The appropriate use of antenatal corticosteroids improves neonatal outcomes, including decreased severity and/or frequency of respiratory distress syndrome (RDS), intracranial hemorrhage, necrotizing enterocolitis and death. Antenatal corticosteroids, when appropriate, are administered in a clinical setting where patients are at risk for preterm delivery within 7 days, irrespective of membrane status and fetal number.
Clinical Actions:
Risk of preterm delivery within 7 days
Between 24w0d to 33w6d – ‘Recommended’
Single course of corticosteroids
Between 22w0d and 23w6d – ‘May be Considered’
23w0d to 23w6d
Single course of corticosteroids
22w0d to 22w6d
Single course of corticosteroids
Note: ACOG and SMFM revised recommendation states
Antenatal corticosteroids may be considered at 22 0/7 weeks to 22 6/7 weeks of gestation if neonatal resuscitation is planned and after appropriate counseling
Some families may choose to forgo resuscitation and support after appropriate counseling
Between 20w0d and 21w6d – ‘Not Recommended’
Antenatal corticosteroids are not recommended due to lack of data suggesting benefit
Late preterm (34w0d – 36w6d)
ACOG
If no previous corticosteroids
Single course of betamethasone
Not indicated in women diagnosed with clinical chorioamnionitis
SMFM
Single course of betamethasone in specific populations
Population included in ALPS trial: Recommended
Nonanomalous singleton gestation
High risk for preterm delivery (medically indicated or spontaneous)
No prior antenatal steroids
Select populations not in the original ALPS trial: Suggest consideration for use in the following clinical scenarios
Multiple gestations reduced to a singleton gestation ≥14w0d
Fetal anomalies
Expected to deliver in less than 12 hours
Low likelihood of delivery <37 weeks: Recommend against
Pregestational diabetes: Recommend against due to risk for worsening neonatal hypoglycemia
Repeat or Rescue Courses
Regularly scheduled repeat courses or serial (> 2) courses
Not recommended
If a patient has received one prior course of corticosteroids > 14 days ago, is less than 34w0d gestation and is at risk of preterm delivery within 7 days
a single repeat course of corticosteroids should be considered (change from previous ‘may’)
Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario (based on Cochrane meta-analysis)
Preterm prelabor rupture of membranes (PPROM)
There is insufficient evidence to make a recommendation for or against repeat or rescue courses
Dose and Regimen: give first dose even if 2nd dose unlikely
Screening & Treatment of Gynecologic infections in the HIV-Positive Woman
Gynecologic infections are more common, and may be more difficult to eradicate, in the HIV population. Overall, treatment protocols remain the same, irrespective of HIV status, although there are some differences depending on the disorder.
CLINICAL ACTIONS:
Screen at entry to care and at least annually for the following: N.gonorrhoeae, C. trachomatis, syphilis and vaginal trichomoniasis
Screen for hepatitis C on entry to care
At-risk seronegative individuals should be screened at least annually
Consider type specific HSV serologic testing for those presenting for an STD evaluation
Approximately 70% of persons with HIV are HSV-2 seropositive | 95% are seropositive for either HSV-1 or HSV-2
HSV-2 infection increases the risk of HIV acquisition two- to three-fold and in coinfected patients
HSV-2 reactivation results in increases in HIV RNA levels in blood and genital secretions
Screen on entry to care for hepatitis B with HBsAg, anti-HBc and/or anti-HBs
Offer vaccination to seronegative individuals with hepatitis B or combined hepatitis A and B vaccine
Recheck immunity after vaccination complete
SYNOPSIS:
While it is critical to remain vigilant with regard to STDs and pelvic infections, women with ulcerative conditions of the genitalia, including syphilis and herpes, are at increased risk of HIV acquisition and transmission to partners, lending an urgency to prompt treatment or suppression (see separate entry on ulcerative conditions).
