management.
Indicator: Percentage of women with first time diagnosis receiving surgical treatment.
!
For symptomatic women with a
#
1year history of leiomyomata, unresponsive to conservative treatment,
consider surgical management.
Indicator: Percentage of women with a
#
1year history of leiomyomata and one or more of the
following: anemia, intractable pain or pressure, rapidly enlarging tumor size who received surgical
intervention.
References /Resources:
New Zealand Guidelines Group. Guidelines for the management of uterine fibroids.
(1999, August). Available online: National Guideline Clearinghouse,
http://www.guideline.gov/VIEWS/summary.asp?guideline=1505. Accessed May 21, 2001.
Garcia CR, Pfeifer S, Wallach E. Gynecologic disorders uterine fibroids: Treat or ignore? Patient Care
Archive (1997, January). Available online:
http://pc.pdr.net/pc/public.htm?path=content/journals/p/data/1997/p1a/p1a048.html. Accessed May 22,
2001.
Shoupe, D. Hysterectomy or an alternative? Hospital Practice (2000, September). Available online:
http://www.hosppract.com/issues/2000/09/shoupe.htm. Accessed May 22, 2001.
Treatment of Endometriosis
Symptoms suggestive of
endometriosis
Mild to Moderate Pain
Mild to Moderate Pain
Moderate to Severe Pain
Moderate to Severe Pain
Empiric treatment with OCPS
GnRH agonist or progestins
Operative laparoscopy
with postoperative
empiric GnRH agonist
therapy
Operative laparoscopy Diagnostic laparoscopy
Normal pelvis
Disease missed
Progressive disease
because of
inadequate resection
Residual disease
Empiric therapy with
GnRH agonist for 2-3
mos
Operative excision or
biopsy
Empiric GnRH agonist
for 6 mos + add-back
therapy
Operative
laparoscopy
Second
operative
laparoscopy
with
postoperative
GnRH agonist
Laparoscopy
with resection if
disease present
Empiric
treatment
with
GnRH
agonist
Retreatment
with
GnRH agonist
with add-back
therapy
Consider
prolonged
medical
suppression
with add-back
therapy
Pain
improves?
Consider:
Diagnostic laparoscopy
or
Operative laparoscopy
Review in 6
months
Pain
improves
Pain not
improved
Full 6-mo
course of
GnRH
agonist add-
back therapy
Operative
laparoscopy
Postoperative GnRH
agonist for residual disease
+ add-back therapy
Consider
prolonged
medical
suppression
with add-back
therapy
Persistent
problems or
treatment
failure?
Review in 6
months
Bilateral
oophorectomy,
Hysterectomy
Pelvic pain persists or returns
Retreatment
with GnRH - $
Chronic pelvic pain
Abnormal uterine bleeding
Low abdominal pain
Dysmenorrhea
Dyspareunia
Pain with defecation
Infertility
No
Yes
No Yes
A B
A
B
Prompt attention and treatment may
prove to be the best way of ameliorating
the recurrence of symptoms.
Prompt attention and treatment may
prove to be the best way of ameliorating
the recurrence of symptoms.
Diagnostic laparoscopy provides method of diagnosing most anatomic
gynecologic disease states; only definitive test for detecting
endometriosis.
Operative laparoscopy allows surgical excision and ablation to be
completed at time of diagnosis, decreasing time, cost, and side effects.
Patient is spared a second surgery (laparotomy) if performed at time of
diagnosis.
A
B
TREATMENT OF ENDOMETRIOSIS
Medical Treatment of Endometriosis
Drug Dosage Adverse Effects
Danazol (Danocrine) 800 mg per day in 2 divided doses Estrogen deficiency, androgenic side
effects
Oral contraceptives 1 pill per day (continuous or cyclic) Headache, nausea, hypertension
Medroxyprogesterone
suspension (Depo-Provera)
100 mg IM every 2 weeks for 2 months;
then 200 mg IM every month for 4
months or 150 mg IM every 3 months
Weight gain, depression, irregular
menses or amenorrhea
Medroxyprogesterone (Provera) 5-20 mg orally per day Same as other oral progestins
Norethindrone acetate
(Aygestin)
5 mg per day orally for 2 weeks; then
increase by 2.5 mg per day every 2
weeks up to 15 mg per day
Same as other oral progestins
Leuprolide (Lupron) 3.75 mg IM every month for 6 months Decrease in bone density, estrogen
deficiency
Gosarelin (Zoladex) 3.6 mg SC (in upper abdominal wall
every 28 days
Estrogen deficiency
Nafarelin (Synarel) 400 mg per day: 1 spray in 1 nostril in
a.m.; 1 spray in other nostril in p.m.;
start treatment on day 2 to 4 of
menstrual cycle
Estrogen deficiency, bone density
changes, nasal irritation
Surgical vs. Medical Treatment
Treatment Advantages Disadvantages
Surgical Beneficial for infertility Expensive
Long-term results may be better Invasive
Definitive diagnosis
Option for definitive treatment
Medical Lower initial cost Adverse effects common
Empiric treatment Not likely to improve fertility
Effective for pain relief
Physician focus for Treating Endometriosis:
!
For appropriate patients with mild to moderate pain, try pharmacotherapy for initial treatment.
Indicator:
Percentage of patients receiving endocrine-based drug therapy.
!
Bilateral oophorectomy and hysterectomy should be reserved for use in women with intractable pain
who no longer desire pregnancy, and for whom conservative therapy failed.
Indicator:
Percentage of women who received operative laparoscopy with postoperative empiric drug therapy
prior to definitive surgery.
References/Resources:
Wellbery C. Diagnosis and treatment of endometriosis. Am Fam Physician . 1999;60:1753-68. Available
online: http://www.aafp.org/afp/991015ap/1753.html. Accessed May 10, 2001.
Winkel C. Laparoscopy plus GnRH analogues: a practical approach to endometriosis. Contemporary Ob-
Gyn. April 1999.
Dysfunctional Labor
Intrapartum care may include:
Chart evaluation
Cervical exam
Supportive care/comfort measures
po fluids
position changes
back rubs, music, etc
ambulation
bath/shower
Adequate pain relief
nalbuphine hydrochloride
(Nubain)
butorphanol tartrate (Stadol)
meperidine (Demerol)
hydroxyzine hydrochloride
(Vistaril)
epidural or intrathecal
narcotics for patients in active
progressing labor
Documentation of progress of labor
Monitoring of fetal heart rate
This guideline applies only to
women in labor who meet ALL
of the following criteria:
Nulliparous
No concomitant medical problems
Term pregnancy (36 weeks completed)
Having contractions
Singleton fetus
Cephalic presentation
No evidence of fetal distress
Caregiver expects normal spontaneous
vaginal delivery
labor is NOT induced
Patient in labor
(see guideline limits to left
and definition to right)
Intrapartum
care (see box to left)
<1 cm
dilation x2
consecutive
hours?
no
yes
Stage II Labor
yes
Consider amniotomy,
unless contraindicated*
Operative
vaginal delivery
contra-
indicated?
***
no
Operative vaginal delivery
Cesarean-section
Has SROM
occurred?
Normal vaginal delivery
yes
no
yes
Failure to progress diagnosis--
initiate active management of
labor and consider:
Artificial rupture of membranes
Ensure adequate maternal analgesia
Oxytocin augmentation**
Obtain an obstetrical/surgical
consult if necessary
* Contraindications to amniotomy include:
Presentation unknown, floating or unstable
Cervix dilated <3cm
Patient refuses
**Contraindications to oxytocin augmentation include:
unknown presentation or floating/unstable
unable to monitor contractions adequately
patient refuses
***Contraindications to operative vaginal delivery include:
presenting part is too high
provider is inexperienced
fetal distress with inability to do timely operative vaginal delivery
patient refuses
Progress?
(fetal descent
>1 cm/hr)
Management of protraction
disorder, consider:
Evaluation of maternal position
and fetal position
Evaluation of fluid balance
Oxytocin augmentation**
Obtain an obstetrical/surgical
consult if necessary
Descent
or rotation?
yes
no
no
Labor is defined as:
Regular contractions resulting in
progressive dilation/effacement of
cervix
Cervical dilation 3 cm or greater
Spontaneous rupture of membrane
Physician focus for managing dysfunctional labor:
!
Emphasize close monitoring for early detection and intervention of failure to progress.
!
Emphasize close monitoring for early detection and intervention of protracted labor
Dystocia and the Augmentation of Labor. ACOG Technical Bulletin. Number 218, December 1995.
Hadi H. Cervical Ripening and Labor Induction: Clinical Guidelines. Clinical Obstetrics and Gynecology
2000;43(3):524-536.
Institute for Clinical Systems Improvement. Health Care Guideline: Prevention, Diagnosis and Treatment
of Failure to Progress in Obstetrical Labor. December 1999. http://www.icsi.org (2001, April 17)
Ramsey, PS, Ramin KD, Ramin SM. Labor Induction. Current Opinion in Obstetrics and Gynecology
2000;12(6):463-473.
http://www.acog.org
http://www.aafp.org
http://www.icsi.org
Induction of Labor
ACOG Dating Criteria for
term gestation:
Fetal heart tones documented for
20 wks by non-electronic fetoscope
or for 30 wks by Doppler
36 weeks since positive serum or
urine HCG pregnancy test was
performed by a reliable laboratory
An U/S measurement of crown-
rump length, obtained at 6-12
weeks, supports a gestational age
of at least 39 wks
An U/S obtained a 13-20 weeks
confirms the gestational age of at
least 39 weeks determined by
clinical history and physical
examination
Indications for inducing labor may
include:
Pregnancy-induced hypertension, pre-
eclampsia, or chronic hypertension
Premature rupture of membranes
Chorioamnionitis
Suspected fetal jeopardy (i.e. fetal growth
restriction, isoimmunization)
Maternal medical problems (i.e. DM, renal
disease, chronic pulmonary disease)
Fetal demise
Logistical factors (i.e. risk of rapid labor,
distance from the hospital, psychosocial
indications)
Postdate pregnancy
Oligohydramnios
Abruptio placentae
Consideration of
Labor Induction
Do
benefits
to mother and
fetus outweigh the
risks of continuing
the pregnancy?
no
Reconsider Induction
yes
Is
cervix
favorable?
no
Repeat doses of
ripening agent
as appropriate
Proceed with amniotomy and/or oxytocin
induction (10U of oxytocin in 1 L of IV
solution) as appropriate.
Does the
patient meet
dating criteria
for term?
yes
Initiate cervical ripening (if appropriate) with one of the following:
IV Oxytocin (Pitocin)--0.5-6 mU/min initial dose (max 25mU/min)
Intracervical Dinoprostone gel (Prepidil)--0.5 mg initial dose, may
repeat q6 hours (maximum of 3 doses in 24 hours)
Intravaginal Dinoprostone insert (Cervidil)--10 m (once only)
Intravaginal Misoprostol* (Cytotec)--25 ug initial dose, may repeat q3-6
hours (maximum of 6-8 doses) Wait at least 4 hours to begin oxytocin.
Other options for cervical ripening include: stripping of the membranes,
amniotomy, balloon catheters
Absolute contraindications for
inducing labor include:
Placenta or vasa previa
Transverse fetal lie
Prolapsed umbilical cord
Previous transfundal uterine surgery
Active genital herpes infection
Pelvic structural abnormality
Invasive cervical cancer
Obstetric conditions that may
require special care during induction
(relative contraindications):
Mulitfetal gestation
Polyhydramnios
Maternal cardiac disease
Abnormal fetal heart rate patterns not
requiring emergency birth
Grand mulitparity
Severe hypertension
Breech presentation
Presenting part above the pelvic inlet
One or more previous low-transverse
cesarean deliveries
yes
no
Consider Bishop
score (see page 2)
Is
induction
likely to be
successful?
no
yes
*Do not use Misoprostol in patients with
prior c-section or major uterine surgery.
Fetal heart rate
and uterine
activity should be
continuously
monitored from
the time the PGE2
vaginal insert is
placed until at
least 15 minutes
after it is removed
Induction of Labor p.2
Assessment
score
Dilation
(cm)
Effacement
(%)
Fetal
station
Consistency Position
0 0 0-30 -3 Firm Posterior
1 1-2 40-50 -2 Medium Mid
2 3-4 60-80 -1, 0 Soft Anterior
3 4-5 90-100 +1, +2, +3 -- --
Bishop System of Cervical Scoring (Table from Harman et al)
Note: Add the score for each of the clinical assessments. If the total score is greater than 8, the success of
induction approaches that of spontaneous labor. A Bishop score of "5 is associated with induction failure.
Possible complications associated with oxytocin infusion include:
Uterine Hyperstimulation --> uterine contractions more often than every 2 minutes that last
longer than 90 seconds with or without fetal heart changes. Excessive uterine contractions may
lead to uteroplacental hypoperfusion and fetal hypoxia, uterine rupture, or abruptio placentae.
Hyperstimulation may be treated by decreasing or stopping the oxytocin and with administration
of terbutaline 0.125 mg IV or SC.
Water Intoxication --> because of its similarity to pituitary antidiuretic hormone (ADH), large
doses can result in water intoxication that can lead to hyponatremia, confusion, convulsion, coma,
congestive heart failure, and death. To avoid this complication, monitor intake and output closely
and use oxytocin judiciously.
Uterine Rupture --> occurs more commonly in multiparous patients, in those with previous
uterine scar, with fetal malpresentations, and with multiple pregnancy or overdistended uterus.
These conditions are relative contraindications to oxytocin use.
Other complications of oxytocin infusion include: abruptio placentae, precipitous delivery,
postpartum uterine atony and hemorrhage, neonatal hyperbilirubinemia, hypotension, and
amniotic fluid embolism.
Physician focus for managing labor induction:
!
Discuss risks/benefits with women considering induction and document in chart.
!
Confirm adequate fetal dates prior to induction and document in chart.
Hadi H. Cervical Ripening and Labor Induction: Clinical Guidelines. Clnical Obstetrics and Gynecology
2000;43(3):524-536.
Harman JH, Kim A. Current Trends in Cervical Ripening and Labor Induction. Am Fam Physician
1999;60:477-84.
Induction of Labor. ACOG Practice Bulletin Number 10, November 1999.
Ramsey, PS, Ramin KD, Ramin SM. Labor Induction. Current Opinion in Obstetrics and Gynecology
2000;12(6):463-473.
Response to Searles Drug Warning on Misoprostol. ACOG Committee on Obstetric Practice. Number 248,
December 2000.
Rinehart BK, Terrone DA, Hudson C, Isler CM, Larmon JE, Perry KG. Lack of utility of standard labor
curves in the prediction of progression during labor induction. Am J Obstet Gynecol 2000;182:1520-6.
Simpson KR, Poole JH, Simpson KR. Labor Induction and Augmentation: Knowing When, and How, to
Assist Women in Labor. AWHONN Lifelines 1998;2(6):39-42.
Zlatnik FJ. Elective Induction of Labor. Clinical Obstetrics and Gynecology 1999;42(4):757-765.
http://www.acog.org/
http://www.aafp.org
Breech Presentation
Selection Criteria for Vaginal
Breech Delivery:
Estimated fetal weight from 2,000
to 4,000 g (4 lb, 6 oz to 8 lb, 13 oz)
Frank or complete breech
presentation
Flexed fetal head
No major fetal anomalies or
placenta previa on ultrasound
Adequate magnetic resonance,
computed tomography, x-ray, or
clinical pelvimetry
Exclusion Criteria for External
Cephalic Version:
Multiple pregnancy
Evidence of uteroplacental
insufficiency
Significant third-trimester bleeding
Suspected intrauterine growth
restriction
Amniotic fluid abnormalities
Uterine malformation
Placenta previa
Maternal cardiac disease
Pregnancy-induced hypertension
Uncontrolled hypertension
A nonreassuring fetal monitoring
pattern
Major fetal anomaly
Successful
version?
no
Maternal
self-assessment
Consider repeat version
attempt weekly and monitor
for spontaneous conversion
to vertex
Breech presentation
by Leopolds maneuver
or vaginal examination
and at least 36 weeks
gestation
Perform U/S to:
Confirm position
Determine amniotic fluid
index (AFI)
Note placental location
r/o congenital anomalies
r/o presence of nuchal cord
Confirms
breech?
no
Routine prenatal
care
Attempt external cephalic
version when >=37 weeks
gestation (consider tocolysis
for nulliparas)
yes
Assess for C-section
or trial of labor
Presence
of exclusion
criteria?
yes
Prior to version attempt:
Draw CBC and type/screen
Establish IV access
Assess NST or BPP
Following version attempt:
Administer Rhogam (Rho (D)
immune globulin) to Rh-negative
women
Perform NST and Ultrasound
yes
no
Monitor for
reversion to breech
Advise patient of risk of cord
prolapse with rupture of
membranes and need for
immediate evaluation if PROM
occurs.
