The USPSTF reaffirms its recommendation for screening of all pregnant women for syphilis

The US Preventive Services Task Force (USPSTF) today reaffirmed its 2009 recommendation for early screening of all pregnant women for syphilis following a massive surge of cases of congenital syphilis. The statement was published September 4 in the JAMA with an accompanying editorial in JAMA Dermatology.

The newest guidance is a class ‘A’ recommendation which means that there exists substantial evidence in favor of the benefits of early screening for mother and fetus. 

Vertical transmission of syphilis can occur any time and at any stage during pregnancy, and congenital syphilis is associated with adverse outcomes such as preterm birth, low birth weight, stillbirth, congenital anomalies, active syphilis in the newborn (NB) and long-term health sequelae such bone deformities and neurologic impairment.

In the US, the incidence of congenital syphilis has increased by nearly 87% between 2012 to 2016, after a steady decline during the previous 4 years.  The rise coincides with rising national rates of syphilis among women of reproductive age – from 0.9 cases of primary and secondary syphilis infection per 100,000 women in 2012 to 1.9 cases in 2016.

The USPSTF recommends that all pregnant women should be screened for syphilis as early as possible when they present at the healthcare provider’s office. If a woman presents directly in labor and has not received any testing earlier, she should be immediately tested.

The screening test for syphilis is a two-step process– initially a “nontreponemal” antibody test (i.e., Venereal Disease Research Laboratory test or rapid plasma reagin [RPR] test) is done to detect biomarkers released from damage caused by syphilis infection, followed by a confirmatory “treponemal” antibody detection test (i.e., fluorescent treponemal antibody absorption or T pallidum particle agglutination test).

A newer alternative is a reverse sequence screening algorithm that involves an automated treponemal test (such as an enzyme-linked, chemiluminescence, or multiplex flow immunoassay first, followed by a nontreponemal test.

The CDC has recommended parenteral benzathine penicillin G for the treatment of syphilis in pregnant women. Evidence in favor of the safety of alternative treatment is limited; therefore, women who present with an allergy to penicillin should be evaluated and desensitized first and treated with the drug.

One way to decrease the incidence of congenital syphilis is to bring down the rates of primary and secondary syphilis infection among all women. Lower rates of syphilis in women prevent the sexual transmission and subsequent vertical transmission of congenital syphilis. Hence, the USPSTF recommends screening for syphilis in nonpregnant adolescents and adults at increased risk for infection.

The current recommendations are in accordance with those issued by other professional organizations. The CDC recommends screening for syphilis infection in all pregnant women at their first contact with the provider. The CDC, AAP, and ACOG also recommend repeat screening at 28 weeks of gestation and again at delivery in women who are at high risk for syphilis infection.

High-risk women include those with HIV or a history of incarceration or commercial sex worker. ACOG and AAP also recommend repeat screening after encountering an infected partner.

JAMA Full article

JAMA Dermatology editorial

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News from ACOG 2018: Aspirin cuts down the risk of superimposed preeclampsia in women with chronic hypertension

Keeping up with the American College of Obstetricians and Gynecologists (ACOG) 2016 practice guideline of supplementing low-dose aspirin to pregnant women with chronic hypertension was associated with a 57% decrease in superimposed preeclampsia.

Investigators at Thomas Jefferson University presented the results of this retrospective study in a poster presentation at the ACOG 2018 annual meeting (April 27–30, 2018, Austin, Texas).

The study participants included 715 women with chronic hypertension carrying singleton pregnancy, who delivered at Thomas Jefferson University Hospital between January 2008 to July 2017.

The women were divided into 2 groups based on whether they delivered before and after ACOG recommendations. The pre-ACOG group included 635 women while the post-ACOG group had 80 women.

The cohort was further stratified based on additional risk factor for the development of superimposed preeclampsia (SIP) like a previous history of preeclampsia or pregestational diabetes. The primary outcome of interest was the development of preeclampsia, while the secondary outcomes studied were the incidence of SIP with severe features (SIPSF), small for gestational age, and preterm birth was also studied.

The incidence of SIP was dramatically reduced by 57% in women with chronic HT who received low dose aspirin (OR 0.43 (95% CI 0.26-0.73).

