Antenatal Corticosteroids – When to Administer?

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

  • Betamethasone: 12 mg IM, 2 doses 24 hours apart
  • Dexamethasone:  6 mg IM, 4 doses 12 hours apart

Learn More – Primary Sources

ACOG Committee Opinion 713: Antenatal Corticosteroid Therapy for Fetal Maturation

ACOG Practice Advisory: Use of Antenatal Corticosteroids at 22 Weeks of Gestation

ACOG Practice Bulletin No. 171 : Management of Preterm Labor

Society for Maternal-Fetal Medicine (SMFM) Consult #58: Use of Antenatal Corticosteroids for Individuals at Risk for Late Preterm Delivery

Society for Maternal-Fetal Medicine Special Statement: Quality metrics for optimal timing of antenatal corticosteroid administration – American Journal of Obstetrics & Gynecology (ajog.org)

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

Learn More – Primary Sources:

ACOG Practice Bulletin 167: Gynecologic Care for Women and Adolescents with Human Immunodeficiency Virus

NIH Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents

CDC: Sexually Transmitted Infections Treatment Guidelines 2021

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

Herpes Simplex (HSV)
Syphilis
Chancroid
Lymphogranuloma Venereum (LGV)
Granuloma Inguinale (donovaniasis)

Herpes Simplex lesions:

  • Caused by herpes simplex viruses (HSV)
  • Common and may be severe, painful and atypical
  • 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
  • Z21 HIV infection

Learn More – Primary Sources:

2015 Sexually Transmitted Disease Treatment Guidelines

ACOG Practice Bulletin 167: Gynecologic Care for Women and Adolescents with Human Immunodeficiency Virus

NIH Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents

Zika virus: transmission, symptoms and management

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

Learn More – Primary Sources:

CDC: Zika Virus For Healthcare Providers

CDC: Areas with Risk of  Zika

ACOG Committee Opinion 784: Management of Patients in the Context of Zika Virus 

ACOG Zika Tool Kit 

FDA Drug Safety Communication: FDA has reviewed possible risks of pain medicine use during pregnancy

FDA bans the use of powdered surgical gloves

SUMMARY:

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.

Learn More – Primary Sources:

Federal Register: Banned Devices; Powdered Surgeon’s Gloves, Powdered Patient Examination Gloves, and Absorbable Powder for Lubricating a Surgeon’s Glove

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.”

Learn More – Primary Sources:

ACOG / American Society of Anesthesiologists Committee Opinion 775: Nonobstetric Surgery During Pregnancy

FDA Drug Safety Communication: FDA approves label changes for use of general anesthetic and sedation drugs in young children

Does General Anesthesia Exposure in Infancy Impact Neurodevelopment?