Review contraindications
Obtain informed consent
Physician focus for Treating Breech Presentation:
!
Perform a confirmatory ultrasound prior to performing external cephalic version attempt.
Indicator: Percentage of women diagnosed with breech presentation (>35 weeks gestation) that
receive a confirmatory ultrasound prior to undergoing external cephalic version attempt.

!
Perform a non-stress test (NST) and an ultrasound following external cephalic version attempts.
Indicator: Percentage of women undergoing external cephalic version attempts that receive post-
attempt NST and ultrasound.
Coco AS, Silverman SD. External Cephalic Version. American Family Physician 1998;58(3):731-744.
External Cephalic Version. ACOG Practice Bulletin Number 13, February 2000.
Hofmeyr GJ. External cephalic version facilitation for breech presentation at term (Cochrane Review) In:
The Cochrane Library, 1, 2001. Oxford: Update Software.
Hofmeyr GJ. External cephalic version for breech presentation before term (Cochrane Review). In: The
Cochrane Library, 1, 2001. Oxford: Update Software.
Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term (Cochrane Review). In:
The Cochrane Library, 1, 2001. Oxford: Update Software.
Management of the Breech Presentation. ACOG Technical Bulletin Number 95, August 1986.
http://www.acog.org/
http://www.aafp.org
Non-Reassuring Fetal Status
Non-Reassuring Patterns:
Fetal tachycardia
Fetal bradycardia
Saltatory variability
Variable decelerations associated
with a non-reassuring pattern
Late decelerations with preserved
beat-to-beat variability
Ominous Patterns:
Persistent late decelerations with loss
of beat-to-beat variability
Non-reassuring variable
decelerations associated with loss of
beat-to-beat variability
Prolonged severe bradycardia
Sinusoidal pattern
Confirmed loss of beat-to-beat
variability not associated with fetal
quiescence, medications or severe
prematurity
Labor with Electronic
Fetal Monitoring (EFM)
Reassuring
FHR pattern?
no
Continue
labor monitoring
until delivery
yes
Reassuring
FHR
pattern?
no
Vaginal delivery
Perform
Cesarean
Section
yes
Emergency Interventions for Non-reassuring Patterns:
Check maternal blood pressure - if hypotensive and epidural in
place, administer IVF bolus
Change maternal position (lateral or knee-chest)
Call anesthesia to evaluate, if no improvement
If no epidural, give IVF bolus, and reposition - if no
improvement, evaluate for cause of maternal hypotension
Consider tocolysis (for uterine tetany or hyperstimulation)
Decrease or discontinue oxytocin if infusing
Consider amnioinfusion (for variable decelerations)
Determine whether operative intervention is warranted and, if
so, how urgently it is needed
Delivery
imminent?
no
yes
Fetal Heart Rate (FHR) tracing
should be interpreted ONLY in
the context of the clinical
scenario, and any therapeutic
intervention should consider the
maternal condition as well as
that of the fetus.
Non-Reassuring Fetal Status p.2
Causes of Fetal Tachycardia:
Fetal hypoxia
Maternal fever
Hyperthyroidism
Maternal or fetal anemia
Parasympatholytic drugs
Atropine
Hydeoxyzine (Atarax)
Sympathomimetic drugs
Ritodrine (Yutopar)
Terbutaline (Bricanyl)
Chorioamnionitis
Fetal Tachyarrhythmia
Prematurity
Signs of Non-Reassuring Variable Decelerations that Indicate Hypoxemia:
Increased severity of the deceleration
Late onset and gradual return phase
Loss of shoulders on fetal heart rate (FHR) recording
A blunt acceleration or overshoot after severe deceleration
Unexplained tachycardia
Saltatory variability
Late decelerations or late return to baseline
Decreased variability
Causes of Severe Fetal Bradycardia:
Prolonged cord compression
Cord prolapse
Tetanic uterine contractions
Paracervical block
Epidural and spinal anesthesia
Maternal seizures
Rapid descent
Vigorous vaginal examination
Physician focus for managing non-reassuring fetal heart rate (FHR) patterns:
!
Emphasize appropriate emergency interventions for non-reassuring or ominous fetal heart rate patterns.
Fetal Heart Rate Patterns: Monitoring, Interpretation, and Management. ACOG Technical Bulletin Number
207, July 1995.
Institute for Clinical Systems Improvement. Health Care Guideline: Intrapartum Fetal Heart Rate
Management. December 1999. http://www.icsi.org (2001, April 17)
Morrison EH. Common Peripartum Emergencies. Am Fam Phys 1998;58(6):1593-1607
Sweha A, Hacker TW, Nuovo J. Interpretation of the Electronic Fetal Heart Rate During Labor. Am Fam
Phys 1999;59(9):2487-2506.
ACOG practice guideline.
http://www.acog.org
http://www.aafp.org
http://www.icsi.org
Fetal Macrosomia
Risk Factors for Fetal Macrosomia:
Maternal diabetes
Maternal impaired glucose intolerance
Multiparity
Previous macrosomic infant
Prolonged gestation
Maternal obesity
Excessive maternal weight gain
Male fetus
Parental stature
Maternal age
Maternal race
Paternal birth weight
Need for labor augmentation
Prolonged second stage
# Prepare and drill labor and
delivery staff in the basics and
management of shoulder dystocia,
including:
% McRoberts maneuver
% Suprapubic pressure on the
impacted shoulder
% Woods maneuver
% Delivery of the posterior arm
% Zavanelli maneuver
To date, no management algorithm involving selective interventions based on estimates
of fetal weight has demonstrated efficacy in reducing the incidence of either shoulder
dystocia or brachial plexus injuryplanned interventions based on estimates of fetal
weight do not reduce the incidence of shoulder dystocia and do not decrease adverse
outcomes attributable to fetal macrosomia.
--Sacks and Chen, Obstetrical and Gynecological Survey 2000
Current guidelines state that a planned cesarean delivery for a diabetic pregnant
woman whose fetal weight estimates exceed 4250 to 4500 gm may be reasonable...
--ACOG Practice Patterns Number 7, October 1997
With an estimated fetal weight greater than 4500 gm, a prolonged second stage of labor
or arrest of descent in the second stage is an indication for cesarean delivery
--ACOG Practice Bulletin Number 22, November 2000
For almost all macrosomic pregnancies including diabetic mothers, previous deliveries
with shoulder dystocia, or women considering VBAC, expectant management with
vigilance for evidence of fetopelvic disproportion will have optimal results.
--Zamorski and Biggs, American Family Physician 2001
Labor Pattern Nulligravida Multipara
Protraction disorders
Dilation
Descent
<1.2 cm/h
<1.0 cm/h
<1.5 cm/h
<2.0 cm/h
Arrest Disorders
Dilation
Descent
>2 hours
>1 hour
>2 hours
>1 hour
From ACOG Technical Bulletin No. 218
Abnormal labor patterns and diagnostic criteria
Forceps should be used
cautiously - if at all -
with fetal macrosomia.
Physician focus for delivery of the macrosomic fetus:
!
Emphasize preparedness of staff for management of shoulder dystocia.
Fetal Macrosomia. ACOG Practice Bulletin Clinical Management Guidelines for Obstetrician-
Gynecologists. Number 22, November 2000.
Berkus MD, Conway D, Langer O. The Large Fetus. Clinical Obstetrics and Gynecology 1999;42(4):766-
784.
Conway DL, Oded L. Elective delivery of infants with macrosomia in diabetic women: Reduced shoulder
dystocia versus increased cesarean deliveries. Am J Obstet Gynecol 1998;178(5):922-25.
Dystocia and the Augmentation of Labor. ACOG Technical Bulletin. Number 218, December 1995.
Gonen R, Bader D, Ajami M. Effects of a policy of elective cesarean delivery in cases of suspected fetal
macrosomia on the incidence of brachial plexus injury and the rate of cesarean delivery. Am J Obstet
Gynecol 2000;183:1296-300.
Rasmussen TL. The Use of Ultrasound to Identify Fetuses with Macrosomia in Diabetic Pregnancies: A
Review of Current Literature. Journal of Diagnostic Medical Sonography 2000;16(2):76-79.
Sacks DA, Chen W. Estimating Fetal Weight in the Management of Macrosomia. Obstetrical and
Gynecological Survey 2000;55(4):229-239.
Shoulder Dystocia. ACOG Practice Patterns, Evidence-Based Guidelines for Clinical Issues in Obstetrics
and Gynecology. Number 7, October 1997.
Sokol RJ, Chik L, Dombrowski MP, Zador IE. Correctly identifying the macrosomic fetus: Improving
ultrasonography-based prediction. Am J Obstet Gynecol 2000;182;1489-95.
Zamorski MA, Biggs WS. Management of Suspected Fetal Macrosomia. American Family Physician
2001;63:302-6.
http://www.acog.org
http://www.aafp.org
http://www.icsi.org
Vaginal Birth after
Cesarean Section
Complicated labor results from:
Failure to progress (see Dysfunctional
Labor guideline)
Fetal distress (see Non-Reassuring
Fetal Status During Labor guideline)
Maternal complication (e.g. cardiac
disease, exhaustion)
Uterine Rupture
The same considerations for
intervention in labor apply to VBACs
as for other attempted deliveries.
Contraindications to VBAC (and see page 2):
Previous classic C-section or T-shaped incision or
other transfundal uterine surgery
Contracted pelvis
Previous uterine rupture or dehiscence
Some maternal/fetal medical conditions (e.g., open
neural tube defect or complete placenta previa)
Inability to perform emergency cesarean delivery
because of unavailable surgeon, anesthesia, sufficient
staff, or facility
Unknown uterine scar if there is a high likelihood of
classical scar
Rare psychological or social conditions
Pregnant woman
with history of
previous C-section
Obtain previous operative records for
type of uterine incision
Perform thorough history and physical
Contra-
indications
to
VBAC?
no
Routine prenatal
care and appropriately
timed cesarean delivery
Patient
desires trial
of labor?
no
yes
Routine prenatal care until labor
Instruct patient to report to
hospital in active labor
yes
Normal
labor?
no
Vaginal birth
Complicated labor
management (see Page 2)
yes
Special considerations of labor
management (see page 2)
Counsel patient regarding
benefits and risks of VBAC
Vaginal
birth
appropriate?
Repeat
C-section
yes no
Vaginal Birth after Cesarean Section
(page 2)
Special considerations of labor management for VBAC candidates:
C-section team should be available within a short time (20-30 min).
Intermittent auscultation or continuous electronic fetal heart rate monitoring should be done.
Augmentation or induction of labor is not contraindicated.
Uterine scars do not require manual exploration post-partum.
Epidural anesthesia is not contraindicated.
Amnioinfusion is not contraindicated
Intrauterine pressure catheters are not necessary unless there are other obstetric indications.
The use of prostaglandins in women with previous c-sections has not been thoroughly studied.
Each situation should be weighed individually.
The following are NOT contraindications to VBAC:
Two or more previous C-sections
Previous failure to progress in labor and/or CPD
Post C-section infection
Vaginal delivery with a known overdistended uterus (i.e., twins,
macrosomia, hydramnios)
Physician focus for Vaginal Birth after C-section (VBAC):
!
Discuss risks/benefits of VBAC with patient and document in chart
!
Document prior uterine surgeries, including c-section(s) in patients chart.
!
Facilities are encouraged to have a general VBAC policy that is agreed on by the obstetrics and
gynecology department, with a built-in monitoring and evaluation system.
Vaginal Birth After Previous Cesarean Delivery. ACOG Practice Bulletin, Clinical Management
Guidelines for Obstetrician-Gynecologists. Number 5, July 1999
AAFP Reference ManualClinical Policies. Trial of Labor versus Elective Repeat Cesarean Section for
the Woman with a Previous Cesarean Section. April 1995. http://www.aafp.org/policy/camp/rep-505.html/
(2001, April 16)
Appleton B, Targett C, Rasmussen M, Readman E, Sale F, Permezel M. Vaginal Birth After Caesarean
Section: An Australian Multicentre Study. Obstetrical and Gynecological Survey 2000;55(11):680-682
Jongen VHWM, Halfwerk MGC, Brouwer WK. Vaginal Delivery After Previous Caesarean Section for
Failure of Second Stage of Labour. Obstetrical and Gynecological Survey 1999;54(4):226-227.
Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Vaginal Birth After Cesarean.
December 1999 http://www.icsi.org/guidelst.htm/ (2001, April 16)
Wing DA and Paul RH. Vaginal Birth After Cesarean Section: Selection and Management. Clinical
Obstetrics and Gynecology 1999;42(4):836-848.
ACOG practice guideline. VBAC.
http://www.acog.org
http://www.aafp.org
http://www.icsi.org
Pregnancy-Associated Hypertensive
Disease
Findings suggestive of preeclampsia syndrome:
Blood pressure>=160 systolic or >=110 diastolic
Proteinuria of 2.0 g or more in 24 hours (2+ or 3+ on
qualitative examination)
Increased serum creatinine (>1.2 mg/dL)
Platelet count less than 100,000 cells/mm3 and/or
evidence of microangiopathic hemolytic anemia
Elevated hepatic enzymes (ALT or AST)
Pulmonary edema
Oliguria - <400cc/24
0
Intrauterine growth retardation or oligohydramnios
Persistent headache or other cerebral or visual
disturbances
Persistent epigastric pain
Hypertension in
pregnancy
(>140/90 mmHg on
two or more
determinations)
Always carefully consider the risks
and benefits to a woman and her fetus
with continuing or initiating
pharmacotherapy for hypertensive
disease during pregnancy.
Antihypertensive treatment for mild
chronic hypertension benefits the
mother, but the impact on perinatal
outcomes is less clear.
HTN
diagnosed
before 20
weeks gesta-
tion?
no
Consider reducing dose or weaning
current regimen. ACE-Inhibitors
and Angiotensin II Receptor
Blockers MUST be discontinued
due to risk of fetal abnormalities.
If SBP >=150 mmHg or DBP >=100
mmHg and treatment has not yet been
initiated, see page 2 for options
Consider work-up of secondary
hypertension
Is
patient at
<32 weeks
gestation?
Attempt to postpone
delivery if hypertension
is mild, and no renal,
liver, or coagulation
abnormalities are
evident.
yes
no
Continue close observation of
woman and fetus. Initiate
antihypertensive therapy
if/when benefits to mother
appear to outweigh risk to fetus.
Pre-
eclampsia
symptoms
or signs
present?
yes
Consider corticosteroids
to accelerate fetal lung
development.
Likely chronic hypertension
The use of alcohol and tobacco
during pregnancy should be
strongly discouraged.
yes
no
Consider labor
induction
yes
no
Hospitalize patient and
monitor closely for
signs of fetal distress
and symptoms of
headache, visual
disturbances, and right
upper quadrant pain
Consider initiation
of antihypertensive
agent if DBP is 100
mmHg or higher
Has
patient
experienced severe
hypertension
for 24-48 hours? OR
Does patient have
another qualifying
diagnosis?
Continue close observation and
monitoring of woman and fetus
Bed rest
Antihypertensive medications
Magnesium sulfate for seizure
prophylaxis
Qualifying diagnosis for labor induction
when pregnancies are at or near term:
HELLP syndrome
Progressive renal failure
Premonitory signs of eclampsia (including
mild)
Elevated blood pressure
Fetal distress
Administer magnesium sulfate
for seizure prophylaxis during
labor and delivery and for at
least 24 hours post-partum by
continuous IV infusion.