Women who had no other risk factor for the development of SIP, the incidence of SIP and SIP with severe features decreased by 75% and 77% respectively.

The incidence of secondary outcomes did not show any significant changes. Aspirin showed the highest benefits in women with chronic hypertension who did not have any additional risk factor for preeclampsia.

Hence the authors concluded that this study showed that ACOG guidelines have a significant positive impact on bringing down the incidence of superimposed preeclampsia in patients with chronic hypertension.

Abstract

ACOG Practice Advisory on Low-Dose Aspirin and Prevention of Preeclampsia

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News from ACOG 2018: First trimester bleeding linked to increased risk of retained placenta

Women who have a history of first-trimester hemorrhage face 8 times the increased risk of undergoing D&C for removal of the retained placenta as compared to women with a history of bleeding reports the result of a study presented at American College of Obstetricians and Gynecologists (ACOG) 2018 annual meeting at Austin, Texas.

This abstract also won the first prize among the oral award winners at the conference.

These women also have a higher incidence of postpartum hemorrhage and require blood transfusions more frequently says Marissa Le Gallee, of Jewish General Hospital in Montreal, and colleagues who conducted the research.

This case-control study was conducted over a period of four years (2012-2016) at a tertiary care center in Montréal, Canada. Subchorionic hemorrhage was identified by the patient's obstetric history on as an anechoic structure visualized on ultrasound.

The authors recruited 68 cases who had post vaginal delivery D&C for retained placenta and matched them to 330 controls who delivered on the same day but did not have D&C after going through the medical records.

The demographics of cases and controls were similar, except women requiring a D&C for placental removal were slightly older than controls. The incidence of retained placenta requiring D&C was 3/1000 deliveries.

There were 11 women with a history of the first trimester bleeding who underwent post-partum D&C as compared with only two controls without a D&C (adjusted OR 35.00, 95% CI 6.96-175.69, P=0.0002).

This association strongly existed even after adjusting for confounders (OR 7.70, CI 1.-37.5).

A significant number of women who had undergone D&C lost blood greater than 500ml and needed manual removal as well as blood transfusions compared with patients with no D&C.

Dr. Le Gallee hypothesized that Subchorionic bleed leads to adhesion of portions of the placenta that necessitates D&C at birth. It is also associated with placental abruptions and preterm births.

The authors concluded that women with a history of the first-trimester bleed should be watched carefully watched for other potential pregnancy and peripartum complications.

Abstract

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ACOG recommendations for management of suboptimally dated pregnancies.

courtesy:Pexels.com  

The American College of Obstetricians and Gynecologists (ACOG) recently published its recommendations regarding management and delivery of pregnancies in whom the best clinical estimation of gestational dates is not confirmed in forthcoming March 2017 issue of Obstetrics and Gynecology Journal. 

ACOG has always strived to curb elective deliveries before 39 weeks of pregnancy and spread awareness among obstetricians about the negative effects of elective delivery before 39 weeks, which increases neonatal respiratory and nonrespiratory morbidities.[1] 

The article can be accessed here.

This topic was also debated at the ACOG Annual Clinical and Scientific Meeting 2016.[2]

The most accurate method of gestational dating is a first trimester sonography. As the woman advances into second and third trimester the reliability of USG for the purpose of dating decreases linearly.  Pregnancies without an USG performed to confirm or revise the gestational dating before 22 0/7 weeks are labeled as suboptimally dated.

The guidelines for management are:

