This document discusses evidence-based individual decision making (EBID) in obstetrics and gynecology. It emphasizes that evidence-based medicine (EBM) integrates the best available research evidence, clinical expertise, and patient values and preferences. While randomized controlled trials provide the strongest level of evidence, individual patient circumstances may differ. The document notes gaps between research evidence and clinical practice. It concludes that best research evidence, assessment of maternal risk, and good clinical judgment are needed to prevent adverse pregnancy outcomes through EBID.

1. Evidence based
individual decision
making
Dr. Mohammed Abdalla
Damietta general hospital
2011
EBID

2. EBM is not only the best
research evidence
But the clinical expertise and the patient
values are also integrated
clinical
expertise
patient
values
best
research
evidence

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5.  Ia Evidence obtained from meta-analysis of randomised
controlled trials.
 Ib Evidence obtained from at least one randomised
controlled trial.
 IIa Evidence obtained from at least one well-designed
controlled study without randomisation.
 IIb Evidence obtained from at least one other type of well-
designed quasi-experimental study.
 III Evidence obtained from well-designed non-
experimental descriptive studies, such as comparative
studies, correlation studies and case studies.
 IV Evidence obtained from expert committee reports or
opinions and/or clinical experience of respected
authorities.

6. Which doctor do you want?
William Osler, 1900 Smart young doctor

7. Which doctor do you want?
Wise & experienced smart young doctor

8. Our practice must be
based on evidence from
good quality research,
such as RCT, or SRv.

9. overall results may not be
always applicable for patients
seen in everyday practice.
As they may differ in age,
severity of illness, and
presence of comorbidity.

10. • is the healthiest
possible outcome
for mother and
baby.

11. IS EBM A QURAN ?

12. • “In God we trust” -
But all others must show data…

13. Over the years, the prevailing medical wisdom
can swing as dramatically as clothing fashions
and gasoline prices.
there are often
serious
disagreements… …

14. Vioxx: On September 30, 2004 heart attack and stroke .
Fen phen and Redux: heart or lung damage
Trasylol: 2007 , increased the risk of complications or death
Propulsid: withdrawn from the market .
Thiomersal controversy : some parents continue to be
persuaded thiomersal is linked to autism

16. Bed rest during pregnancy for
preventing miscarriage
– There is insufficient evidence of high quality that
supports a policy of bed rest in order to prevent
miscarriage in women with confirmed fetal
viability and vaginal bleeding in first half of
pregnancy.
Cochrane Database of Systematic
Reviews 2005, Issue 2. Art. No.: CD003576.
DOI: 10.1002/14651858.CD003576.pub2.
• > 80% still recommend bed rest to
prevent miscarriage.

17. Progestogen for preventing miscarriage
• There is no evidence to support the routine
use of progestogen to prevent miscarriage
in early to mid-pregnancy.
Cochrane Database of Systematic
Reviews 2008, Issue 2. Art. No.: CD003511.
DOI: 10.1002/14651858.CD003511.pub2.
• > 80% still recommend progestrone
to prevent miscarriage.

18. Magnesium sulphate for preventing
preterm birth in threatened preterm
labour
Magnesium sulphate is ineffective and its
use
Cochrane Database of Systematic
Reviews 2002, Issue 4. Art. No.: CD001060.
DOI: 10.1002/14651858.CD001060.
is associated with an
increased mortality for the
infant.

19. Magnesium sulphate for women at risk of
preterm birth for neuroprotection of the
fetus
• magnesium sulphate therapy has a The
neuroprotective role when given to women
at risk of preterm birth for the preterm fetus.
Cochrane Database of Systematic
Reviews 2009,
> 80% still don't use it

20. The considerable gap between what we
know from research and what is done in
clinical practice is well known

21. VBAC
2004
• most patients who have had a low-transverse uterine incision from
a previous cesarean delivery and who have no contra-indications for
vaginal birth are candidates for a trial of labor. Criteria for selecting
candidates for VBAC include the following:
• (1) one previous low-transverse cesarean delivery;
• (2) clinically adequate pelvis;
• (3) no other uterine scars or previous rupture;
• (4) a physician immediately available throughout active labor who
is capable of monitoring labor and performing an emergency
cesarean delivery;
• (5) the availability of anesthesia and personnel for emergency
cesarean delivery.