Consider bed rest
Outpatient
management may
be considered if
compliance is
expected to be good,
hypertension is
mild, and the fetus
is normal.
Monitor deep tendon reflexes,
respiratory rate, and urinary
output during magnesium
sulfate administration
Pregnancy-Associated Hypertensive
Disease (page 2)
Antihypertensive Drugs Used in Pregnancy (from NHLBI*):
Suggested Drug Comments
Central alpha-agonist Methyldopa is the drug of choice recommended by the NHBPEP** Working Group.
Beta-blockers Atenolol and metoprolol appear to be safe and effective in late pregnancy.
Labetalol also appears to be effective. Beta-blockers can cause IUGR and low
placental weight when used during the second trimester. Other potentially adverse
effects include fetal bradycardia, impaired fetal compensatory response to hypoxia,
and neonatal hypoglycemia.
Calcium antagonists Potential synergism with magnesium sulfate may lead to precipitous hypotension.
ACE-Inhibitors, Fetal abnormalities, including death, can be caused, and these drugs should not be
Angiotensin II receptor blockers used in pregnancy.
Diuretics Diuretics are recommended for chronic hypertension if prescribed before gestation
or if patients appear to be salt-sensitive. They are not recommended in preeclampsia.
Direct vasodilators Hydralazine was the parenteral drug of choice, but is being replaced by IV labetalol
or oral /SL nifedipine based on fewer maternal and perinatal adverse effects.
Conditions Sometimes Confused with
Preeclampsia or Eclampsia:
Viral hepatitis
Acute fatty liver of pregnancy
Acute pancreatitis
Gallbladder disease
Appendicitis
Kidney stones
Glomerulonephritis
Hemolytic-uremic syndrome
Exacerbation of systemic lupus erythematosus
Autoimmune thrombocytopenia
Thrombotic thrombocytopenic purpura
Cerebral venal thrombosis
Encephalitis of various causes
Cerebral hemorrhage
Laboratory tests to consider in early
gestation for women who are High-risk for
preeclampsia*** or who present with
hypertension before gestation week 20:
CBC
serum creatinine and uric acid levels
24-hour urine collection for protein and creatinine
IF routine urine analysis shows 1+ or greater protein
with clean catch specimen
Early sonogram for dating if conditions not optimal
for clinical dating
Baseline sonogram for evaluating fetal growth at 25
to 28 weeks
*NHLBI, National Heart, Lung, and Blood Institute (a division
of the NIH).
**NHBPEP, National High Blood Pressure Education
Program
***High-risk for preeclampsia includes a history of increased
blood pressure before conception or in a previous gestation;
women with diabetes, collagen vascular disease, or underlying
renal vascular or renal parenchymal disease; and those with a
multifetal pregnancy.
Laboratory evaluation for women who
develop hypertension after gestation
week 20--at initial diagnosis of
hypertension, and consider repeating
biweekly:
CBC
protein excretion quantification (e.g., 24-hour
collection)
serum creatinine, uric acid, and transaminase
levels
serum albumin, lactic acid dehydrogenase, blood
smear, and coagulation profile
Hypertension
*Consider simultaneous initiation of
pharmacotherapy if patient is a diabetic or
has signs/symptoms of end-organ damage.
**B-blockers should not be started during
an acute worsening of clinical status or when
patient has fluid overload. FDA-approved
B-blockers for CHF include Carvedilol
(Coreg), Bisoprolol (Zebeta) and Metoprolol
succinate (Toprol XL)
Goal blood pressure:
<140/90 for adult without diabetes
<130/80 for adults with diabetes
Elevated blood
pressure
identified
Perform additional work-up
as indicated.
Begin or continue
lifestyle modifications*
Smoking cessation
Weight reduction
Regular physical activity
Moderation of alcohol intake
Reduction of sodium intake
Lipid measurement
Confirm elevated
blood pressure within
1-8 weeks and perform
diagnostic testing if
BP still above normal
ACE-Inhibitor
Diabetes mellitus
Heart failure (CHF)**
Myocardial infarction
Vascular disease
Is a
secondary
cause
suspected?
Encourage maintenance
of lifestyle modifications
and regular follow-up for
monitoring
yes
no
no
Beta blocker
Uncomplicated hypertension
Myocardial infarction
Heart failure
Diuretic
Uncomplicated hypertension
Heart failure
Isolated systolic hypertension
(in older persons)
Long-acting dihydropyridine
calcium antagonist
Isolated systolic hypertension
(in older persons)
Complete history and
physical exam, look
for signs of end-organ
damage
Diagnostic tests to consider:
CBC
Electrolytes
Creatinine
Fasting glucose
Urinalysis
Lipid profile
Electrocardiogram
Adequate
response?
yes
Initiate one of the following
medications based upon
the compelling indication:
Start with a low dosage
of a long-acting once-
daily drug and titrate.
Is the
drug well
tolerated?
yes
no
Substitute
another drug
from a different
class
Is goal
blood pressure
achieved?
Follow up at least every
6 months.
Continue lifestyle modifications
Increase dose of initial agent.
If maximal dose inadequate,
add a second agent.
no
yes
Consider ARBs as an
alternative to ACE inhibitors
in patients unable to tolerate
the latter.
Physician focus for Evaluating and Treating Hypertension (HTN):
!
Prescribe ACE-Inhibitors (or nitrates plus hydralazine) for all CHF patients without
contraindications.*
Indicator: Percentage of adults with diagnosis of CHF treated with ACE-Inhibitors (OR nitrates
plus hydralazine)
!
Titrate ACE-Inhibitors to target dose, as tolerated, in patients with CHF.
Indicator: Percentage of adults with diagnosis of CHF, treated with ACE-Inhibitors, at target
doses. These target doses are outlined on page 2 of the CHF guideline.
!
Prescribe B-blockers for CHF patients, NYHA Class I-III, without contraindications.
Indicator: Percentage of adults with diagnosis of CHF treated with B-blockers.
* Angiotensin II Receptor Antagonists (ARB) may be used as an alternative to ACE inhibitors in
patients who cannot tolerate the latter but have comorbid conditions for which ACE inhibitors are
indicated.
Kaplan NM. What is goal blood pressure for the treatment of hypertension? Archives of Internal Medicine
2001;161:1480-1482.
Kaplan NM. Angiotensin II receptor antagonists in the treatment of hypertension. American Family
Physician 1999;60:1185-90.
Yarows S et al. University of Michigan Medical Center. UMMC Hypertension Guidelines. February 1997.
Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Hypertension Diagnosis and
Treatment. November 2000. http://www.icsi.org/guidelst.htm/ (2001, March 7)
Kaplan NM. Treatment of Hypertension: Insights from the JNC-VI Report. Am Fam Physician
1998;58:1323-30..
U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and
Research. (1994, June). Heart Failure: Evaluation and Care of Patients with Left-Ventricular Systolic
Dysfunction. Clinical Practice Guideline No. 11. Retrieved from http://www.ahrq.gov/ (2001, March 7)
University of Michigan Health System. Guidelines for Clinical Care: Heart FailureSystolic Dysfunction.
http://cme.med.umich.edu/iCME/default.asp/ (2001, March 7)
University of Washington Physicians. Heart Failure Due to Systolic Dysfunction (HF) Guidelines.
http://healthlinks.washington.edu/guideline/hf/processes.html/ (2001, February 20)
http://www.ahcpr.gov/clinic/cpgonline.htm
http://www.americanheart.org
http://www.hfsa.org
http://www.praxis.md.com
Hyperlipidemia
Coronary Artery Disease (CAD) Risk
Factors:
Positive
Risk
Factors
Age:
!
Male >=45
!
Female >=55, or premature menopause
without HRT
Family history of premature CHD:
Definite MI or sudden death
!
before 55 y/o in father or other male first-
degree relative
!
before 65 y/o in mother or other female first-
degree relative
Current cigarette smoking
Hypertension:
!
>140/90*
!
or on antihypertensive medication
Low HDL-cholesterol
!
<40 mg/dL*
Diabetes mellitus
Negative
Risk
Factors
High HDL-cholesterol
!
> 60 mg/DL
If HDL-cholesterol is > 60, subtract one risk
factor
*Confirmed by more than one measurement.
Yes
Repeat screening
every 5 years
No
Perform fasting lipid panel for
all adults >20 years old
every 5 years
Calculate number of
risk factors
(see table to right)
Does
patient have
any risk
factors?
LDL-
cholesterol
less than
160 ?
Determine goal LDL,
based upon risk factors
and baseline LDL-cholesterol
No Yes
0-1 risk factor
GOAL LDL-cholesterol
is <160
2+ risk factors
(10-year risk &20%)*
is <130
CHD or CHD equivalents
(10-year risk >20%)*
is <100
Discuss with patient their risk
level and preferences regarding
continuing a trial of behavioral
and dietary therapies or
initiating lipid-lowering
medication.
Consider estrogen-replacement
therapy in appropriate women
Continue health
maintenance and
management
Non-pharmacological treatment trial (3-12 months):
Initiate dietary therapy: Step I diet (or Step II diet if known CAD or if patient is already on a Step I diet)
Consider referral to dietician
Initiate physical activity, weight management, and smoking cessation programs as indicated.
Consider ruling out secondary causes of hyperlipidemia with urinalysis, TSH, blood sugar, alk phos, etc.
Has goal
LDL-cholesterol
been met?
Recheck lipid levels in 6 weeks
Yes No
Decision
to initiate
lipid-lowering
therapy?
Initiate lipid-
lowering
pharmacotherapy
(see page 2)
Has goal
LDL-cholesterol
been met?
Recheck lipid
levels in 6 weeks
No
Yes
Consider increasing dose
of lipid-lowering agent or
adding a second agent
(see page 2)
*Using Framingham projections of 10-year absolute CHD risk to identify certain
patients for more intensive treatment
Follow-up in office
every 4-6 months for
the first year, then
at least annually
Yes
No
Is LDL
>130?
Consider immediate
initiation of a Statin for
aggressive lipid reduction
No
Yes
Hyperlipidemia Page 2
Focus on the Patient:
Simplify medication regimens
Provide explicit patient instruction and use good counseling techniques to teach the patient how to follow the
prescribed treatment
Encourage the use of prompts to help patients remember treatment regimens
Use systems to reinforce adherence and maintain contact with the patient
Encourage the support of family and friends
Reinforce and reward adherence
Increase visits for patients unable to achieve treatment goal
Increase the convenience and access to care
Involve patients in their care through self-monitoring
Drug Class Indication Cautions/Contraindications
Statins
(HMG-CoA
reductase inhibitors)
!
Drug of choice in patients with known
CAD
!
Reduces LDL-C 25-40%
!
Reduces triglyceride levels
!
Modest increase in HDL-C
!
Demonstrated decreased mortality from
CAD
!
Contraindicated in active liver disease
!
Hepatotoxicity occurs in <2% of
patients, and is usually reversible
!
Myositis is unusual complication
!
Caution when combining with
fibrates or niacin
Bile Acid
Sequestrants
(Cholestyramine and
colestipol HCl)
!
Typically first-line for primary
prevention (hyperlipidemia without
known CAD)
!
Can reduce total cholesterol and
LDL-C 15-30%
!
Increases triglyceride levels
!
Can be combined with other drugs (e.g.
statins)for severe forms of
hypercholesterolemia
!
Gastrointestinal side effects may
preclude or limit dosage
Niacin
(i.e. Nicotinic acid,
Niaspan)
!
Reduces LDL-C cholesterol and
triglycerides
!
Increases HDL-C levels
!
Contraindicated in chronic liver
disease, severe gout
!
Relative contraindication with peptic
ulcer disease
!
Flushing is common side effect. This
may be alleviated by titrating dose,
taking with a meal and/or
pretreatment with aspirin
!
Requires monitoring of liver function
Fibrates
(i.e. gemfibrozil)
!
Reduces triglyceride levelsmost
valuable for treatment of very high
triglyceride levels
!
May elevate both LDL-C and HDL-C
levels
!
Can use as combination therapy with a
statin for mixed lipid abnormalities
monitor for myopathy and potential
hepatic toxicity
!
Doesnt usually produce substantial
LDL-C reduction
!
May elevate both LDL-C and HDL-C
levels
!
Myositis and gallstones are unusual
complications
!
Contraindicated in severe renal
disease, severe hepatic disease
Estrogen
Replacement
Therapy
!
Should be considered as a possible
alternative or adjunct to therapy for
women with elevated LDL-cholesterol
levels
!
Increases HDL-C levels
!
Reduces LDL-C levels
!
Combine with progestins for women
with intact uterus
Physician focus for Treating Hyperlipidemia:
!
Select a statin for lipid-lowering therapy in patients with known coronary artery disease (CAD).
Indicator: Percentage of adults diagnosed with hyperlipidemia with a co-existing diagnosis of
CAD or MI that are treated with a statin.

!
See patients diagnosed with hyperlipidemia for office follow-up within 4 months of initial
diagnosis.
Indicator: Percentage of adults diagnosed with hyperlipidemia with a follow-up appointment
within 4 months of initial diagnosis.
Abookire SA, Karson AS, Fiskio J, Bates DW. Use and Monitoring of Statin Lipid-Lowering Drugs
Compared With Guidelines. Arch Intern Med. 2001; 161:53-58.
Ansell BJ, et al. An evidence-based assessment of the NCEP Adult Treatment Panel II guidelines. JAMA
1999: 282:2051-7.
Harvard Pilgrim Health Care, Inc. Guidelines for lipid screening and management for primary and
secondary prevention of coronary heart diseases (CHD) in adults. Released 1997 Oct. Accessed at the
National Guideline Clearinghouse.
National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High
Blood Cholesterol in Adults (Adult Treatment Panel III). U.S. Department of Health and Human Services,
Public Health Service, National Institutes of Health, National Heart, Lung and Blood Institute. JAMA
2001:285(19): 2486-2497.
Sikkink J, et al. Health Care Guideline: Treatment of Lipid Disorder in AdultsPatients Without Known
Coronary Artery Disease. Institute for Clinical Systems Improvement (ICSI). November 2000.
http://www.icsi.org/guidelst.htm/
Task Force, Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Dyslipidemia and
Prevention of Atherogenesis. AACE medical guidelines for clinical practice for the diagnosis and
treatment for dyslipidemia and prevention of atherogenesis. Endocrine Practice 2000. 6(2): 162-213
American Heart Association, Step I and II Diets:
http://www.americanheart.org/Heart and Stroke A Z Guide/step1.html/
Stable Angina
Evaluation to include (where appropriate):
Complete History and Physical
EKG (optimally during symptoms)
Blood work--CBC, chem profile, TSH, FLPs
Chest X-ray
Echocardiogram (if suspect dysfunction/failure)
Signs/Symptoms
of Angina
Does patient
have intermediate
or high risk
unstable
angina?
Go to
Unstable
Angina
Algorithm
yes
no
Assessment
yields
intermediate or
high risk for
adverse
event?
No
yes
Initiate
Medical Therapy
and Lifestyle
Modification
(see page 2)
Yes
No
Consider cardiac
catheterization or
pharmacological
stress test
Able to
achieve necessary
increased
heart rate via
stress test?
No
yes
Contra-
indications to
stress
testing?
Follow-Up in
2-6 weeks
Baseline
EKG
normal?
no
Consider ECHO or
nuclear stress test
Exercise stress test
Test results
suggestive of
high risk?
no
Consider further evaluation with:
Nuclear stress test
Stress Echocardiography
Cardiac catheterization
Do test
results suggest
significant
lesions?
Refer for cardiac
catheterization and
myocardial
revascularization.
yes
yes Yes
no
Treadmill results indicating high risk:
<5 METs duration
ST segment depression
Hypotension
Inability to attain target heart rate--85% of
max predicted heart rate (MPHR=220-age)
Exercise-induced angina
Ventricular ectopy at low workload
Features of intermediate or
high risk unstable angina:
Rest pain lasting > 20 min.