1. The decision about timing the delivery in a suboptimally dated pregnancy should be based on the best clinical estimate of the gestational age.
2. There is no role for elective delivery in suboptimally dated pregnancies to avoid the neonatal morbidity because the pregnancy may be earlier in gestation than believed to be. Decision to administer antenatal corticosteroids should be based on the best clinical judgement if a woman with suboptimally dated pregnancy is identified to be at risk for preterm delivery.
3. Amniocentesis to determine fetal lung maturity should not be used to decide the time of delivery in suboptimally dated pregnancies because  it is not reliable in predicting pulmonary maturity and other non-respiratory outcomes.
4. A follow-up sonography after 3-4 weeks of the initial one is always advisable in women with suboptimally dated pregnancies. It helps to support the prediction of gestational dating as well as fetal well-being in terms of weight gain. If IUGR is suspected, a close surveillance with umbilical cord Doppler should be considered.
5. It is always difficult to manage a presumably late-term pregnancy that lacks accurate dating because of the risk of overlooking post maturity and associated fetal morbidity and mortality. Therefore, is advised to begin antepartum fetal surveillance at 39–40 weeks of gestation and to deliver at 41 weeks using the best clinical judgement because it could be more postdated than it is believed to be.
6. In women with suboptimally dated pregnancy with a previous history of low transverse C-section incision a trial of labor can be given based on the clinical assessment of gestational age. If a woman requests a repeat elective C-section, it should be planned around 39 weeks based on best clinical judgement.
7. Women with suboptimally dated pregnancy should be well informed about the risks of neonatal morbidity and mortality because of inaccurate dating.

The full text of the  journal article can be accessed here.  

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[1] https://obgynupdated.blogspot.com/2017/01/choosing-wisely-and-acog-advises.html

[2] https://obgynupdated.blogspot.com/2016/05/elective-induction-of-labor-iol-at-39.html

A novel ultrasound parameter help predicts mid-trimester cerclage failure-- -- News from SMFM 2017, Las Vegas.

UCA  acute and obtuse Courtesy Researchgate 

Increasingly wide utero cervical angle (UCA) after mid trimester cerclage operation signifies increase risk of preterm delivery.

Dr. Jordan Knight and his colleagues from Indiana University School of Medicine, Indianapolis, IN presented a pilot study, utilizing UCA in predicting the failure of mid-trimester transvaginal cerclage operations. [1]

UCA is defined as the triangular area between the lower uterine segment and cervical canal measured by Transvaginal Ultrasonography (TVUS).

Researchers are exploring the possibilities of using a novel ultrasound parameter, the anterior utero cervical angle (UCA) as a predictor of Spontaneous Preterm Birth along with Cervical length (CL). Previously this angle has been used as one of the parameter for successful induction of labor.

The pathophysiological   principle behind this is based on physics and trigonometry. Pregnant uterus exerts pressure on cervix and depending on the angle of inclination, the cervix is either shut if the angle is acute or opened wide if the angle is obtuse.

The current retrospective study collected data on 142 women who underwent transvaginal cerclage between 2010-2015. UCL was measured thrice in same patient: prior, one week after cerclage placement and prior to delivery by TVUS.

Delivery before 36 weeks was labelled as cerclage failure.

After Univariate regression, it was seen that CL and UCL was strongly associated with gestational age at birth.

UCL angle of 108 degree prior to 34 weeks was a better predictor of preterm delivery than CL = 25 mm. Before28 weeks the UCL angle of 112 degree had 100 sensitivity as compared to 29% that of CL.

Patients with UCA angle> 108 degree had 35 times higher odds of spontaneous preterm birth (PTB) before 34 weeks while the UCL > 112 degree conferred 42 times higher odds of delivering before 28 weeks.

The corresponding odds of delivery if cervical length CL<25mm are 4.7 and OR 6.0 prior to 34 and 28 weeks respectively.

The study cohort had 38% cerclage failure rate and delivered at mean gestational age of 29 +/- 5.2 weeks compared to those who delivered at 37.9 +/- 2.8 weeks (p<0.001).

A study presented at the 36th Annual Pregnancy Meeting concluded that “A wide uterocervical angle ≥95 and ≥105 degrees detected during the second trimester was associated with an increased risk for spontaneous preterm birth <37 and <34 weeks, respectively. Uterocervical angle performed better than cervical length in this cohort.”[2]

The authors concluded that increasing obtuse UCA signify increase chances of cerclage failure and give the obstetrician valuable time to make arrangements for delivery at tertiary center.

UCA performed better than CL as a screening parameter for predicting preterm births (PTB) because of increased sensitivity and NPV.

In fact, a combination of UCA and CL synergistically can be best predictor of PTB in cerclage patients.

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[1] http://www.ajog.org/article/S0002-9378(16)31012-2/fulltext

[2] http://www.ajog.org/article/S0002-9378(16)00525-1/abstract

SMFM recommendations for routine cervical length screening for preventing Preterm Births.