KEY POINTS:
Bacterial vaginosis is more prevalent/persistent in HIV-positive women
Diagnosis and treatment options are the same
Vulvovaginal candidiasis is more common among HIV-positive women and associated with decreased CD4+ counts
Treatment is the same as for HIV-negative women
For azole-refractory Candida glabrata vaginitis
Boric acid 600 mg vaginal suppository once daily for 14 days
Note: Severe or recurrent vaginitis should be treated with oral fluconazole (100 to 200 mg) or topical antifungals for ≥7 days
Treatment for gonorrhea/chlamydia is the same as for HIV-negative women
Retest 3 months after treatment as reinfection is common
Pelvic inflammatory disease is treated with the same antimicrobials for the same duration as for HIV-negative
There is a greater incidence of tubo-ovarian abscess among HIV-positive, but overall response to therapy is the same as for HIV-negative
Trichomoniasis is more prevalent among HIV-positive and should be treated with a one week course of metronidazole
Parasitic conditions such as scabies or pediculosis pubis are treated the same regardless of HIV status
Ulcerative Genital Conditions in the HIV-Positive Woman
Genital, anal, or perianal ulcers are generally caused by syphilis or herpes. Chancroid, lymphogranuloma venereum (LGV), and granuloma inguinale (donovaniasis) are less likely diagnoses; however, all these conditions are associated with increased HIV acquisition and transmission. Guidelines for screening and treatment differ in some cases from those for the HIV-negative patient.
CLINICAL ACTIONS:
Evaluate first for herpes and syphilis first
Other causes such as chancroid and lymphogranuloma venereum should then be considered
Offer HSV type-specific serologic testing on initial HIV evaluation for asymptomatic individuals
HSV DNA polymerase chain reaction (PCR) and viral culture are preferred methods for diagnosis of mucocutaneous HSV lesions caused by HSV
Consider suppression or episodic therapy to decrease clinical manifestations if HSV-2 is detected
Does not reduce risk for HIV transmission or HSV-2 transmission to susceptible sex partners
Generally higher doses/longer duration of treatment are recommended for HIV-positive women
Daily suppression
Acyclovir 400-800 mg BID or TID
or
Valacyclovir 500 mg BID
or
Famciclovir 500 mg BID
Episodic flares
Acyclovir 400 mg TID x 5-10 days
or
Valacyclovir 1 g BID x 5-10 days
or
Famcycolovir 500 mg BID x 5-10 days
Syphilis:
Systemic disease caused by Tremonema Pallidum
Primary syphilis is characterized by genital ulcers, though secondary/ tertiary/latent forms are not
A presumptive diagnosis of syphilis requires a treponemal test (i.e fluorescent treponemal antibody absorbed tests [FTA-ABS]) plus a nontreponemal test (i.e. Venereal Disease Research Laboratory [VDRL] or Rapid Plasma Reagin [RPR])
Screen for syphilis on initial HIV evaluation and annually thereafter
Treatment is the same regardless of HIV status
Penicillin G IM is the preferred treatment for all stages; the preparation (benzathine, aqueous procaine aqueous crystalline), dosage and length of treatment depend on the stage
Chancroid:
Painful, genital ulcers with suppurative lymphadenopathy caused by ducreyi
Treatment is the same regardless of HIV status
Close follow up is required as treatment failure is increased in the HIV positive
Treatment
Azithromycin 1 gm po
or
Ceftriaxone 250 mg IM
or
Ciprofloxacin 500 mg po BID x 3 days
or
Erythromycin 500 mg tid x 7 days
Lymphogranuloma Venereum (LGV)
Tender, unilateral groin/femoral lymphadenopathy with a self-limited genital ulcer/papule caused by C. trachomatis serovars L1, L2, or L3
Proctitis may occur
Diagnose by identifying C. trachomatis from the lesion by culture, direct immunofluorescence or nucleic acid detection
Treatment is the same regardless of HIV status
Treatment
Doxycycline 100 mg BID x 3 weeks
or
Erythromycin base 500 mg QID x 3 weeks
Granuloma Inguinale (Donovanosis):
Painless ulcerative disease characterized by beefy red, highly vascular lesions caused by Klebsiella granulomatis
Diagnose by identifying dark-staining “Donovan Bodies” on biopsy or tissue
Treatment is the same regardless of HIV status
Treatment
Azithromycin 1 gm once/week or 500 mg/day x 3 weeks/until lesions healed
or
Doxycycline 100 mg BID X 3 weeks/until lesions healed
or
Ciprofloxacin 750 mg BID x 3 weeks/until lesions healed
or
Erythromycin base 500 mg QID x 3 weeks/until lesions healed
or
Trimethoprim-sulfamethoxazole double strength BID x 3 weeks/until healed
SYNOPSIS:
Vaginal, vulvar, and sexually transmitted infections may increase the risk of HIV transmission. Prompt diagnosis and treatment decreases the likelihood of transmission; public health standards require providers to presumptively treat any patient, regardless of HIV status, with suspected syphilis immediately and before test results are available. Presumptive treatment of primary herpes is also recommended as early treatment maximizes success.