Age >65 y/o
ST and T wave changes
Pulmonary edema
Elevated cardiac enzymes
ANGINA SIGNS/SYMPTOMS
MAY INCLUDE:
Pain/discomfort in chest and/or
adjacent areas
Nitroglycerin used to shorten/
alleviate/prevent angina attacks
Anginal equivalent symptoms
may include: nausea, palpitations,
diaphoresis, unusual weakness or
fatigue, shortness of breath (often
with exertion)
RISK ASSESSMENT:
Low Intermediate High
Prior vascular dz. Accelerated tempo angina
atypical >20 min C.P. @ rest >20 min C.P. at rest
(resolved) (ongoing)
Pulm edema
MR murmur
S3
hypotension
Normal EKG >.2 mV T-wave >0.05mV ST changes
(or unchanged) BBB, sustained. v. tach
Stable Angina (page 2)
General Contraindications for Exercise Stress Test
Consider pharmacologic stress test under the
following circumstances:
Acute thrombophlebitis or deep venous thrombosis
Neuromuscular, musculoskeletal or arthritic condition
that precludes treadmill exercise
Patients inability or lack of desire to perform the test
Easy fatigability
Consider cardiac catheterization under the
following circumstances:
Recent (within 6 weeks) acute myocardial infarction
Angina at rest
Severe symptomatic left ventricular dysfunction
Potentially life-threatening arrhythmias
Acute pericarditis, myocarditis or endocarditis
Severe aortic stenosis
Acute pulmonary infarct or embolus
Acute or serious general illness
Medical therapy and lifestyle modification recommendations (if no contraindications):
B-blocker--titrate to achieve a resting heart rate of 50-60 beats per minute
Calcium channel blocker* and/or nitrates** (if symptoms persist with B-blocker monotherapy)
ACE-I for patients with CHF, LV dysfunction (EF<40), hypertension, or diabetes
Aspirin 75-325 mg qd (or, Clopidogrel 75 mg/d if Aspirin contraindication)
Lipid-lowering therapy (see Hyperlipidemia guideline)
Low-cholesterol diet education
Physical exercise education
Smoking cessation
Nitroglycerin (sublingual or spray)--patient must be instructed in its use.
*Caution with negative inotropic agents IF impaired left ventricular function present (consider
dihydropyridines as Ca-channel blockers of choice in compensated CHF)
**Long-acting nitrates, with daily nitrate-free interval.
Physician focus for Evaluating and Treating Stable Angina:
!
See patients diagnosed with stable angina within two months of initial diagnosis.
Indicator: Percentage of adults diagnosed with stable angina who have a follow-up appointment
with their PCP or Cardiologist within 2 months of initial diagnosis
!
Prescribe beta-Blocker therapy for patients with stable angina, unless contraindicated or not
tolerated.
Indicator: Percentage of adults with stable angina filling a prescription for a beta-Blocker.
!
Prescribe short-acting nitrates (sublingual or spray) for all patients with stable angina, unless
contraindicated.
Indicator: Percentage of adults with the diagnosis of stable angina with a current nitroglycerin
(sublingual or spray) prescription. This prescription could be recent or up to one-year prior.
Gibbons RJ, Chatterjee K, Dale J, et al. ACC/AHA/ACP-ASIM guidelines for the management of patients
with chronic stable angina: executive summary and recommendations: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of
Patients With Chronic Stable Angina). Circulation 1999: 99:2829-2848.
Heidenreich PA, McDonald KM, Hastie T, Fadel B, Hagan V, Lee BK, Hlatky MA. Meta-analysis of Trials
Comparing beta-Blockers, Calcium Antagonists, and Nitrates for Stable Angina. JAMA 1999;
281(20):1927-1936.
Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Stable Coronary Artery Disease.
January 2000. http://www.icsi.org/guidelst.htm/ (2001, March 7)
Lehman G. et al. ICSI Health Care Guideline: Stable Coronary Artery Disease. Institute for Clinical
Systems Improvement January 2000
Thadani U. Treatment of stable angina (Ischemic Heart Disease). Current Opinion in Cardiology1999;
14(4):349-358.
Zanger DR, Solomon AJ, Gersh BJ. Contemporary Management of Angina: Part I. Risk Assessment.
American Family Physician 1999; 60:2543-52.
Zanger DR, Solomon AJ, Gersh BJ. Contemporary Management of Angina: Part II. Medical Management
of Chronic Stable Angina American Family Physician 2000; 61:129-38.
Agency for Healthcare Research and Quality, Clinical Practice Guidelines:
American Heart Association: http://www.americanheart.org
Praxis MD: http://www.praxis.md.com
Unstable Angina
Signs/Symptoms
of Angina
Evaluation to include (where
appropriate):
Complete History and
Physical
EKG (optimally during
symptoms)
Blood work--CBC, chem
profile, TSH, FLPs
Chest X-ray
Echocardiogram (if suspect
dysfunction/failure)
Intermediate
or high risk
unstable
angina?
Go to
Stable
Angina
Algorithm
Assessment
yields
intermediate or
high risk for
serious cardiac
event?
Outpatient management
Symptom-free after
6-12 hours observation
ANDrepeat EKG
and cardiac
markers
negative?
Inpatient management
Consider referral for
cardiac catheterization
(if patient is a
candidate)
Is patient
hemodynamically
unstable?
Consider consultation for
urgent cardiac cathetherization
Exercise Stress Test
Test results
suggestive of
high risk?
Outpatient management
with re-evaluation
within 72 hours
Refer for cardiac
catheterization and
myocardial
revascularization.
Consider further evaluation with:
Nuclear stress test
Stress Echocardiography
Cardiac catheterization
Test
results
suggest
significant
lesions?
If not already initiated,
begin antithrombotic therapy
(Unfractionated heparin + Aspririn
or Low molecular weight heparin)
Unable to exercise
ANGINA SIGNS/SYMPTOMS MAY INCLUDE:
Pain/discomfort in chest and/or adjacent areas
Nitroglycerin used to shorten/ alleviate/prevent
angina attacks
Anginal equivalent symptoms may include:
nausea, palpitations, diaphoresis, unusual
weakness or fatigue, shortness of breath (often
with exertion)
Features of intermediate or high risk
Unstable Angina:
Rest pain lasting > 20 min.
Age >65 y/o
ST and T wave changes
Pulmonary edema
Elevated cardiac enzymes
RISK ASSESSMENT (see Table I for a comprehensive outline):
Low Intermediate High
prior vasc dz. Accel tempo angina
atypical >20 min C.P. @ rest >20 min C.P. at rest
(resolved) (ongoing)
Pulm edema,
MR murmur, S3,
hypotension
Normal EKG >.2 mV T-wave >0.05mV ST changes
(or unchanged) BBB, sust. v. tach,
elevated troponin,
CKMB levels
Consider the following (unless contraindications)
Aspirin (or a thienopyridine if ASA intolerant)
O2 (2-4 L/min by NC)
Nitroglycerin (SL, spray, transdermal, or IV)
MSO4 (1-5 mg IV, repeat q15-30 min prn pain
Trial of antacid if suspect GI origin of pain
B-blocker (or, if contraindicated, a nondihydropyridine calcium
antagonist)
ACE-Inhibitor if persistent HTN and LV dysfunction (or CHF)
and in patients with diabetes
Antithrombotic regimen (IV unfractionated heparin or SQ low
molecular weight heparin)
Platelet glycoprotein IIb/IIIa (GP IIB/IIIa) receptor antagonist (IF
continuing ischemia, high-risk features, or cath planned)
Close monitoring of HR, BP, and cardiac rhythm
Test results indicating high
risk:
<5 METs duration
ST segment depression
Hypotension
Unable to attain target heart
rate--85% of max predicted
heart rate (MPHR=220-age)
Exercise-induced angina
Ventricular ectopy at low
workload
Initiate
Medical Therapy and
Lifestyle Modification
(see page 2)
No
Yes
Yes No
No
Yes
Yes
No
Yes
No
Yes
No
Yes
No
Physician focus for Evaluating and Treating Unstable Angina:
!
See patients admitted with a diagnosis of unstable angina for office follow-up within 3 days of
diagnosis.
Indicator: Percentage of adults admitted for 24 hours or less for unstable angina having a
follow-up visit within 3 days (with PCP or Cardiologist).
!
Prescribe beta-Blocker therapy for patients with unstable angina, unless contraindicated or not
tolerated.
Indicator: Percentage of adults with unstable angina filling a prescription for a beta-Blocker.
!
Prescribe short-acting nitrates (sublingual or spray) for patients with unstable angina, unless
contraindicated.
Indicator: Percentage of adults with the diagnosis of unstable angina with a current nitroglycerin
(sublingual or spray) prescription. This prescription could be recent or up to one-year prior.
!
Prescribe ASA 75 to 325 mg/d unless contraindicated. (Clopidogrel 75 mg/d may be used for
patients with contraindications to ASA.)
!
Lipid lowering agents and diet for patients with low-density lipoprotein (LDL) cholesterol of
#
125 mg/dL.
!
ACEIs for patients with CHF, LV dysfunction (EF
'
0.40), hypertension, or diabetes.
Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, Jones RH, Kereiakes D,
Kupersmith J, Levin TN, Pepine CJ, Schaeffer JW, Smith EE III, Steward DE, Theroux P. ACC/AHA
guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial
infarction: executive summary and recommendations: a report of the American College of Cardiology/
American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients
With Unstable Angina). Circulation 2000;102:1193-1209.
Clinical Practice Guideline, Unstable Angina: Diagnosis and Management (AHCPR Publication No. 94-
0604)
Hamm CW, Braunwald E. A Classification of Unstable Angina Revisited (Current Perspective).
Circulation 2000:102:118-122.
Mozaffarian D. Non-ST Elevation Acute Coronary Syndromes (Unstable Angina and Non-Q-wave
Myocardial Infarction). Best Practice of Medicine 2001. Accessed from praxis.md web site
(www.praxis.md.com) Article url: http://praxis.md/index.asp?page=bpm_brief&chapter=BPM01CA14.
Research. (1994, June). Clinical Practice Guideline, Unstable Angina: Diagnosis and Managment.
Retrieved from http://www.ahrq.gov/ (2001, March 7)
Agency for Healthcare Research and Quality, Clinical Practice Guidelines:
American Heart Association: http://www.americanheart.org
Congestive Heart Failure (CHF)
*For ACE-I and B-blockers, start with very low doses
and titrate to target dosage (see page 2) as tolerated
**B-blockers should not be started during an acute
worsening of clinical status or when patient has fluid
overload. FDA-approved B-blockers include Carvedilol
(Coreg), Bisoprolol (Zebeta) and Metoprolol succinate
(Toprol XL)
Common Symptoms of CHF:
Paroxysmal nocturnal dyspnea or supine cough
Orthopnea
Dyspnea or cough on exertion
Edema in the lower extremities
Decreased exercise tolerance
Unexplained confusion, altered mental status, or fatigue
Abdominal symptoms associated with ascites and/or
hepatic engorgement
Uncommon Symptoms of CHF:
Pulmonary or systemic embolism in the absence of an
obvious cause
Unexplained pleural effusions
Abnormal liver enzymes
Symptoms and
signs of heart
failure
Likely diastolic dysfunction,
valvular heart disease,
or a non-cardiac etiology
(beyond scope of this guideline)
Reversible cause (e.g.,
ischemic or valvular
heart disease)?
Assess LV function
(Echocardiogram,
Radionuclide
Ventriculogram)
Asymptomatic
(NYHA Class 1)
ACE-I*
B-blocker*, **
Is
ejection
fraction
<40%
Consider referral to
address cause, then
reconsider pharmacologic
therapy
Systolic dysfunction.
Determine symptom
class and treat
as follows (unless contra-
indications exist)
yes
yes
no
no
Include
comprehensive
patient education
(see page 2)
Symptomatic
(NYHA Class II-IIIa)
ACE-I*
B-blocker*, **
Diuretic (may be prn edema
and congestion)
I f symptoms persist:
Digoxin
Symptomatic with history of
recent rest dyspnea
(NYHA Class IIIb)
ACE-I*
B-blocker*, **
Diuretic (dosing may be
modified depending upon
magnitude of congestion)
Spironolactone
Digoxin
Symptomatic with rest dyspnea
(NYHA Class IV)
ACE-I*
Diuretic (dosing may be
modified depending upon
magnitude of congestion)
Spironolactone--monitor
potassium (<5.0) and
creatinine (<2.5)
Digoxin
Consider Aspirin (especially if patient has known CAD)
Consider warfarin anticoagulation in patients with left ventricular ejection fraction of 35% or less
Warfarin anticoagulation in patients with heart failure and atrial fibrillation (goal INR= 2.0 to 3.0), unless contraindicated
In symptomatic patients, if ACE-I is not tolerated, consider Hydralazine and Isosorbide Dinitrate combination. Alternatively,
may consider Angiotensin II Receptor Blockers (ARBs), although not shown to have comparable decrease in mortality, available
with beta blockers and ACE-I
Avoid drugs that may exacerbate CHF: Class I anti-arrhythmics, NSAIDs, some first-generation calcium channel blockers
(i.e., diltiazem, nifedipine, verapamil)
Complete history and
physical exam and
clinically appropriate
diagnostic tests
Diagnostic tests to consider:
CBC
AST, alkaline phosphatase
Sodium, potassium
Creatinine, BUN
Protein or albumin
Urinalysis
Thyroid function
Magnesium, calcium
Iron/ferritin
Electrocardiogram
Chest radiograph
Cath or
image study
suggests
CAD?
yes
CHF (Page 2)
NYHA Class NYHA Symptom Description
I Asymptomatic. No limitation of physical activity. Ordinary physical activity does not cause undue
fatigue, palpitation, or dyspnea.
II Mildly symptomatic. Slight limitation of physical activity. Comfortable at rest, but ordinary physical
activity results in fatigue, palpitation or dyspnea.
III Moderately symptomatic. Marked limitation of physical activity. Comfortable at rest, but less than
ordinary activity causes fatigue, palpitation or dyspnea.
IV Symptoms at rest. Unable to carry out any physical activity without discomfort. Symptoms of cardiac
insufficiency at rest. If any physical activity is undertaken, discomfort is increased.
Patient Education
Low-salt diet
Moderation of fluid intake
Alcohol restriction
Self-monitoring with daily weights (especially NYHA
Class III-IV)
Symptoms of exacerbation
Smoking cessation (if applicable)
Exercise regimen
Importance of flu and pneumococcal vaccination
ACE-I target doses
Captopril 150 mg/d
Enalapril maleate 20 mg/d
Ramipril 10 mg/d
Lisinopril 40 mg/d
Quinapril hydrochloride 40 mg/d
Tandolapril 4 mg/d
*Renal function and serum potassium levels
should be assessed within 1-2 weeks of
initiation and every 2-3 months thereafter.
Physician focus for Evaluating and Treating Congestive Heart Failure (CHF):
!
Prescribe ACE-Inhibitors (or nitrates plus hydralazine) for all CHF patients without
contraindications.
Indicator: Percentage of adults with diagnosis of CHF treated with ACE-Inhibitors (OR nitrates
plus hydralazine)
!
Titrate ACE-Inhibitors to target dose, as tolerated, in patients with CHF.
Indicator: Percentage of adults with diagnosis of CHF, treated with ACE-Inhibitors, at target
doses. These target doses are outlined on page 2 of the CHF guideline.
!
Prescribe B-blockers for CHF patients, NYHA Class I-III, without contraindications.
Indicator: Percentage of adults with diagnosis of CHF treated with B-blockers.
Chavey W et al, University of Michigan Health System. UMHS Heart Failure Guideline. August 1999.
Farmer J, Torre G. Congestive Heart Failure: Specific Therapies. Current Practice of Medicine 1999;
2(11)2117-2131.
Gomberg-Maitlnd M, Baran DA, Fuster V. Treatment of Congestive Heart Failure: Guidelines for the
Primary Care Physician and the Heart Failure Specialist. Arch Int Med. 2001;161:342-352
Heart Failure Society of America (HFSA). HFSA Guidelines for Management of Patients with Heart
Failure Caused by Left Ventricular Systolic DysfunctionPharmacological Approaches. Journal of
Cardiac Failure 1999;5:357-382.
