MATERNAL AND EARLY CHILD HEALTH

Health Evidence Bulletins - Wales

Date of completion: 27.10.97

The contents of this bulletin are likely to be valid for approximately one year, by which time significantly new research evidence may be available


4. Infections in pregnancy

(Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation)

Infection is no longer a major cause of maternal or perinatal mortality in the United Kingdom, but certain maternal infections may be transmitted to the infant. Transmission may occur in utero, at the time of delivery or, in the case of HIV, during breast feeding and may be the cause of congenital anomaly and/or fetal or perinatal infection(i).
 
i. Internal Review Group (Type V evidence - expert opinion. See Contributors)
4.1 ASYMPTOMATIC BACTERIURIA  
The Statements The Evidence
4.1a. 3-8% of women have asymptomatic bacteriuria in pregnancy and about one third of these will, if untreated, develop symptomatic infection. Screening followed by antibiotic therapy is beneficial in reducing the development of symptomatic infection and its complications (i).
(Health gain notation - 1 " beneficial")
i. Chalmers I, Enkin M, Kierse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 534-538
(Type I evidence - systematic review. Summary in Enkin M, Kierse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 114-116)
4.2b. There is evidence that single dose therapy may be effective in the management of asymptomatic bacteriuria (i).

(Health gain notation - 2 " likely to be beneficial")

i. Chalmers I, Enkin M, Kierse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 534-538
(Type I evidence - systematic review. Summary in Enkin M, Kierse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 115)

Top

4.2 CHICKEN POX  
The Statements The Evidence
4.2a. Current expert advice on the management of chicken pox in pregnancy is available (i).
(Health gain notation - 2 " likely to be beneficial")
The risk of congenital varicella syndrome secondary to maternal infection in pregnancy (before 20 weeks gestation) is approximately 2%.
i. Royal College of Obstetricians and Gynaecologists. Chicken pox in pregnancy. Guideline No. 13. London: Royal College of Obstetricians and Gynaecologists, July 1997
(Type V evidence - expert opinion)
4.3 CHLAMYDIA  
The Statements The Evidence
4.3a. Screening for, and appropriate antibiotic treatment of, chlamydia in pregnancy is likely to be beneficial, especially as newer testing methods utilizing urine make testing more acceptible to the pregnant woman(i,ii).

(Health gain notation - 2 "likely to be beneficial")

i. Brocklehurst P, Rooney G. The treatment of genital chlamydia trachomatis infection in pregnancy.Cochrane database of systematic reviews. Cochrane Library 1997 Issue 4. (Type I evidence - systematic review)
ii. Templeton A (ed.). The prevention of pelvic infection. Recommendations arising from the 31st Royal College of Obstetricians and Gynaecologists Study Group. London: Royal College of Obstetricians and Gynaecologists, 1996. pp.4-5
(Type V evidence - expert opinion)

Top

4.4 GROUP B STREPTOCOCCI  
The Statements The Evidence
4.4a. This organism is a significant cause of maternal and perinatal morbidity and even mortality (i). i. Departments of Health. National Advisory Body. Confidential enquiry into stillbirths and deaths in infancy. Annual report for 1 January - 31 December 1993. Part II. London: Department of Health, 1996. p.38
(Type IV evidence - statistical information )
4.4b. Intrapartum antibiotic treatment of women colonised with Group B streptococci reduced neonatal colonisation (odds Ratio, OR=0.10: 95% CI 0.07-0.14) and earlt onset neonatal infection with Group B streptococci (OR=0.17: 95% CI 0.07-0.39) but a difference in neonatal mortality was not seen.(i) Antibiotic treatment should be allied to prompt delivery for women with signs of intrauterine infection(ii).
(Health gain notation - 1 " beneficial")
i. Smaill F. Intrapartum antibiotics for Group B streptococcal colonisation . Cochrane database of systematic reviews. Cochrane Library 1997 Issue 4
(Type I evidence - systematic review)
ii. Chalmers I, Enkin M and Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989. p.689
(Type Vevidence - expert opinion)
4.4c. Available data show that administration of antibiotics in pregnancy is only temporary in eradication of vaginal colonisation with Group B streptococci. Further trials are indicated(i)i.
(Health gain notation - 4 " unknown")
i. Smaill F. Intrapartum antibiotics for Group B streptococcal colonisation . Cochrane database of systematic reviews. Cochrane Library 1997 Issue 4.
(Type I evidence - systematic review)
4.4d. While there is clear evidence that treatment should be given to colonised women in labour there is insufficient evidence to recommend population screening for Group B streptococci in pregnancy i.
(Health gain notation - 4 "unknown")
caveat: There is a need for rapid methods of diagnosis and a number of these are currently under development.
i. Chalmers I, Enkin M, Kierse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 551-555
(Insufficient evidence from trials to date. Summary in Enkin M, Kierse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 123-124)

