Society for Maternal-Fetal Medicine (SMFM) issues guidelines for HCV in pregnancy

The Society for Maternal-Fetal Medicine (SMFM) has issued guidelines for screening and management of Hepatitis C infection in pregnancy.  

The guidelines were published ahead of print in American Journal of Obstetrics and Gynecology.

It is estimated that on average nearly 1-2.5% of pregnant women in US are infected with the virus and the risk of vertical transmission is 5%.

The recommendations are:

1) All women who are at increased risk for Hepatitis C should get tested for anti-HCV antibodies at their first prenatal visit. If the risk persists till later in pregnancy or new risk factor arise, the screening should be repeated again. (GRADE 1B)

According to American Liver Foundation the risk of Hepatitis C is increased if:

• Shared needles to inject drugs or straws to inhale them
• Had tattoos or body piercings in an unclean environment using unsterile equipment
• Worked in a place where you came in contact with infected blood or needles, for example, healthcare workers
• Received a blood transfusion or organ transplant before July 1992
• Received a blood product for clotting problems made before 1987
• Needed to have your blood filtered by a machine (hemodialysis) for a long period of time because your kidneys weren’t working
• Were born to a mother with HCV
• Had unprotected sex with multiple partners
• Have or had a sexually transmitted disease
• Have HIV

2) All HCV positive pregnant women should be screened for other sexually transmitted diseases (STDs) including HIV, syphilis, gonorrhea, chlamydia, and hepatitis B virus (HBV). (GRADE 1B)

3) All patients with HCV, including pregnant women should be advised to refrain from consuming alcohol. (Best Practice)

4) Direct-acting antiviral medications (DAA) are not to be used in pregnancy, except in settings of clinical trials. The treatment should be initiated after the delivery of the patient in the postpartum period. (Grade 1C).

5) If invasive prenatal testing is requested than amniocentesis is preferred over chorionic villus sampling (CVS) because of limited data on the risk of vertical transmission for CVS over amniocentesis. (Grade 2C).

 6) HCV infection solely is not an indication for Cesarean section in absence of other obstetric indications. (GRADE 1B)

7) Internal fetal monitoring, prolonged rupture of membranes, and episiotomy should be avoided during labor in HCV+ women (Grade 1B).

8) Positive HCV status is not a contraindication for breast feeding. (Grade 1A).

Society for Maternal-Fetal Medicine (SMFM) issues evidence-based guidelines for management of Amniotic fluid embolism

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A systematic literature review was performed using MEDLINE, PubMed, EMBASE, and the Cochrane Library. English language articles published between 1966 to March 2015 were included. RCTs were given preference, but commentaries and reviews were also included. The bibliographies of the included articles were also looked at. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was used for defining the strength of recommendations and rating quality of the evidence.[1] 

The guidelines for diagnosis and management as published in Am J Obstet Gynecol 2016 are as under:

• Amniotic fluid embolism(AFE) should always be considered in differential diagnosis of sudden cardiorespiratory collapse in patients in labor or recently delivered (GRADE 1C);
• Amniotic fluid embolism remains a clinical diagnosis and no specific laboratory test is needed to confirm or rule out the diagnosis (GRADE 1C);
• The patient should be provided with immediate, advance cardiopulmonary resuscitation with standard basic cardiac life support and protocols followed in cases of cardiac arrest due to AFE (GRADE 1C);
• Immediately call upon a multidisciplinary team of anesthesian, respiratory therapist, critical care personnel and maternal-fetal medicine specialist in the ongoing management (Best Practice);
• If the pregnancy is more than 23 weeks, than immediate delivery of the fetus is recommended (GRADE 2C);
• Avoid excessive fluid overload, adequate oxygenation, ventilation, use of vasopressors and inotropic agents to stabilize the hemodynamics status of the patient (GRADE 1C);
• Assess the clotting status as coagulopathy will follow the cardiovascular collapse. Manage the clinical bleeding by following the standard transfusion protocols. A large amount of blood and blood products should be kept ready (GRADE 1C).

For research and uniformity of reporting and to improve quality of clinical and translational research diagnostic criteria outlined by Clark et al. in Am J Obstet Gynecol 2016. [2]

• Sudden onset of cardiorespiratory arrest, or both hypotension (systolic blood pressure <90 mm Hg) and respiratory compromise (dyspnea, cyanosis, or peripheral capillary oxygen saturation [S_pO₂] <90%).
• Documentation of overt DIC following appearance of these initial signs or symptoms, using scoring system of Scientific and Standardization Committee on DIC of the ISTH, modified for pregnancy. Coagulopathy must be detected prior to loss of sufficient blood to itself account for dilutional or shock-related consumptive coagulopathy.
• Clinical onset during labor or within 30 min of delivery of placenta.
• No fever (≥38.0°C) during labor

Article source:  Society for Maternal-Fetal Medicine (SMFM), Pacheco LD, Saade G, Hankins GVD, Clark SL. SMFM clinical guidelines No. 9: amniotic fluid embolism: diagnosis and management.

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[1] http://www.ajog.org/article/S0002-9378(16)00474-9/abstract

[2] http://www.ajog.org/article/S0002-9378(16)30382-9/fulltext