Hood WB Jr, Dans A, Guyatt GH, Jaeschke R, McMurray J. Digitalis for treatment of congestive heart
failure in patients in sinus rhythm (Cochrane Review). In: The Cochrane Library, 1, 2001. Oxford: Update
Software.
Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Congestive Heart Failure in
Adults. November 2000. http://www.icsi.org/guidelst.htm/ (2001, March 7)
Ramahi TM. Beta Blocker Therapy for Chronic Heart Failure. Am Fam Physician 2000;62:2267-74.
http://healthlinks.washington.edu/guideline/hf/processes.html
Shamsham F, Mitchell J. Essentials of the Diagnosis of Heart Failure. Am Fam Physician 2000;61:1319-28.
Research. (1994, June). Heart Failure: Evaluation and Care of Patients with Left-Ventricular Systolic
Dysfunction. Clinical Practice Guideline No. 11. Retrieved from http://www.ahrq.gov/ (2001, March 7)
University of Michigan Health System. Guidelines for Clinical Care: Heart FailureSystolic Dysfunction.
http://cme.med.umich.edu/iCME/default.asp/ (2001, March 7)
http://healthlinks.washington.edu/guideline/hf/processes.html/ (2001, February 20)
http://www.americanheart.org
http://www.hfsa.org
http://www.praxis.md.com
Peptic Ulcer Disease
Symptoms of
Dyspepsia
Emphasize Non Emphasize Non- -Medical Treatment Recommendations throughout algorithm (see page Medical Treatment Recommendations throughout algorithm (see page 2) 2)
Alarm
Symptoms
Present?
Yes No
Endoscopy
Are
symptoms
more consistent
with GERD?
Yes
No
Go to
GERD
pathway
Urea Breath Test
or
H. pylori serological
testing **
Positive?
Yes
No
Reconsider
Diagnosis--
Consider Barium
UGI or
Endoscopy
Treat H. pylori
Infection
(see FDA
approved list
attached)
Symptoms
resolve?
No
Yes
Review in
6 months
Biopsy for
H. pylori
Rapid Urease Test
(CLO-test)*
Positive?
Yes
Reconsider
Diagnosis
(ie. Zollinger-Ellison,
Crohns Disease,
Malignancy)
No
*Antacids, Pepto-Bismol Antibiotics, and Proton Pump
Inhibitors can all interfere with diagnosis. See page 2 for
recommendations.
**Serology cannot distinguish between active or previous
infection in a patient with prior treatment for H. pylori.
Peptic
Ulcer?
Yes
No
Reconsider
Diagnosis
(ie. GERD)
Counsel on Non-medical
anti-reflux precautions
(see page 2)
Consider Proton Pump
Inhibitor trial
(see page 2)
ALARM SYMPTOMS (and risk
factors for serious disease):
GI bleeding, anemia
Anorexia, weight loss
Advanced age
Dysphagia
Long history of symptoms
Protracted vomiting
No history of ulcerogenic drugs
Palpable mass
SYMPTOMS MAY INCLUDE:
Epigastric abdominal pain
Periodic pain relieved by food/antacids
Pain may be worse at night
Upper GI bleeding
Bloating, belching, heartburn
Nausea, vomiting
Note: Some references
allow for omission of
initial H. pylori testing
and progress directly
to empiric treatment
for H. pylori infection.
PUD Page 2
Avoid known risk factors:
NSAIDS and corticosteroids
tobacco
alcohol
caffeine (coffee, tea, cola)
calcium-containing antacids
Regimen Dose Duration Precautions/Comments
Omeprazole
+ Clarithromycin
40 mg QD
500 mg TID
2 weeks Then, Omeprazole 20 mg QD x 2
weeks
Ranitadine
+ Clarithromycin
400 mg BID
500 mg TID
2 weeks Then, Ranitadine 400 mg BID x 2
weeks
Dysgeusia with clarithromycin
Bismuth
subsalicylate
(Pepto Bismol)
+Metronidazole
+Tetracycline*
a.k.a. HELIDAK
525 mg QID
250 mg QID
500 mg QID
2 weeks Then, H2 receptor antagonist
therapy as directed x 4 weeks
*Although not FDA approved,
Amoxicillin has been substituted for
tetracycline for patients for whom
tetracycline is not recommended.
Lansoprazole
+Clarithromycin
+Amoxicillin
30 mg BID
500 mg TID
1 g BID
10 days Penicillin allergy; dysgeusia with
clarithromycin
Ranitadine
+Clarithromycin
400 mg BID
500 mg BID
2 weeks Then, Ranitadine 400 mg BID x 2
weeks
Dysgeusia with clarithromycin
Omeprazole
+Clarithromycin
+Amoxicillin
20 mg BID
500 mg BID
1 g BID
clarithromycin
Lansoprazole
+Clarithromycin
Amoxicillin
a.k.a. PREVPAK
30 mg BID
500 mg BID
1 g BID
clarithromycin
Treatment options for H. pylori eradication using FDA-approved medications:
Non-medical anti-reflux treatment recommendations:
Physician focus for Evaluating and Treating Peptic Ulcer Disease (PUD):
!
Use FDA-approved medications in the identified regimens for H. pylori eradication.
Indicator: Percentage of adults diagnosed with PUD and treated with one of the identified
Regimens (PUD page 2) for H. pylori eradication.
!
Prior to prescribing a second trial of H. pylori eradication treatment, perform appropriate
diagnostic testing (endoscopy, barium swallow, or urea breath test).
Indicator: Percentage of adults receiving endoscopy, barium swallow, or urea breath test before a
second trial of H. pylori eradication treatment (unless such diagnostic measures were performed
prior to the first treatment trial).
!
See patients with recent diagnosis of PUD in the office within 6 months of diagnosis.
Indicator: Percentage of adults diagnosed with PUD with a follow-up appointment within 6
months of diagnosis.
!
Obtain biopsy for CLO test for H. pylori when performing endoscopy for PUD.
Indicator: Percentage of adults who undergo endoscopy for PUD who have biopsy performed
with CLO test for H. pylori (unless urea breath test or serological testing was performed within 6
months prior to endoscopy).
Anderson J and Gonzalez J. H. pylori infection: Review of the guideline for diagnosis and treatment.
Geriatrics 2000 (June);55:44-49
Bazaldua OV and Schneider FD. Evaluation and Management of Dyspepsia. American Family Physician
1999;60(6):1773-1786.
Delaney BC, Innes MA, Deeks J, Wilson S, Oakes R, Moayyedi P, Hobbs FDR, Forman D. Initial
management strategies for dyspepsia (Cochrane Review). In: The Cochrane Library, 1, 2001. Oxford:
Update Software
Graham DY. Peptic Ulcer Disease. Current Practice of Medicine 1999;2(12):2359-2366.
Helicobacter pylori: Fact Sheet for Health Care Providers. Centers for Disease Control and Prevention.
Updated July 1998. http://www.cdc.gov/ulcer/hpfacts.PDF (2001, February 26)
Howden CW and Hunt RH. Guidelines for the Management of Helicobacter pylori Infection. The
American Journal of Gastroenterology 1998;93(12):2330-2338.
Moayyedi P, Soo S, Deeks J, Delaney B, Harris A, Innes M, Oakes R, Wilson S, Rolfe A, Bennett C,
Forman D. Eradication of Helicobacter pylori for non-ulcer dyspepsia (Cochrane Review). In: The
Cochrane Library, 1, 2001. Oxford: Update Software.
Soll AH. Medical Treatment of Peptic Ulcer Disease: Practice Guidelines. JAMA 1996;275(8):622-629.
Helicobacter Foundation www.helico.com
The Cochrane Group www.update-software.com
American Academy of Family Practice www.aafp.org
Dynamic Medical www.dynamicmedical.com
CDC website on Ulcers http://www.cdc.gov/ulcer/
GERD
Reflux Symptoms
Counsel on Non-
medical anti-reflux
Precautions
(see page 2)
Endoscopy
Alarm
Symptoms
Present?
yes no
Does
endoscopy show
signs of GERD?
(i.e. erosive esophagitis,
Barretts esophagus,
peptic strictures,
etc.)
yes
no
Reconsider
diagnosis
8-12 week empiric trial of
H2-Receptor Antagonists
BID (see page 2)
8-12 week Proton Pump
Inhibitor(PPI) treatment--
titrate as needed
(see page 2)
Good
response?
yes
no
Maintenance therapy
with lowest effective
dose of H2RA or
OTC H2RA or antacid
(on demand or
continuous, as needed)
Good
response?
yes
no
Maintenance therapy
with lowest effective
dose of PPI or H2RA
or OTC H2RA or
antacid (on demand or
continuous, as needed)
Confirm diagnosis
with EGD, 24 hour
esophageal pH study,
or Barium Esophagram,
depending upon
clinical scenario
Study
confirms
GERD?
yes
no
Consider surgical
consultation for
fundoplication
Follow-up
in office
within 6
months
Follow-up
in office
within 6
months
Consider further
diagnostic testing
if patient requires
continuous chronic
therapy OR develops
alarm symptoms
Emphasize Non Emphasize Non- -Medical Treatment Recommendations throughout algorithm (see page Medical Treatment Recommendations throughout algorithm (see page 2) 2)
Heartburn
Substernal or epigastric burning pain or discomfort
Nocturnal cough
Belching, regurgitation, hypersalivation
Chronic cough
Hoarseness
Recurrent asthma/bronchospasm
Chronic nausea
ALARM SYMPTOMS:
Dysphagia
Weight loss
GI blood loss (acute or
chronic)
Anemia
Anorexia
GERD page 2
Non-medical anti-reflux precautions:
Lifestyle modification
smoking cessation
elevation of head of bed
avoid overeating
avoid eating within 3-4 hours of going to bed
consider weight reduction
avoid tight clothing
Consider over the counter medications for mild
symptoms:
Antacids
OTC H2-receptor blockers
Avoid known risk factors:
tobacco
alcohol
onions
citrus fruits and juices
spicy food
caffeine (coffee, tea, cola)
fatty foods
chocolate
peppermints
tomato-based foods
Medication
(Available Dosage Strengths)
Dosage Regimen
Cimetidine (Tagamet)
(200mg, 300mg, 400mg, 800mg)
800-1600 mg/day
in divided doses
Ranitidine (Zantac)
(150mg, 300mg)
300-600 mg/day
in divided doses
Nizatidine (Axid)
(150mg, 300mg)
600 mg/day
in divided doses
Famotidine (Pepcid)
(20mg, 40mg)
40 mg/day
in divided doses
Omeprazole (Prilosec)
(10mg, 20mg)
20-60 mg/day
in divided doses
Rabeprazole (Aciphex)
(20mg)
20 mg/day
Pantoprazole (Protonix)
(40mg)
40 mg/day
Lansoprazole (Prevacid)
(15mg, 30mg)
30-60 mg/day
in divided doses
Metoclopramide (Reglan)
(5mg, 10mg)
40 mg/day
in divided doses
Gastroesophageal Reflux Disease (GERD) Medication Review
Physician focus for Evaluating and Treating GERD:
!
See patients diagnosed with GERD for office follow-up within 6 months of diagnosis.
Indicator: Percentage of adults diagnosed with GERD with a follow-up appointment within
6 months of diagnosis.
DeVault KR, Castell DO, and The Practice Parameters Committee of the American College of
Gastroenterology. Updated Guidelines for the Diagnosis and Treatment of Gastroesophageal Reflux
Disease. American Journal of Gastroenterology. 1999. 94:1434-1442.
Richter, JE. Gastroesophageal Reflux Disease. Current Practice of Medicine 1999. 2(12):2307-2315
Scott, M. and Gelhot, AR. Gastroesophageal Reflux Disease: Diagnosis and Management. American
Family Physician 1999. 59(5):1161-1171.
van Pinxteren B, Numans ME, Bonis PA, Lau J. Short-term treatment with proton pump inhibitors, H2-
receptor antagonists and prokinetics for gastro-oesophageal reflux disease-like symptoms and endoscopy
negative reflux disease (Cochrane Review). The Cochrane Library, 1, 2001. Oxford: Update Software.
Cochrane Library Abstracts http://www.update-software.com/cochrane/cochrane-frame.html
National Guideline Clearinghouse http://www.guidelines.gov/index.asp/
Diverticulosis and Diverticulitis
*Endoscopic exams and Barium Enema are NOT
recommended during acute phase of attack because of risk
of perforation.
**Can increase intracolonic pressure and worsen symptoms
No
Yes
Is patient stable
for outpatient
therapy?
Is diagnosis
certain?
No
Yes
Symptoms of acute
Diverticulitis
Physical exam, including
rectal and pelvic exams as
appropriate
Plain abdominal radiographs
(flat and upright)
Consider CXR, CBC, U/A, blood
cultures if indicated
Free
air on
XRAY?
Surgical consult
Yes
Clear liquid diet
Hold high-fiber foods
Broad spectrum antibiotics (see page 2)
No
IV Fluids
NPO/clear liquid diet
Broad spectrum IV antibiotics
(see page 2)
Avoid morphine for analgesia**
Good
response?
Continue conservative management.
Consider Barium enema and Sigmoidoscopy
or Colonoscopy in 10-14 days to corroborate
diagnosis and rule out other causes of
exacerbation.
High fiber diet after symptoms resolve
(see Nutrition Guide)
Yes
No
Consider CT scan
and/or
surgical consult
CT scan, Ultrasound (may be particularly
useful in female patients), or water-soluble
contrast enema*
Is
study
consistent
w/divertic-
ulitis?
Yes
No
Reconsider
diagnosis
Note: The majority of
cases of diverticulosis
are asymptomatic,
and the diagnosis is
usually made by
incidental discovery
on endoscopy or
barium enema.
High fiber diet (see Nutrition Guide)
Adequate fluid intake
Consider fiber supplements and/or stool softeners
Asymptomatic
(or non-acute
symptoms)?
Non-specific complaints:
chronic constipation
abdominal pain
fluctuating bowel habits
diarrhea and/or flatulence
LLQ abdominal pain
Physical exam, including rectal
exam, stool test for occult blood,
and pelvic exam for women.
Consider colonic imaging studies:
Contrast Barium Enema
Sigmoidoscopy
Colonoscopy
Yes
No
No Adequate
response to
outpt.
tx?
Yes
Abdominal pain (typically
LLQ but may be midline or
RLQ)
Leukocytosis
Fever
Palpable, tender mass
Nausea, vomiting,
constipation, diarrhea,
dysuria, or urinary
frequency
Diverticulitis page 2
Broad Spectrum Antibiotic Therapy for Acute Diverticulitis
Goal is for aerobic and anaerobic coverage--below is a list of possible medications
(and combinations) to meet this goal.
Recommended duration of intravenous and/or po therapy is 7-10 days.
Parenteral Options (choose one of the five listed options):
1) Metronidazole or Clindamycin
PLUS Aminoglycoside (e.g. gentamicin or tobramycin)
or 3rd generation Cephalosporin (e.g. ceftazidime, cefotaxime, ceftriaxone)
or Monobactam (e.g. aztreonam)
or
2) Piperacillin/Tazobactam
or
3) Ampicillin-sulbactam (e.g. Unasyn)
or
4) 2nd generation Cephalasporin (e.g. cefoxitin or cefotetan)
or
5) Ticarcillin/Clavulanate (Timentin)
Enteral Options (choose one of the three listed options):
1) Metronidazole or Clindamycin
PLUS Ciprofloxacin or TMP/SMZ DS BID
or
2) Augmentin
or
3)Trovafloxin
Bulk-forming over-the-counter agents:
Methylcellulose
Polycarbophil
Psyllium
Brand name OTC bulk-forming agents:
Alramucil
Citrucel
Cologel
Effer-syllium
Fiberall
Fibercon
Konsyl
Maltsupex
Metamucil
Mylanta Fiber Supplement
Reguloid
Physician focus for Evaluating and Treating Diverticulosis and Diverticulitis:
!
Select antibiotic therapy that covers BOTH anaerobic and aerobic bacteria.
Indicator: Percentage of adults diagnosed with diverticulitis and treated with one of the identified
broad-spectrum antibiotics or antibiotic combinations.