Courtesy: Pixabay 

A summary of Society for Maternal-Fetal Medicine  recommendation for Cervical Length ( CL) screening to prevent Preterm births. 

Preterm birth (PTB) remains a major cause of neonatal death and short and long term disability across the globe. The current global preterm birth rate is 5% to 18% and statistic shows a steady increase recently. CDC data quotes that in the year 2014, every 1 in 10 infants was born preterm in US. 

 Nearly 2/3 of 15 million preterm births are spontaneous with a very high recurrence. A history of previous PTB is the strongest risk factor for preterm delivery in the current pregnancy. Among various other contributing factors prior uterine surgery, especially those performed on cervix (induced termination of pregnancy (I-TOP) or spontaneous abortion (SAB)) has been implicated in its causation.

There are few laboratory tests to predict preterm birth in a pregnancy.

Transvaginal Cervical Length measurement helps in predicting the risk of preterm birth so the obstetrician and his team gets time to intervene, delay or transfer the patient to high risk units.

At present, a single mid-trimester transvaginal CL measurement is the best clinical predictor of a preterm birth. Those with the shortest cervix has the highest risk of prematurity.

The Society for Maternal-Fetal Medicine issued recommendation about the role of routine cervical length screening in selected high-and low-risk women for preterm birth prevention.

• SMFM recommends “routine transvaginal cervical length screening for women with singleton pregnancy and history of prior spontaneous preterm birth (GRADE 1A).”

Transvaginal assessment at 16 and 24 weeks’ gestation by a trained sonologist or obstetrician should be performed. Routine CL screening is not advisable before 16 weeks and after 24 weeks in asymptomatic women.  

In women with prior history of preterm births serial CL measurements are performed every week beginning at 16 weeks to 24 weeks.

• SMFM recommends “Practitioners who decide to implement universal CL screening should follow strict guidelines (GRADE 2B).”
• SMFM recommends “Routine transvaginal CL screening not be performed for women with cervical cerclage, multiple gestation, PPROM, or placenta previa (GRADE 2B).”

Evidence does not support additional screening for women who have undergone cervical conning or LEEP beyond the standard recommendations.

No additional clinical benefit is derived for repeated CL screening in women who have undergone cerclage operation. Although research demonstrates that progressive CL shortening after the stitch increases the risk for PTB, but no options exist to reinforce the short cervix after cerclage.

Routine cervical screening is not recommended by SMFM in multiple gestation as no additional clinical benefit is derived from it.

Transvaginal CL measurement serves as an adjunct to fetal fibronectin (FFN) in predicting PTB in women with CL of 20-29 mm (the grey zone). Cervical length more than 30 mm and less than 20 mm is independently a strong predictor of minimum chances for PTB or high risk for  PTB respectively. 

Not much clinical benefit is derived from cervical length estimate in Preterm premature rupture of membranes (PPROM). Few observational studies have shown that with a transvaginal CL <2 cm, the positive predictive value of delivery within 7 days was 62%.

Routine transvaginal CL measurement is not performed in case of placenta previa as studies do not show any additional benefit is derived for management.

• SMFM recommends “sonographers and/or practitioners receive specific training in the acquisition and interpretation of cervical imaging during pregnancy”.

Steps for proper cervical length measurement as recommended by SMFM.[1]

(1) Ensure patient has emptied her bladder.

(2) Prepare the cleaned probe using a probe cover.

 (3) Gently insert the probe into the patient’s vagina.

 (4) Guide the probe into the anterior fornix.

 (5) Obtain a sagittal, long-axis image of the entire cervix.

(6) Remove the probe until the image blurs and then reinsert gently until the image clears (this ensures you are not using excessive pressure).

(7) Enlarge the image so that the cervix occupies two thirds of the screen.

 (8) Ensure both the internal and external os are seen clearly.

 (9) Measure the cervical length along the endocervical canal between the internal and external os.

(10) Repeat this process twice to obtain 3 sets of images/ measurements.

(11) Use the shortest best measurement.

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[1] SMFM. Role of routine cervical length screening for preterm birth prevention. Am J Obstet Gynecol 2016.