Choosing Wisely: Twenty Things Physicians and Patients Should Question

In March 2021, the Society for Maternal-Fetal Medicine (SMFM) released its list of “Twenty Things Physicians and Patients Should Question” in high-risk obstetrics as part of the Choosing Wisely® campaign, led by the American Board of Internal Medicine (ABIM) Foundation.  This list builds on the "Fifteen Things Physicians and Patients Should Question" released in April 2019, the "Ten Things Physicians and Patients Should Question" released in February 2016, and the "Five Things Physicians and Patients Should Question" released in February 2014. 

SMFM’s list includes twenty evidence-based recommendations that can support maternal-fetal medicine subspecialists and their patients in making wise choices about their care.  The items included in the list were developed based on a review of the literature and evidence from SMFM’s published documents by the following SMFM Publications Committee members: Cynthia Bean, MD; Joseph Biggio, Jr, MD; Manisha Gandhi, MD; Lorie Harper, MD, MSCI; Jeffrey Kuller, MD; Mary Norton, MD; Flint Porter, MD; Vineet Shrivastava, MD; Anthony Sciscione, DO (Chair, Choosing Wisely Work Group)

The combined list of items include the following:

1. Don’t do an inherited thrombophilia evaluation for women with histories of pregnancy loss, fetal growth restriction (FGR), preeclampsia and abruption.
2.  Recommendation Withdrawn  
3. Don’t make irreversible decisions based on the results of cell-free DNA screening test.
4. Don’t screen for fetal growth restriction (FGR) with Doppler blood  flow studies.
5. Don’t use progestogens for preterm birth prevention in uncomplicated multifetal gestations.
6. Don't perform routine cervical length screening for preterm birth risk assessment in asymptomatic women before 16 weeks of gestation or beyond 24 weeks of gestation.
7. Don't perform antenatal testing on women with the diagnosis of gestational diabetes who are well controlled by diet alone and without other indications for testing.
8. Don't place women, even those at high-risk, on activity restriction to prevent preterm birth.
9. Don't order serum aneuploidy screening after cfDNA aneuploidy screening has already been performed.
10. Don't perform maternal serologic studies for cytomegalovirus and toxoplasma as part of routine prenatal laboratory studies.
11. Don't recommend diagnostic testing following sonographic identification of an isolated echogenic intracardiac focus (EIF) or choroid plexus cyst (CPC) in women with low-risk aneuploidy screening results.
12. Don't perform serial cervical length measurement following cerclage placement.
13. Don't test women for MTHFR mutations.
14. Don't screen asymptomatic pregnant women for subclinical hypothyroidism.
15. Don't use amniotic fluid index to make a diagnosis of oligohydramnios (in the third trimester).
16. Don’t perform routine cell-free DNA screening for microdeletions.
17. Don’t perform routine midtrimester serum biomarker risk stratification for preterm birth or preeclampsia in asymptomatic patients.
18. Don’t recommend delivery in a nondiabetic patient for suspected macrosomia before 39 0/7 weeks of gestation.
19. Don’t routinely exclude women with two prior low transverse cesarean deliveries from having the choice to undertake a trial of labor after cesarean.
20. Don’t perform 3rd trimester Group B streptococcus (GBS) culture in patients with GBS bacteriuria during pregnancy.