!
Select abdominal plain film XRAY and/or CT scan of the abdomen and/or Ultrasound of the
abdomen for diagnostic testing during early evaluation of symptoms.
Indicator: Percentage of adults receiving abdominal plain-film XRAY and/or CT scan of the
abdomen and/or Ultrasound of the abdomen within four days of initial diagnosis of acute
diverticulitis.

!
See patients diagnosed with diverticulitis for office follow-up within 6 months of diagnosis.
Indicator: Percentage of adults diagnosed with diverticulitis with a follow-up appointment within
6 months of diagnosis.
!
Perform appropriate confirmatory diagnostic evaluation following hospitalization for initial
diagnosis and treatment for acute diverticulitis (barium enema &/or sigmoidoscopy &/or
colonoscopy approximately 2 weeks after admission for acute diverticulitis).
Indicator: Percentage of adults who receive barium enema and/or sigmoidoscopy and/or
colonoscopy approximately two weeks after admission for acute diverticulitis.
!
Avoid invasive diagnostic procedures (e.g. sigmoidoscopy/colonoscopy, barium enema) during
evaluation of acute diverticulitis.
Indicator: Percentage of adults receiving a barium enema and/or endoscopic exam (colonoscopy
or sigmoidoscopy) during acute phase of diverticulitis.
Diverticular Disease of the Colon. In L.M. Tierney, Jr., S.J. McPhee, M.A. Papadakis (Eds.), CURRENT
Medical Diagnosis and Treatment 2000 (pp. 641-644). New York, NY: Lange Medical Books/McGraw-
Hill.
Ferzoco LB, et al. Acute diverticulities. N Engl J Med May 21, 1998; 338:1521-6.
Roberts P, Abel M, Rosen L, et al. (The Standards Task Force American Society of Colon and Rectal
Surgeons). Practice Paramenters for Sigmoid DiverticulitisSupporting Documentation. Diseases of the
Colon and Rectum 1995; 38(2): 125-32.
Stollman NH and Raskin JB, Diagnosis and Management of Diverticular Disease of the Colon in Adults
(Practice Guidelines). The American Journal of Gastroenterology 1999; 94(11): 3110-3121.
Available at www-east.elsevier.com/ajg/issues/9411/ajg1501fla.htm
Taylor TV. Diverticulitis. Current Practice of Medicine 1999; 2(12): 2422-2429.
The Cochrane Group www.update-software.com
Low Back Pain
Signs/Symptoms of
Acute Low Back
Pain
Comprehensive History
and Physical Exam
Are Critical
Exclusionary
Diagnoses
Present?
Initiate up to 4 weeks of conservative therapy, which may include:
Patient education
Activity modification
Oral medication (ie. NSAIDs)
Self-applied thermal modalities
Manual medicine modalities (as prescribed by Osteopathic or
Chiropractic physicians)
Consider referral
to appropriate
specialist for care
Repeat history.
Perform AP and lateral
spine XRAYS.
Are
symptoms
improved?
Continue useful
conservative measures,
perform exercise,
and return to regular
activity as appropriate.
Is
there a
neuro deficit
on exam OR are
X-rays
abnormal?
yes
Consider treatment modifications for an
additional four weeks:
Change oral analgesic
Manual medicine modalities
(as prescribed by Osteopathic
or Chiropractic physicians)
Consider the following clinical pictures
and consider referral to appropriate
specialist:
Are
symptoms
improved
?
no
Herniated Nucleus Pulposus:
young patient (20-50 years)
predominant leg pain
with or w/o neuro deficit
tension signs present
Unremitting
Low Back Pain:
Spinal Stenosis:
patients over 50 years
variable neurologic findings
leg pain and/or back pain
that is increased with
upright posture
Spondylolysis or
Lytic Spondylolisthesis or
Degenerative
Spondylolisthesis/Stenosis:
Mild or moderate
Pain control and
exercise training
back first aid
oral or
epidural
corticosteroids
joint mobility
stabilization
Clinically severe
or poor response
Order confirmatory
studies:
MRI
CT
myelogram
electrodiagnostic
studies
Consider confirmatory
studies:
MRI
CT
myelogram
electrodiagnostic
studies
bone scan
psychological eval
Rule out instability
or neurological
deficit.
Consider non-
operative options:
NSAIDs
trial of bracing
1-3 injection
program
Active exercise
treatment
psych eval
If severe symptoms or
poor response to non-
operative tx, consider
confirmatory studies:
MRI
CT
myelogram
Acute Low Back Pain:
pain does not radiate past the knee
duration of symptoms <6 weeks
Critical Exclusionary Diagnoses:
Cauda equina syndrome
Progressive neurological deficit
Fracture
Neoplasm
Infection
Chronic pain syndrome
Persistent pain resulting from
previous spinal surgery
Extra-spinal conditions
Counsel patient and consider surgical options if:
Poor response to conservative measures and/or
Pathology found on confirmatory studies suggest surgical treatment and
correlate with clinical symptoms
yes
no
yes no
no
yes
Low Back Pain Page 2
Table 1 Differential Diagnosis of Back Pain (adapted from University of Michigan Health System
Guideline)
Systemic Causes Dangerous local causes of
back pain
Local pathology that mimics
radiating low back pain
Aortic aneurysm
Renal infection
Renal calculi
Peritonitis
Tumors
Subacute bacterial endocarditis
Metabolic disorders
!
Porphyria
!
Sickle cell disease
!
Renal osteodystrophy
Seronegative spondylitic arthritis:
!
Ankylosing spondylitis
!
Reiters syndrome
!
Arthritis of ulcerative colitis
!
Psoriatic arthritis
Other arthritis:
!
Diffuse Idiopathic Skeletal
!
Hyperostosis (DISH)
!
Schuermans epiphisitis
!
Rheumatoid arthritis-uncommon
Connective tissue disorders:
!
Marfans syndrome
!
Ehlers-Danlos syndrome
Myopathy
Inflammatory radiculopathy
Tumor
Disk space infection
Epidural abscess
Fractures
Osteoporosis with fracture
Disk herniation
Spinal Stenosis
Spondylolisthesis
!
Congenital
!
Isthmic
!
Degenerative
!
Traumatic
!
Tumor related
Failed back surgery syndrome
Arachnoiditis
Osteoarthritis of the hip
Aseptic necrosis of the femoral head
Sciatic nerve injury due to pressure,
stretch or piriformis muscle
entrapment
Cyclic radiating low back pain
endometriosis on the sciatic nerve/
sacral plexus
Intrapelvic massesbenign or
malignant
Peroneal (fibular) nerve entrapment at
the fibular head
Sacroiliac joint dysfunction
Facet joint syndrome
Internal disk disruption
Gordon Waddels five non-organic pain signs
1. Overreaction during the exam
2. Simulated testing--pain with axial loading or rotation of the pelvis and
shoulders in the same plane
3. Distracted testing--test straight leg raise while distracted when sitting.
4. Superficial, non-anatomical or variable tenderness. When skin rolling
over the back markedly increases the pain
5. Non-anatomical motor or sensory disturbances. Positive when sensory
loss does not follow a dermatome or entire leg is numb or without stretch
or when there is a ratchety giveway on strength testing.
Presence of two or more of these findings correlates with poor surgical
outcome, but not rehabilitation outcome. Patient is at risk for becoming
chronically disabled. Should not be interpreted as specific for malingering.
Physician focus for Evaluating and Treating Acute Low Back Pain
!
Prescribe a conservative treatment plan for patients with Acute Low Back Pain before ordering
diagnostic radiological studies (unless critical exclusionary diagnoses are present).
Indicators:
Percentage of patients with low back pain receiving AP or lateral x-rays.
Percentage of patients with low back pain receiving MRI or CT.
American Academy of Orthopaedic Surgeons/North American Spine Society (AAOS/NASS) Spine
Algorithm Task Force. Clinical guideline on low back pain. Released 1996. Accessed at the National
Guideline Clearinghouse, http://www.guidelines.gov/index.asp/ (2001, February 20)
Hagen KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute low back pain and sciatica (Cochrane
Review). In: The Cochrane Library, 1, 2001. Oxford: Update Software
Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Adult Low Back Pain.
November 1999. http://www.icsi.org/guidelst.htm/ (2001, February 20)
Low Back Pain Syndrome (LBP). http://www.dynamicmedical.com/ (2001, February 20)
Marcus DA. Treatment of Nonmalignant Chronic Pain. Am Fam Physician 2000;61:1331-8, 1345-6.
Tulder MW van, Scholten RJPM, Koes BW, Deyo RA. Non-steroidal anti-inflammatory drugs for low
back pain (Cochrane Review). In: The Cochrane Library, 1, 2001. Oxford: Update Software.
Research. (1994, December). Acute Low Back Problems in AdultsClinical Practice Guideline Number
14. Retrieved from http://www.ahrq.gov/
Research. (1993, February). Acute Pain Management In Adults: Operative ProceduresQuick Reference
Guide for Clinicians No. 1a. Retrieved from http://www.ahrq.gov/
University of Michigan Health System. (1997, November) Guidelines for Clinical CareAcute Low
Back Pain. http://cme.med.umich.edu/iCME/default.asp (2001, February 26)
University of Washington Physicians. Acute Low Back Limitation Guidelines.
http://healthlinks.washington.edu/guideline/alb/processes.html/
Well Close Square rheumatology resource: the back examination. (Online).
http://www.wellclosesquare.co.uk/rheum/back.htm/ (2001, February 26)
Carpal Tunnel Syndrome
Symptoms of Median
Nerve Compression
Focused History
and
Physical Exam
Is
thenar
weakness or
wasting present?
yes
no
Follow up in
2 weeks
Perform laboratory evaluation,
as indicated by history and
physical exam (see page 2)
Metabolic
cause for
symptoms?
yes
no
Treat any metabolic
cause for symptoms
2-6 week trial of conservative therapy:
Patient education
Activity modification/alter aggravating factors
(may include ergonomic modifications at workplace)
Neutral-position splinting (full time)
Analgesics (NSAIDS if not contraindicated)
Manual medicine modalities (as prescribed by
Osteopathic or Chiropractic physicians)
Good
response?
yes
No
Continue conservative
management; patient
may resume normal
activities as tolerated.
CONSIDER the following diagnostic and
therapeutic options:
Physical therapy for flexibility, mobility,
and strength
Corticosteroid injection
Alternative NSAID
Manual medicine modalities (as prescribed
by Osteopathic or Chiropractic physicians)
Consider specialist
referral AND/OR
additional
diagnostic testing
(see page 2)
Good
response?
no
yes
HISTORY:
Family or personal history of
diabetes
thyroid
connective tissue diseases
Pregnancy
History of trauma
Occupational history
Hobbies
Change in the level of activity
PHYSICAL EXAM (may be normal):
Regional exam
Cervical spine and upper extremities exam
Tinel test
Phalen test
Thumb abduction strength testing
Proximal compression test at elbow
parasthesia and/or mild pain in the
distribution of the median nerve
(palmar side of thumb, index, middle
and part of ring finger and generally
excludes the little finger)
intermittent or constant pain
weakness or clumsiness of the hand
aggravation of pain during sleep
(see page 2 for Differential Diagnosis)
may have improvement of symptoms
with shaking or massaging the hand
CTS Page 2
Differential Diagnosis for Carpal Tunnel Syndrome:
Cervical Radiculopathy (especially C7)
Angina pectoris
deQuervains tenosynovitis
Complex regional pain syndrome (aka Reflex Sympathetic Dystrophy)
Osteoarthritis
Rheumatoid arthritis
Brachial plexopathy
Proximal median neuropathy
Peripheral neuropathy
Vascular or neurogenic thoracic outlet syndrome
Central disorders such as multiple sclerosis and cerebral infarction
Diagnostic Testing for Carpal Tunnel Syndrome:
Depending on the presenting symptoms and/or response to conservative management, consider:
Laboratory testing:
TSH
pregnancy test
blood sugar
Imaging (radiography or magnetic)
wrist
cervical spine
chest
Electrophysiology
Electromyography (EMG)
Nerve conduction studies (NCS)
Further endocrine, hematologic, or neuropathy evaluation as indicated.
Potential Aims for Medical Groups When Using this Carpal Tunnel Syndrome Guideline:
!
Request patient to follow-up in office within two months of initial diagnosis of carpal tunnel
syndrome.
Indicator: Percentage of adults diagnosed with carpal tunnel syndrome who have a follow-up
appointment within two months.
!
Treat all patients with carpal tunnel syndrome (without thenar weakness/wasting and without
metabolic cause for CTS) with neutral-position wrist splinting.
Indicator: Percentage of adults receiving a wrist splint at the time of initial diagnosis.
!
Attempt a trial of conservative management for all patients with carpal tunnel syndrome
(without thenar weakness/wasting and without metabolic cause for CTS) before ordering an
EMG or nerve conduction study.
Indicator: Percentage of adults with carpal tunnel syndrome undergoing EMG or nerve
conduction study that have had at least one prior claim for diagnosis of carpal tunnel syndrome (or
hand parasthesias, etc.) by their PCP during the six months prior to diagnosis.
American Academy of Orthopedic Surgeons (AAOS) Task Force on Clinical Algorithms; AAOS
Committee on Clinical Policies. Clinical guideline on wrist pain. 1999. Accessed at the National
Guideline Clearinghouse, http://www.guidelines.gov/index.asp/
American Society of Plastic Surgeons (ASPS). Carpal tunnel syndrome. Released Jan 24, 1998. Accessed
at the National Guideline Clearinghouse, http://www.guidelines.gov/index.asp/
DArcy CA, McGee S. Does This Patient Have Carpal Tunnel Syndrome? (The Rational Clinical Exam)
JAMA 2000;283(23):3110-3117.
Novak LM. Carpal Tunnel Syndrome (Protocol). Lippincotts Primary Care Practice 2000;4(6):642-648.
Report of the Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter
for carpal tunnel syndrome (summary statement). Neurology 1993;43:2406-2409.
Walker WC, et al. Neutral wrist splinting in carpal tunnel syndrome: a comparison of night-only versus
full-time wear instructions. 2000;81:424-9.
Cochrane Library Abstracts http://www.update-software.com/cochrane/cochrane-frame.html
National Guideline Clearinghouse http://www.guidelines.gov/index.asp/
Uncomplicated Acute Bronchitis
Symptoms suggestive of
acute bronchitis
Focused history and
physical exam
Viral Bronchitis Bacterial Bronchitis Bronchitis associated with
Influenza?
Cough with/without phlegm
Cough lasting <3 weeks
Sore throat
Rhinorrhea
Minimal/no change in breath sounds
Low-grade fever
Malaise
Purulent sputum,
high fever, chills,
systemic
symptoms?
Epi-link to case?
Seasonal, high
fever, chills,
systemic
symptoms?
Severe
symptoms or
suspected
pneumonia?
Obtain Chest X-Ray
Chest X-ray
shows
infiltrates?