22. VBAC
Jan 2007
• New evidence is emerging to indicate that
VBAC may not be as safe as
originally thought.

24. VBAC rate was 5% in 1985.
due to recommendations favoring TOLAC By 1996
VBAC rises to 28.3% .
reports of uterine rupture and other complications
during TOLAC also rises consequently..
By 2006, the VBAC rate had decreased to 8.5%. and
the total cesarean delivery rate had increased to 31.1%

25.  In a 2010 consensus conference, (NIH) examined the safety
and outcome of TOLAC and VBAC and factors associated with
decreasing rates. The NIH panel recognized that TOLAC was a
reasonable option for many women with a prior cesarean
delivery and called on organizations to facilitate access to
TOLAC. In addition, the panel recognized that
“concerns over liability have a major impact on the
willingness of physicians and healthcare institutions
to offer [TOLAC]” .

26. Antenatal Corticosteroids to Reduce
Neonatal Morbidity and Mortality
Antenatal corticosteroids should be given to all women
at risk of iatrogenic or spontaneous preterm birth up
to 34+6 weeks of gestation. April 1996
Evidence
level 1++
Antenatal corticosteroids should be given to all women
for whom an elective caesarean section is planned
prior to 38+6 weeks of gestation. October 2010

27. Metroplasty versus expectant management
for women with recurrent miscarriage and a
septate uterus
• Hysteroscopic metroplasty in women with recurrent miscarriage and a
septate uterus is being performed in many countries to improve
reproductive outcomes in women.This treatment has been assessed in
non-controlled studies, which suggested a positive effect on pregnancy
outcomes. However, these studies are biased due to the fact that the
participants with recurrent miscarriage treated by hysteroscopic
metroplasty served as their own controls. Until now, the effectiveness and
possible complications of hysteroscopic metroplasty have never been
considered in a randomised controlled trial.Taking this into account there
is insufficient evidence to support this treatment in these women.
Published Online: 15 JUN 2011 Cochrane

29. Aspirin or anticoagulants for treating
recurrent miscarriage in women without
antiphospholipid syndrome
There is a paucity in studies on the efficacy and
safety of aspirin and heparin in women with a
history of at least two miscarriages without
apparent causes other than inherited
thrombophilia, the use of anticoagulants
in this setting is not recommended.
Cochrane Database of Systematic
Reviews 2009, Issue 1. Art. No.: CD004734.
DOI: 10.1002/14651858.CD004734.pub3.

33. Cervical assessment by ultrasound for
preventing preterm delivery
• Currently there is insufficient evidence to
recommend routine screening of asymptomatic
or symptomatic pregnant women with TVU CL.
• future studies should include a clear protocol for
management of women based on TVU CL
results, so that it can be easily evaluated and
replicated.
Cochrane Database of Systematic Reviews
2009, Issue 3. Art. No.: CD007235. DOI:
10.1002/14651858.CD007235.pub2

35. If you received a notice from the
ultrasound department that your
patient—a primigravida at 21 weeks'
gestation—has a cervical length of 19
mm with funneling.
What are your
management options if
the patient reports no
contractions or changes
in vaginal discharge?

36. the same cervix, 20 seconds apart, without
and with applying pressure
funneling
Dynamic
change
Without fundal pressure With fundal pressure

37. Cervical assessment by ultrasound for
preventing preterm delivery
• Currently there is insufficient evidence to
recommend routine screening of asymptomatic
or symptomatic pregnant women with TVU CL.
• future studies should include a clear protocol for
management of women based on TVU CL
results, so that it can be easily evaluated and
replicated.
Cochrane Database of Systematic Reviews
2009, Issue 3. Art. No.: CD007235. DOI:
10.1002/14651858.CD007235.pub2

38. SHE HAS GOT PREGNANT BY ICSI.
YOUR PATIENT IS 37YEARS AGE

39. Urgent, or therapeutic, cerclage often is
recommended for women who have
ultrasonographic changes consistent with a
progressive shortening cervix or evidence of
funneling.
ACOG Practice Bulletin No. 48, appeared in the November 2003 issue
Therapeutic cerclage is the
short answer

42. conclusion

43. EBM firm adherence may blocks
many things that could be
useful if you're in need now.
OR, the firm evidence you
need now has not yet been
developed - or has been developed,
and hasn' t been published yet.

44. ( EBID ) IS EVIDENCE-BASED
MEDICINE AS PRACTICED BY THE
INDIVIDUAL HEALTH CARE PROVIDER.
( EBG ) IS THE PRACTICE OF
EVIDENCE-BASED MEDICINE AT THE
ORGANIZATIONAL OR INSTITUTIONAL
LEVEL.

45. With today's emphasis on
evidence-based medicine,
it often is difficult to
decide on an appropriate
action, especially when
conflicting reports
abound.

46. Best research evidence
,Assessment of maternal
risk ,quality of human
judgment and decision
making, are the gate for
prevention of adverse
pregnancy outcomes.

47. Thank you