KEY POINTS:
Genital, anal, or perianal lesions may not necessarily be infectious (e.g. trauma, carcinoma, aphthous, drug eruption, psoriasis)
Medical history and physical exam findings are frequently inaccurate and should be followed by tests that reflect conditions prevalent in the area
Consider biopsy for ulcers not responding to therapy or if the diagnosis is unclear
If HIV status is unknown, HIV testing should be offered to any woman with genital/anal ulcers presenting for treatment.
Diagnosis codes:
D28.9 benign neoplasm of female genital organs, unspecified
Zika virus disease is a nationally notifiable condition:
Healthcare providers should report suspected Zika virus disease cases to their state, local, or territorial health department, who will report to the CDC.
WHAT IS IT?
The Zika virus (ZIKV) was first discovered in 1947, but has only become a global public health threat in the last decade with marked geographic spread in the last 5 years
The Zika virus is named after the Zika forest in Uganda where it was first found, is a Flavivirus and is related to similar viruses such as dengue, West Nile and Japanese encephalitis
The infectious viral particle (virion) is primarily composed of a single strand of RNA which is released into the infected cell’s cytoplasm, overtakes the infected cell’s genetic and cellular machinery, leading to replication and release of additional Zika virus
ZIKV, typical for a Flavirus, is predominantly spread via mosquito vectors, however transmission via blood transfusion and sexual contact can occur
KEY POINTS:
Clinical symptoms appear 3 to 14 days after a mosquito bite and should resolve within 2 to 7 days
Most people will be asymptomatic
20% will have typical viral signs and symptoms, usually of a mild nature
Fever
Maculopaular rash
Conjunctivitis
Arthralgias
Headache
Management is that of typical viral illness and includes:
Rest
Antipyretics
Note: current drug labels state that NSAIDs should not be used by pregnant women in their third trimester of pregnancy because of the risk of premature closure of the ductus arteriosus in the fetus
Nutrition and adequate fluids
Monitor for signs and symptoms of severe infection such as coagulopathies and organ damage – ICU care is rare but any concern should be escalated
Guillain-Barré syndrome, an autoimmune neurological disorder, has been reported and while uncommon should generate a referral for diagnosis and management
The FDA has recently released an official ban on powdered surgeon’s gloves, powdered patient examination gloves, and absorbable powder for lubricating a surgeon’s glove. Many providers have already transitioned to powderless gloves. Powdered gloves are associated with asthma, lung inflammation and surgical adhesions. It is important to note, these products not only pose risks to patients, but providers as well. The rule, published on December 19, 2016, is available in the link below.
ACOG Response to FDA Communication on Anesthesia in Pregnancy
SUMMARY:
In 2016, the FDA released a warning stating that repeated or lengthy use of general anesthetic or sedation drugs in children less than 3 years of age or in pregnant women in their 3rd trimester may be harmful to children’s brain development. The FDA issued an update (2017) requiring warnings to be added to labels of these medications. The FDA does point out in the update that the concern relates to procedures >3 hours and that most surgeries in the 3rd trimester are generally well within that time frame. Therefore, the FDA safety communication states
We are advising that in these situations, pregnant women should not delay or avoid surgeries or procedures during pregnancy, as doing so can negatively affect themselves and their infants
In response to the initial warning, ACOG released a practice advisory (2016) making the following important points
The data used to derive this warning were obtained from a pediatric study only – no pregnant women were included
There are potential negative clinical implications if healthcare professionals hesitate in providing appropriate care and management
The FDA did not seek input from ACOG and obsetetrician-gynecologists were not involved in the development of this warning
As a result of the above and based on current evidence
ACOG continues to recommend that women in any trimester of pregnancy should be counseled regarding evidence-based benefits and risks of any proposed interventions which may involve the use of general anesthetic or sedative agents, and no woman should be denied a medically indicated surgery or procedure which may involve the use of these agents
ACOG and the American Society for Anesthesiologists (2019) confirmed the above in their committee opinion and state that presently there is “no evidence that in utero human exposure to anesthetic or sedative drugs has any effect on the developing fetal brain.”
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Disclaimer
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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