Pneumonia diagnosis
Treat
(See Community -
Acquired Pneumonia
Guideline)
Symptomatic treatment
Cough suppressants
Acetaminophen or aspirin
Antibiotic treatment only if
strong indication of bacterial
infection, using narrow-spectrum
agents:
erythromycin
tetracycline
Patient education
Increase fluids
Adequate rest
Avoid smoking or quit
Cough suppressants
Acetaminophen or aspirin
Bronchodilators for patients
with asthma or COPD
Explain rationale for no antibiotic
treatment
Patient education
Increase fluids
Adequate rest
Cough suppressants
Acetaminophen
Antiviral agents
amantadine (flu - A)
rimantadine (flu- A)
zanamivir (flu - A/B)
oseltamivir (flu - A/B)
Explain rationale for no
antibiotic treatment
Patient education
Increase fluids
Adequate rest
Follow-up if symptoms worsen
Administer flu vaccine annually to all persons at increased
risk of complications
Differential Diagnosis:
Community-Acquired Pneumonia
Influenza
Pertussis
Asthma
Tuberculosis
Cystic fibrosis
Lung cancer
GERD
Medication-induced cough
Bronchitis treatment considerations:
Self-limited infection of bronchial tree
Characterized by pronounced cough
Treatment focus is the management of cough and associated symptoms
Usually viral in origin
Antibiotic therapy recommended only when bacterial component suspected
Determine presence of underlying immune compromise or coexisting
diseases (i.e., pneumonia, cystic fibrosis, COPD, heart failure)
Bronchitis treatment considerations:
Self-limited infection of bronchial tree
Characterized by pronounced cough
Treatment focus is the management of cough and associated symptoms
Usually viral in origin
Antibiotic therapy recommended only when bacterial component suspected
Determine presence of underlying immune compromise or coexisting
diseases (i.e., pneumonia, cystic fibrosis, COPD, heart failure)
History:
Signs and symptoms of cough
Exposure to persons with similar symptoms
Exposure to irritants and allergens
Underlying immune compromise or coexisting disease (i.e. heart
failure, cardiopulmonary disease, cystic fibrosis)
Physical Exam:
Assess severity and nature of cough and breathing
Pharyngeal inflammation, postnasal drip
Inspect sputum for evidence of purulence
Perform complete chest exam
Lab tests are not indicated for otherwise healthy adults
PPD skin test for persons at increased risk of TB
Chest film - only if severe symptoms or pneumonia suspected
Bronchoscopy - only if patient is severely immunocompromised, and
biopsies and/or special cultures are required to guide therapy (i.e.
presence of unusual pathogen or patient fails to respond to treatment)
History:
Signs and symptoms of cough
Exposure to persons with similar symptoms
Exposure to irritants and allergens
Underlying immune compromise or coexisting disease (i.e. heart
failure, cardiopulmonary disease, cystic fibrosis)
Physical Exam:
Assess severity and nature of cough and breathing
Pharyngeal inflammation, postnasal drip
Inspect sputum for evidence of purulence
Perform complete chest exam
Lab tests are not indicated for otherwise healthy adults
PPD skin test for persons at increased risk of TB
Chest film - only if severe symptoms or pneumonia suspected
Bronchoscopy - only if patient is severely immunocompromised, and
biopsies and/or special cultures are required to guide therapy (i.e.
presence of unusual pathogen or patient fails to respond to treatment)
Yes
Yes
Yes
Yes
Physician focus for Evaluating and Treating Acute Bronchitis
!
For patients with diagnosis of uncomplicated acute bronchitis, consider antibiotic treatment using first-
line agents.
Indicator: Percentage of patients diagnosed with uncomplicated acute bronchitis with pharmacy claims
data for first-line agents (i.e. erythromycin or tetracycline).
Indicator: Percentage of patients with uncomplicated acute bronchitis with pharmacy claims data for
second-line agents (i.e. clarithromycin, ofloxin).
!
For patients at increased risk of complications from influenza (i.e.
(
50 years, residents of chronic care
facilities, those with cardiovascular or pulmonary disorder, and those with a chronic metabolic disorder),
administer yearly flu vaccination.
Indicator: Percentage of patients at increased risk of complications of influenza receiving a flu shot
within the measurement year.
Chow AW. Acute bronchitis. Best Practices of Medicine (200,May). Available online:
http://praxis.md/index.asp?page=bpm. Accessed May 11, 2001.
Snow V, Mottur-Pilson C, Gonzales R. Principles of appropriate antibiotic use for treatment of acute
bronchitis in adults. Annals of Internal Medicine 2001;134:518-520.
Becker L, Glazier R, McIsaac W, et al.: Antibiotics for acute bronchitis. Oxford: Update Software Cochrane
Library. 1999.
Hafner J-P, Ferro TJ. Acute bronchitis in adults: A modern approach to management. Hospital Medicine.
1998;34(8):41-50.
Community-Acquired Pneumonia(CAP)
Patient education
Explain rationale for no antibiotic treatment
Follow-up if symptoms worsen
Symptoms suggestive
of Community Acquired
Pneumonia
Chest
x-ray shows
infiltrate?
yes
no
yes
Follow-up:
By telephone 24-48 hours
In office 6-8 weeks (consider
f/u CXR to confirm resolution)
1st line antibiotics:
amoxicillin/Clavulanate
+ macrolide*, OR
Cefuroxime axetil/
cefpodoxime/cefprozil
+ macrolide*, OR
fluoroquinolones
*add a macrolide if there is a
reasonable likelihood of an
atypical agent causing the
pneumonia
yes
Pneumonia
Severity Index
(PSI) < 91
points?
Pneumonia diagnosis--
calculate Pneumonia
Severity Index (PSI)
(see box below)
Drug
intolerance?
no
2nd line atibiotics:
fluoroquinolones
yes
1st line antibiotics:
macrolide or
doxycycline
no
CAP SYMPTOMS MAY
INCLUDE:
rigors
pleuritic chest pain
shortness of breath
chest tightness
deep cough
sputum production
fever >100
0
F or lasting >72 hours
night sweats
wheezing
Obtain chest x-ray, especially if patient
has two or more of these signs:
Temp >100
0
F (37.8
0
C)
Pulse > 100
Decreased breath sounds
Rales
Respiratory rate > 20
Comorbidities
or clinical status
suggest treatment
of LRTI?
Chest
x-ray suggests
non-infectious
process?
yes yes
Out of guideline
Treat with macrolide,
doxycycline, or
TMP/SMX
no no
Patient education
Criteria for follow-up
Home care
Smoking cessation
Antibiotics
Return to function/work
Secondary prevention
Contagion and recurrence
Influenza/pneumococcal vaccine
Hospitalization
(out of guideline)
no
Age
>50 years?
Pneumonia Severity Index (PSI)
Score = total points accumulated below
Demographic Factors
Age Males age(yrs)
Females age(yrs) -10
Nursing Home Resident +10
Comorbid Illnesses
Neoplastic disease +30
Liver disease +20
Congestive heart failure +10
Cerebrovascular disease +10
Renal disease +10
Physical Examination Findings
Altered mental status +20
Respiratory rate ( 30/minute +20
Systolic BP<90mmHg +15
Temperature <95F(35C)or (104)F(40C) +15
Pulse ( 125/minute +10
Laboratory Findings
pH<7.35 +30
BUN ( 30mg/dL(11mmol/L) +20
Sodium < 130mEq/L +20
Glucose > 250mg/dL(14mmol/L) +10
Hgb<9gm (Hematocrit<30%) +10
PO
2
< 60mmHg(O
2
sat<90%)* (room air) +10
Pleural effusion +10
*patients with these findings may warrant
hospitalization despite their risk classification.
Criteria for follow up:
difficulty breathing
worsening cough
worsening or onset of rigors
fever persisting >48 hours
medication intolerance
Note: some patients with
psychosocial and economic
considerations, but a PSI
score <91 may also require
hospitalization.
Physician focus for Evaluating and Treating Community Acquired Pneumonia (CAP):
!
For adults < 50 y/o diagnosed by CXR with CAP and treated as an outpatient, prescribe a
macrolide, doxycycline, or TMP/SMX as first-line antibiotic choice (unless contraindicated or
not tolerated)
Indicator: Percentage of adults with CXR-confirmed diagnosis of CAP < 50 years old treated as
an outpatient with a macrolide or doxycycline.
!
For adults > 50 y/o diagnosed by CXR with CAP and treated as an outpatient, prescribe
amoxicillin/clavulanate or cefuroxitime axetil/cefpodoxime/cefprozil (with or without a
macrolide), or a fluoroquinolone for first-line antibiotic choice.
Indicator: Percentage of adults with CXR-confirmed diagnosis of CAP > 50 years old treated
with amoxicillin/clavulanate or cefuroxitime axetil/cefpodoxime/cefprozil (with or without a
macrolide), or a fluoroquinolone.
!
Counsel patients diagnosed with CAP regarding smoking cessation.
Indicator: Percentage of adults diagnosed with CAP who receive smoking cessation education, as
documented in the medical record (or billing charges).
Bartlett JG, Dowell SF, Mandell LA, File TM, Musher DM, Fine MJ. Practice Guidelines for thr
Management of Community Acquired Pneumonia in Adults. Clinical Infectious Diseases 2000;31:347-82.
Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, Coley CM, Marrie TJ, Kapoor
WN. A Prediction Rule to Identify Low-Risk Patients with Community-Acquired Pneumonia. N Engl J
Med 1997;336(4):243-50.
Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Community-Acquired
Pneumonia. July 2000. http://www.icsi.org/guidelst.htm/ (2001, April 17)
Marras TK, Gutierrez C, Chan CK. Applying a Prediction Rule To Identify Low-Risk Patients With
Community-Acquired Pneumonia. Chest 2000;118(5):1339-1343.
Marrie TJ, Lau CY, Wheeler SL, Wong CJ, Vandervoort MK, Feagan BG. A Controlled Trial of a Critical
Pathway for Treatment of Community-Acquired Pneumonia. JAMA 2000;283(6):749-755.
Moola S, et al. A multicenter study of grepafloxacin and clarithromycin in the treatment of patients wit
community-acquired pneumonia. CHEST 1999;116:974-83.
Additional definitions from the Pneumonia Severity Index (PSI):
Neoplastic disease - any cancer, except basal or squamous cell carcinoma of the
skin active at the time of presentation or within one year of presentation.
Liver disease- clinical or histological cirrhosis or chronic active hepatitis.
CHF - documented with history, physical exam or CXR findings; echo, MUGA; or
left ventriculogram.
CVD - clinical diagnosis of stroke or TIA; or documented stroke on CT or MRI.
Renal disease- chronic renal disease; or abnormal BUN or creatinine.
CAP (Page 2)
S E V E R I T Y D E S C R I P T I O N / D E F I N I T I O N
Asthma
Establish a diagnosis of
asthma:
complete a thorough
history and
examination
obtain spirometry
Symptoms of Asthma
Mild intermittent:
$symptoms < 2 times a week
$asymptomatic and normal
PEF between exacerbations
$exacerbations are brief (few
hours to a few days)
$nighttime symptoms < 2 times
a month
$FEV1/FVC > 80 percent
predicted and
$PEF variability < 20 percent
History and physical
Assess asthma triggers/allergens
Measure pulmonary function
spirometry - pre- and post- bronchodilator
PEFR(designed as monitoring, not
diagnostic tool)
Consider consultation and/or allergy testing,
particularly in children, as allergy vaccinations may
prevent worsening of asthma
Assess asthma severity
Treat and educate accordingly
Asthma symptoms may include:
wheezing
breathlessness
cough, productive or dry
chest discomfort
nocturnal cough
history of persistent respiratory tract
infections
Conditions associated with asthma (e.g.
nasal polyps, rhinitis, atopic dermatitis)
Previous
diagnosis of
asthma?
yes
no
Indications for emergency care:
Peak flow less than 50% predicted normal
Failure to respond to a "2-agonist
Severe wheezing or coughing
Extreme anxiety due to breathlessness
Gasping for air, sweaty, or cyanotic
Rapid deterioration over a few hours
Severe retractions and nasal flaring
Hunched forward
NOTE: this guideline does not include treatment of
patients requiring hospital care
Mild Persistent:
$symptoms > 2 times a week but
< 1 time a day
$exacerbations may affect
activity
$nighttime symptoms > 2 times a
month
$FEV1/FVC > 80 percent
predicted and
$PEF variability 20-30 percent
Moderate Persistent:
$daily symptoms
$daily use of inhaled short-
acting beta2-agonist
$exacerbations affect activity
$exacerbations > 2 times a
week; may last days
$nighttime symptoms > 1 time a
week
$FEV1/FVC > 60 percent - < 80
percent predicted
$PEF variability > 30 percent
Severe Persistent:
$continual symptoms
$limited physical activity
$frequent exacerbations
$frequent nighttime symptoms
$FEV1/FVC < 60 percent
$PEF variability > 30 percent
Step 1 actions:
Teach basic facts about asthma
Teach inhaler/spacer technique
Discuss roles of medications
Develop self-management plan
Develop action plan for when
and how to take rescue actions
Discuss appropriate
environmental control measures
to avoid exposure to known
triggers
Step 2 actions:
Step 1 actions plus:
Teach self-monitoring
Refer to group education if
available
Review and update self-
management plan
Step 3 actions:
Same as step 2 actions
Step 4 actions:
Step 2 and 3 actions plus:
Refer to individual
education/counseling
Acute rescue:
$Inhaled "2 -agonist, prn, BUT
< 1/week
$Inhaled "2 -agonist,
cromolyn, or nedocromil before
exercise or allergen exposure
$With viral infection:
Inhaled "2 -agonist q4-6
hrs up to 24 hours (longer with
physician consult) but no more
than once every 6-8 weeks.
Systemic corticosteroid if
severe attack or history of severe
attacks with infection
If flares occur more often
than every 6 weeks, seek
consultation
Long-term prevention:
$None needed
$Spirometry every 1-2 years in
every patient; more often in
unstable patients
Acute rescue:
$Short-acting bronchodilator:
inhaled "2 -agonist as needed for
symptoms, not to exceed 3-4x/dy
Daily medications:
$Anti-inflammatory: either
inhaled corticosteroid, 200 mcg,
cromolyn sodium, or nedocromil
(children usually begin with trial
of cromolyn or nedocromil).
$SR theophylline to serum
concentration of 5-15 mcg.mL is
an alternative, but NOT preferred
therapy.
$Zafirlukast or zileuton may be
considered for pts. > 12 y.o.
$Montelukast may be used in pts.
> 6 y.o.
unstable patients
Acute rescue:
$IF increased "2 -agonist use,
may need to increase anti-infl tx.
Daily medications:
$Anti-inflammatory: inhaled
corticosteroid (med. dose) OR
Inhaled corticosteroid AND
long-acting bronchodilator, esp.
for nighttime symptoms ("2 -
agonist, SR theo, or long-acting
"2 tablets) (inhaled preferred)
If needed:
corticosteroids (med-high dose)
AND Add a long-acting
bronchodilator, esp. for nighttime
symptoms ("2 -agonist, SR theo,
or long-acting "2 tablets)
unstable patients
Acute rescue:
$IF increased "2 -agonist use,
may need to increase anti-infl tx.
Daily medications:
corticosteroid (800-2000 mcg/d)
AND
$Long-acting bronchodilator:
either long-acting inhaled "2 -
agonist, sustained release (SR)
theophylline, or long-acting "2 -
agonist tablets (inhaled preferred)
AND
$Coticosteroid tablets or syrup
long term (2 mg/kg/day, max 60
mg/day)
unstable patients
E D U C A T I O N
A C U T E A N D L O N G - T E R M T R E A T M E N T S
Schedule regular follow-up appointments
Asthma page 2
Tobacco smoking
Passive tobacco, wood-
burning stove, or
fireplace smoke
Gastroesophageal
reflux
Sulfites
Exercise
Cold Air
Pollutants
!
Air pollutants
!
Occupational
exposures
Medications
!

"
-blockers
!
Aspirin
!
NSAIDs
Outdoor allergens
!
Pollens
!
Fungi
Respiratory tract
infections
!
Viral URI illnesses
!
Sinusitis
!
Bronchitis
Indoor allergens
!
Domestic mites
!
Animal allergens
!
Cockroach allergens
!
Fungi
Adapted from Gross and Ponte article and UMHS guideline
Common Asthma Triggers:
Problem FEV1 FVC FEV1/FVC%
Obstructive
disease
Decreased Normal or
decreased
Decreased
Restrictive
disease
Decreased or
normal
Decreased Normal or
increased
Reversible
disease
Increased by 12 to
15 percent after
administration of
bronchodilator*
FEV1=forced expiratory vlume in one second; FVC=forced vital capacity;
FEV1/FVC%=FEV1 as percentage of FVC
*Increased in comparison with the baseline FEV1 measurement before the
bronchodilator was administered.
Adapted from Gross and Ponte article.
Interpreting Spirometry:
Referral is recommended when:
Life threatening asthma exacerbations
Is not meeting treatement goals, or unresponsive to therapy
Atypical signs and symptoms
Complicating comorbidities (e.g. sinusitis, nasal polyps, vocal cord dysfunction, COPD)
Additional diagnostic testing indicated
Additional patient education/guidance needed
Immunotherapy considered
Patient has severe persistent asthma
Patient requires continuous oral corticosteroid therapy or high-dose inhaled corticosteroids
Patient is under age 3
Confirmation of history that suggests occupational or environmental inhalant or ingested
substance causing asthma.
