ACOG releases new all-in-one resource on vaccinations in pregnancy

ACOG recently released the new all-in-one resource to help obstetrics care provider ensure that all pregnant women receive the vaccines they need—not only protect themselves but also their unborn child again preventable diseases.

ACOG recommends that all obstetrician should routinely assess the immunization status of their pregnant patients and address their concerns about vaccine safety during prenatal visits.

"Studies consistently demonstrate that when the recommendation and availability of vaccination during pregnancy comes directly from a woman's obstetrician or other obstetric care providers, the odds of vaccine acceptance and receipt are 5-fold to 50-fold higher," write the authors of ACOG committee opinion on vaccination.

During the first prenatal visit, the provider should assess the woman’s immunity status against rubella and varicella. If the woman is not immunized against measles-mumps-rubella (MMR) or varicella, she needs to get these vaccines in the postpartum period, because both the MMR and varicella vaccines are live attenuated vaccines and are contraindicated in pregnancy.

Women who are pregnant during influenza season should receive the flu vaccine during each pregnancy. Other vaccines that are to be given during each pregnancy are tetanus toxoid, reduced diphtheria toxoid and acellular pertussis given as early as possible in the 27 to 36 weeks of gestation window.

All live attenuated vaccines are contraindicated in pregnancy while inactivated virus, bacterial vaccines, or toxoids are entirely safe in pregnancy as indicated by a growing body of research data.

Vaccines that are given in every pregnancy

Inactivated Influenza

Tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap)

Maybe given in pregnancy in particular population

Pneumococcal vaccine

Hepatitis A

Meningococcal disease

Hepatitis B

Contraindicated in pregnancy

Measles-mumps-rubella (MMR)

Varicella

Initiated during the postpartum period or when breastfeeding or both

HPV vaccination series

Inactivated Influenza

Tetanus toxoid reduced diphtheria toxoid and acellular pertussis (Tdap)

Pneumococcal vaccine

Hepatitis A

Meningococcal disease

Hepatitis B

Measles-mumps-rubella (MMR)

Varicella

Vaccines in development

Some vaccines that can significantly reduce infectious disease in neonates are in the process of development and are likely to become part of the maternal/newborn arsenal shortly. It includes:

Streptococcus agalactiae, or group B Streptococcus (GBS)

Respiratory syncytial virus (RSV)

ACOG committee opinion

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ACOG updates it recommendations for selecting the best route of hysterectomy for benign diseases

ACOG updates its committee opinion for choosing the best route for Hysterectomy in Benign Disease. It replaces the Committee Opinion Number 444, issued November 2009.

In the United States, approximately 600,000 hysterectomies are performed each year, and the procedure is the second most frequently performed major surgical procedure among reproductive-aged women.

More than 50% of benign hysterectomies are performed for uterine fibroids followed by Abnormal uterine bleeding (42%), endometriosis (30%) and prolapse (18%), although some indications are overlapping.

Hysterectomies are performed vaginally, abdominally or laparoscopically (total laparoscopic hysterectomy [with or without robotic assistance] or laparoscopically assisted vaginal hysterectomy).

An analysis of data in between 1998 – 2010 shows a decreasing trend of abdominal route (65% to 54%) in favor of Minimal Invasive Surgery. But, the vaginal approach has shown a consistent decline in use from 1998-2010 (25% to 17%).

The recommendations and conclusions are as follows:

Vaginal Hysterectomy should be the route of choice when feasible. Evidence supports that it is associated with shorter operation time, better outcome and it is also the most cost effective of all procedures. Society of Pelvic Reconstructive Surgeons has issued its own guidelines incorporating the uterine size, mobility, and accessibility of uterus to determine the best route of hysterectomy for a patient.

In patient with adnexal pathology, adhesions or endometriosis vaginal hysterectomy is not feasible, in such patient’s laparoscopic hysterectomy is the alternative of choice over open surgery.

Each patient should be evaluated for the route of hysterectomy based on clinical factors, anatomical characteristics and patient’s individual choice combined with surgeon’s training and experience.

The healthcare provider should discuss with each patient the best possible route for her, and she should be informed the pros and cons of each route based on her clinical situation.

Opportunistic salpingectomy can safely be performed at the time of vaginal hysterectomy.  A 2015 study showed that the procedure can be accomplished in 88% of planned cases by vaginal route.

Prophylactic bilateral salpingo-oophorectomy in cases of genetic mutation represents a total different clinical scenario. The procedure should be performed by laparoscopic or open abdominal approach to get proper tissue margins and inspect the peritoneal surface.

If patient choose to have a supracervical hysterectomy, laparoscopic or abdominal approach is best suited.

In case a laparoscopic approach is decided upon, the uterus can be removed intact or scalpel morcellation. Power morcellation is under scrutiny after Dr Amy Reed and her husband lobbied against its use in Minimal Invasive Surgery. The dangers of power morcellation, contained power morcellation should be discussed with patient and she should be explained about presence of an occult malignancy that may worsen the cancer prognosis.

The committee opinion can be accessed here. 

ACOG statement on power morcellator use in gynecological surgery can be accessed here.