General Guidelines for Referral to an Asthma Specialist:
Physician focus for managing patients with asthma:
!
Prescribe anti-inflammatory medication to all patients with persistent asthma.
Indicator: Percentage of patients with persistent asthma with prescriptions for an anti-
inflammatory medication.
!
Monitor patients for overuse of
"
-agonist medication and re-evaluate/educate patient.
Indicator: Percentage of patients with greater than three MDIs filled at pharmacy in a 3 month
period.
!
Utilize objective measures (spirometry or peak flow) for accurate assessment of lung function.
Indicator: Percentage of patients with asthma with spirometry or peak flow documented in the
medical record at the last visit.
!
Educate patients, including an asthma action plan.
Indicator: Percentage of patients with asthma with an asthma action plan in the medical record.
documented in their chart at the last visit.
!
Counsel patients diagnosed with asthma regarding smoking cessation.
Indicator: Percentage of adults diagnosed with asthma who receive smoking cessation education,
as documented in the medical record (or billing charges).
Expert Panel Report 2: Guidelines for the Diagnosis and management of Asthma. National Institutes of
Health. National Heart, Lung, and Blood Institute. NIH Publication No. 97-4051. July 1997
Green L, et al (Asthma Guideline Team). UMHS Asthma Guideline. University of Michigan Health
System. January 2000. http://cme.med.umich.edu/iCME/default.asp (2001, April 17)
Gross KM and Ponte CD. New Strategies in the Medical Management of Asthma. Am Fam Phys
1998;58(1):89-108.
Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Diagnosis and Management of
Asthma. June 2000. http://www.icsi.org/guidelst.htm/ (2001, April 17)
www.aafp.org
www.icsi.org
www.nhlbi.nih.gov
Depression
Symptoms or
presentation suggestive
of Depression
yes
Involve mental health
services/professionals
somewhat
Secondary
cause?
Major
depression?
no
Discuss treatment options with patient:
psychotherapy
pharmacotherapy
both
Consider severity of symptoms, presence
of psychosocial stressors, and presence of
co-morbid conditions
yes
Consider other mood
and anxiety disorders
or somatoform
disorders
no
DEPRESSION SYMPTOMS
AND PRESENTATION MAY
INCLUDE:
multiple (>5/year) medical visits
multiple unexplained symptoms
sleep disturbances
multiple worries or distress
work or relationship dysfunction
fatigue
emotionally flat
tearful
Interview for key symptoms of depression:
Are you often sad, down, blue or teary?
Do you have your usual interest in and
look forward to enjoyable activities?
Are you able to have fun or joy?
How are you sleeping?
How is your appetite?
How is your energy level?
Is patient
accepting of
diagnosis and
interested in
treatment?
Are
key symptoms
present?
yes
Depression likely
not present
Evaluate for secondary causes of
depression, including:
Psychosocial stressors (e.g. death of a
loved one, job change, abuse, divorce)
Medical illness (e.g. cancer, thyroid
disease, stroke)
Medications and withdrawal from
medications (e.g. steroids, propanolol,
hormonal therapy, reserpine, alpha-
methyldopa)
Current substance abuse or withdrawal
(e.g. alcohol, sedatives, anxiolytics,
hypnotics, amphetamines)
See CAGE (AID) screen on page 2
no
Complete evaluation and diagnosis:
DSM-IV criteria (see page 2)
History of present illness (onset,
severity, previous episodes, stressors)
Pertinent medical history
History of substance abuse
Psychiatric co-morbidity (e.g., mania)
Address secondary
cause and reevaluate
Is patient suicidal or homicidal?
Is patient psychotic?
Is patients ability to function
significantly impaired?
See page 2 for assessment of
suicidality
yes
no
Emergency?
yes
Schedule follow-up
appointment and
reevaluate
Refer to psychotherapy
and/or
Initiate pharmacotherapy
(see page 2)
Follow-up in 4-6 weeks
Are
symptoms
improving?
Continue treatment
Pharmacotherapy: consider
adjusting dose
Psychotherapy: consider
augmenting with medical
therapy
Augment or change
treatment
Consider referral
no
Assess response in 4-6 weeks
very much
Select pharmacotherapy based
upon side-effect profiles, past
medical history, and patient
lifestyle
These guidelines are intended for
use in the primary care setting
Emergency may include:
Suicidal thoughts/plans
Assaultive or homicidal thoughts/plans
Psychosis
Significant ongoing inability to work and care for self/family
no
Depression page 2
CAGE(AID) Screen
Have you ever:
C felt you ought to cut down on your
drinking or drug use?
A had people annoy you by criticizing your
drinking or drug use?
G felt bad or guilty about your drinking or
drug use?
E had a drink or used drugs as an eye
opener first thing in the morning to
steady your nerves or get rid of a hang
over or to get the day started?
If substance abuse is present or suspected, consider
referral for chemical dependency assessment.
Major Depressive Episode--DSM IV Criteria
Must have a total of five symptoms for at least two weeks.
One of the symptoms must be depressed mood or loss of interest.
Depressed mood.
Markedly diminished interest or pleasure in all or almost all activities.
Significant (>5% body weight) weight loss or gain or decrease or increase in appetite.
Insomnia or hypersomnia.
Psychomotor agitation or retardation.
Feeling of worthlessness or inappropriate guilt.
Diminished concentration or indecisiveness.
Recurrent thoughts of death or suicide.
Treatment
(Patient Education Considerations)
Both pharmacologic and non-pharmacologic
interventions may be effective depending on the
severity of symptoms. For antidepressant
medications, compliance with a therapeutic dose is
more important than the specific drug selected. The
following educational messages may increase
adherence:
Take the medication daily.
Antidepressants must be taken for two to four
weeks for a noticeable effect.
Continue to take medicine even if feeling better.
Do not stop taking antidepressant without checking
with your provider.
Contact your provider if you have questions about
your medication.
Referral to Psychiatrist
Consider psychiatric consultation for patients with:
History of mania or psychosis
Condition not responding to trials of one or two
medications
Need for combination therapy
Immediate psychiatric evaluation is necessary if
patient may harm themselves or others.
Physician focus for management of depression:
!
Increase the detection and diagnosis of depression in primary care through application of
specific criteria.
Indicator: Percentage of adults complaining of depression containing documentation of DSM-IV
criteria at the time of initial diagnosis.
!
Increase screening for depression in patients with somatic complaints.
Indicator: Percentage of adults complaining of fatigue or sleep disorder who have documentation
of screening for depression.
!
Follow-up patients with newly diagnosed depression within 6 weeks of initial diagnosis.
Indicator: Percentage of adult patients newly diagnosed with depression who have a follow-up
appointment within 6 weeks.
Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Major Depression, Panic
Disorder and Generalized Anxiety Disorder in Adults in Primary Care. March 1999.
http://www.icsi.org/guidelst.htm/ (2001, April 17)
Schulberg HC, Katon W, Simon GE, Rush AJ. Treating Major Depression in Primary Care Practice: An
Update of the Agency for health Care Policy and Research Practice Guidelines. Archives of General
Psyciatry 1998;55(12):1121-1127
Schwenk T and Terrell L et al (Depression Guideline Team). UMHS Depression Guideline. University of
Michigan Health System. January 2000. http://cme.med.umich.edu/iCME/default.asp (2001, April 17)
University of Washington Physicians. Major Depressive Disorder Guidelines. c. 2001
http://healthlinks.washington.edu/guideline/depr/ (2001, April 17)
Whooley MA, Simon GE. Primary Care: Managing Depression in Medical Outpatients. New England
Journal of Medicine 2000;343(26):1942-1950.
American Academy of Family Practice: www.aafp.org
Institute for Clinical Systems Improvement: www.icsi.org
University of Michigan Health Systems: http://cme.med.umich.edu/iCME/default.asp
University of Washington Physicians: http://healthlinks.washington.edu/guideline/depr/
Agency for Healthcare Research and Quality: http://text.nlm.nih.gov
American Medical Association: www.ama-assn.org/consumer/specond.htm
National Depressive and Manic-Depressive Association: www.ndmda.org
National Foundation for Depressive Illness: www.depression.org
National Mental Health Association: www.nmha.org/ccd
Psychology Information Hotline: www.psychologyinfo.com/depression
Screening and Diagnosis of Type 2 Diabetes
*Impaired glucose tolerance: 2 hour glucose >140 mg/dl and <200
mg/dl. Impaired fasting glucose: FBS > 110 mg/dl and <126 mg/dl
Repeat
Screening
every 3 years
Diagnosis:
Impaired
Glucose
Tolerance
Discuss with
patient diet,
exercise,
weight loss
Re-evaluate
3-12 months.
A
See treatment goals
Asymptomatic, undiagnosed Patient meets > 1 risk factor for Diabetes
Risk factors for diabetes:
Over age 45 years
Obese (> 120% desirable body weight or a BMI > 27kg/m
2
)
Family history of diabetes
High risk ethnic population including Hispanics, Native Americans, African Americans, Pacific Islanders
Delivered a baby weighing > 9 lb or has been diagnosed with GDM
Hypertensive
Dyslipidemia especially HDL cholesterol level < 35mg/dl (0.90 mmol/l) and/or a triglyceride level
> 250 mg/dl (2.82mmol/l).
Had impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)*
1. Consider referral to
Endocrinologist/Diabetic
Specialist and/or
2. Consider hospitalization
A. Initiate insulin therapy
B. Implement patient
management program
1. Initiate counseling for diet/nutrition,
exercise, weight control;
2. Consider insulin or oral agents; and
3. Implement patient management
programs
1. Initiate insulin therapy,
treat contributing factors,
and
2. Implement patient
management program
Is
Patient
symptomatic
BG>300mg/dl
and/or
Ketones
>2+?
Is
Patient
asymptomatic
normal weight or
overweight
BG < 300mg/dl and
non Ketotic or
Ketones
1+?
Is
Patient
asymptomatic
and overweight
BG > 400mg/dl and/or
Ketones
2+?
Repeat
FBG:
>126 mg/dl or 2 hour
GTT>200
mg/dl?
Screen for
Diabetes Mellitus:
Random plasma glucose
> 160 mg/dl or fasting
blood glucose
>126mg/dl?
Yes
Diagnosis of Diabetes Confirmed: (Assess)
Blood glucose level
Ketones
Diet/nutrition
HbA
1
c
Co-morbidities
H&P and Weight
Yes
Yes
No
No
Yes
Yes
Yes
Management of Patients with Diabetes Mellitus
* HbA
1
c goal < 7.0, if > 7.0 re-evaluate treatment plan and medication.
Evaluate
in 3 months:
Are goals
met?
A
Initial Intervention
Evaluation by Diabetes Clinical Management Team:
Nutrition/diet
Blood pressure
Exercise counseling
Diabetes education
HGM (home glucose monitoring)
Establish management plan and therapy goals
(Refer to treatment goals)
Start monotherapy oral hypoglycemic agents
(OHA). Refer to Continuing Care Criteria.
Evaluate quarterly:
Monitor for complications
Blood Pressure <130/8 85 5
Review HGM <120 mg/dl pre-meal, 140mg/dL bed time
HbA
1
c* < 7.0
Foot exam
Reinforce diabetes education (exercise, diet,
weight control, medication compliance)
Reassess diabetes self management skills
Maximize oral
hypoglycemic agents
OR Add insulin OR
Switch to Insulin
Monotherapy
OR Consider referral
to endocrinologist
Continue quarterly/annual follow-up
Evaluate therapy
Evaluate
in 1 month:
are goals
met?
Evaluate
in 3 months:
Are goals
met?
Continue quarterly
follow-up:
Evaluate combination
therapy
(See Evaluate
quarterly box.)
Perform Annually:
Dilated funduscopic
eye (DRE) exam by
ophthalmologist or
optometrist.
TSH
Microalbumin measurement
if urinalysis is negative for protein
Lipid profile
Refer to endocrinologist
Yes No
Yes
No
Yes
No
Maximize
Monotherapy
or Add 2nd
OHA.
Evaluate after 3
months. Are
goals met?
Yes No
Diabetes Management Goals
Testing/Examination Performance Goals:
Quarterly Goals: Annual Goals:
!
HbA1c
!
Urinary protein
analysis
!
Blood pressure
!
Foot exam
!
TSH
!
Dilated funduscopic exam performed by an ophthalmologist or
optometrist
!
Fasting lipid profile
!
Diabetes education with nutrition/exercise assessment
!
Influenza vaccine yearly/pneumococcal vaccine every 10 years.
Treatment Goals:
!
HbA1c < 7.0 (<8.5 for children ages 5-11, 7.5-9.3 for children <5)
!
Home Glucose Monitoring a.c. <120mg/dl; h.s. <140mg/dl
!
Blood Pressure <130/85
!
Lipid Profile: (LDL<100mg/dl, HDL>35 (men), >45 (women)).
!
Triglycerides <200mg/dl
Screening for Complications:
Blood Pressure: Blood pressure should be maintained <130/85 Consider ACE inhibitor or as first
choice
Dyslipidemia: Start treatment/medication if LDL >130 mg/dl Start treatment/medication if CAD
is present and LDL >100 mg/dl Consider treatment/medication for TRIG>200 and LDL/HDL>5 or
HDL<35 mg/dl
Nephropathy: Microalbuminuria/creatinine ratio anually (first a.m. urine preferred) for all Type 2
diabetic patients starting at diagnosis and any patient > 12 years of age and within 5 years of
diagnosis.
Peripheral neuropathy: Comprehensive Foot examination each visit; testing with 5.07 mono-
filament and clinical evaluation of nerve and vascular status at least annually.
Inform patients of the following:
!
Never walk barefooted.
!
Do not apply hot water or heating pads to feet.
!
Inspect feet daily, use mirror for plantar surfaces.
!
Keep foot clean, dry between the toes.
!
Lubricate dry skin using non-greasy lotion or cream to
avoid cracking.
!
Wear properly fitting soft shoes.
!
Break in new shoes slowly.
!
Use second pair of shoes at night (larger size for edema).
!
Cut toenails straight across.
!
Visit Foot Care Specialist regularly.
!
Stop smoking.
Retinopathy: Annual dilated eye exam performed by ophthalmologist or optometrist for all Type
2 diabetic patients starting at diagnosis and any patient > 10 years of age within 3 to 5 years of
diagnosis.
Consider for referral:
Type 1 patients on intensive management or patients not meeting treatment goals should be
referred to a diabetic specialist, diabetes nurse practitioner, and registered dietician.
Selected patients to Endocrinology
Type 1 patients not ideally controlled and/or candidates for intensive management
Type 2 patients not optimally controlled on maximal effective oral hypoglycemic agents
and/or insulin.
Patient referral suggested by diabetes educator (and approved by PCP)
Patients with recent DKA
Complex patient with diabetes complications
All patients for diabetes education at time of diagnosis and annually
Children with Type 1 Diabetes
References:
AACE Clinical Practice Guidelines for the Management of Diabetes Mellitus, The American
Association of Clinical Endocrinologists and The American College of Endocrinology, 1995.
Alliance Blue Cross Blue Shield, Practice Guideline for Diagnosis and Management of Diabetes,
1999.
Alliance Blue Cross Blue Shield, Practice Guideline for Cardiovascular Risk Reduction
(Hyperlipidemia), 1998.
American Diabetes Association: Clinical Practice Recommendations 2000, Vol. 23, January 2000.
Applied Therapeutics, 5
th
edition, Mary Anne Koda-Kimble, Lloyd Y. Young, 1992.
Drug Facts and Comparisons. (Steven K. Hebel) (Facts and Comparisons, St. Louis, MO 1997).
Drug Information Handbook. 5
th
Edition, Charles Lacy, ed. Lexi-Comp, Hudson, Ohio, 1998.
Lovelace Healthcare Foundation, Inc. Episode of care: diabetes, 1997.
Texas Diabetes Council, Texas Department of Health, 1998.
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