Top

4.5 HEPATITIS B  
The Statements The Evidence
4.5a. High risk screening only is still performed in many areas but total population screening for the hepatitis B surface antigen (HBsAg) is likely to be introduced shortly(i).
(Health gain notation - 3 "trade-off between beneficial and adverse effects")
Where screening is carried out: Babies born to mothers who are HBeAg +ve, who are HBsAg +ve without e markers (or where e marker status has not been determined), or who have had acute hepatitis during pregnancy should receive HBIG as well as active immunisations (to prevent development of active infection and possible liver tumours). Hepatitis B vaccine, but not HBIG (Hep B immunoglobulin), is recommended for babies born to mothers who are hepatitis B surface antigen +ve but known to be anti-HBe +ve (i,ii).
(Health gain notation - 2 "likely to be beneficial")
i. Jenner, E. Immunisation against infectious disease. London: HMSO, 1996 pp. 95-108
(Type IV evidence - observational studies);

ii. British Paediatric Association, Nicoll A, Rudd P (eds.). Manual on infections and immunizations in children. Oxford: Oxford University Press, 1989. pp. 194-195

(Type V evidence - expert opinion)

4.6 HERPES SIMPLEX  
The Statements The Evidence
4.6a. There is some evidence that Aciclovir given to the woman with recurrent genital herpes simplex in pregnancy reduces viral shedding at delivery, symptomatic relapses and the use of Caesarean section. Controlled studies are underway(i,ii).
(Health gain notation - 4 "unknown")

caveat: Experience with the use of aciclovir in pregnancy is limited(ii)

i. Chalmers I, Enkin M, Kierse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 549-551
(Type II evidence - one controlled trial. Summary in Enkin M, Kierse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 122);

ii. British National Formulary. No.33 March 1997. pp. 268-269, 585
(Type V evidence - expert opinion)

4.6b. Caesarean section is still currently recommended where there is clinical evidence of active disease (i).

(Health gain notation - 2 "likely to be beneficial")

i. Chalmers I, Enkin M, Kierse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 549-551
(Type IV evidence - observational studies. Summary in Enkin M, Kierse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 122-123)
4.6c. Caesarean section is unlikely to be beneficial for non-active herpes simplex before or at the onset of labour (i).

(Health gain notation - 5 "unlikely to be beneficial")

i. Chalmers I, Enkin M, Kierse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 549-551
(Type IV evidence - observational studies. Summary in Enkin M, Kierse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 122-123)

Top

4.7 HIV  
The Statements The Evidence
4.7a. Both symptomatic and asymptomatic women may transmit HIV. Offering counselling and screening to women considered to be at high risk will detect only a proportion of infected women, thus limiting optimum interventions in pregnancy in terms of zidovudine treatment, delivery and infant feeding(i).
(Health gain notation - 3 "trade-off between beneficial and adverse effects")
Current recommendations in the UK are for population screening in areas of high prevalence (e.g. in London 1:580 pregnant women are HIV positive) as compared with areas of low prevalence (1:9600 outside South East England)(ii).
i. Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press, 1995. p. 124;

ii. Newell ML, Peckham CS. HIV-1 infection in pregnancy. PACE self-assessment test. Review No. 96/05. London: Royal College of Obstetricians and Gynaecologists, 1996

(Figures relate to 1994)

4.7b. The evidence on whether elective delivery by Caesarean Section reduces the risk of fetal transmission is inconclusive(i) but one study suggests that this may be reduced (NNT = 12 Caesarean sections to prevent infection in one infant)(ii).

(Health gain notation - 4 "unknown")

i. Dunn DT, Newell ML, Mayaux MJ et al. Mode of delivery and vertical transmission of HIV-1 infection: a review of prospective studies. Journal of Acquired Immune Deficiency Syndromes. 1994; 7 :1064-1066
(Type I evidence - meta-analysis);
ii. European Collaborative Study. Caesarean section and the risk of vertical transmission to HIV-1 infection. Lancet. 1994; 343: 1464-1467.
(Type IV evidence - Case study of 1253 HIV-infected mothers and their children)
 4.7c. Zidovudine treatment is likely to be beneficial in decreasing the risk of mother-to-child HIV infection(i) (8.3% infants infected in the zidovudine group and 25.5% infected in the control group for one trial)(ii), even at high viral loads(iii) but further trials are necessary.

(Health gain notation - 2 "likely to be beneficial")

 i. Brocklehurst, P. Zidovudine for the prevention of mother-to-child transmission of HIV infection. Cochrane database of systematic reviews. Cochrane Library 1997, Issue 4
(Type I evidence - systematic review);
ii. Connor EM, Sperling RS, Gelber R, Kiselev P, Scott G et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. New England Journal of Medicine. 1994; 331: 1173-1180
(Type II evidence - randomised controlled trial of 363 births to women known to have HIV infection);

Top

iii. Sperling RS, Shapiro DE, Coombs RW et al. Maternal viral load, zidovudine treatment, and the risk of transmission of human immunodeficiency virus type 1 from mother to infant. New England Journal of Medicine. 1996; 335: 1621-1629
(Type II evidence - randomised controlled trial of 402 mother-infant pairs)

 4.7d. Transmission of HIV through breast milk is a substantial added risk. It is estimated that breast feeding doubles the risk of infection of the infant and should be avoided (i).
(Health gain notation - 6 "likely to be harmful")
 i. Newell ML, Peckham CS. HIV-1 infection in pregnancy. PACE self-assessment test. Review No. 96/05. London: Royal College of Obstetricians and Gynaecologists, 1996
(Type IV evidence - observational studies)
4.7e. If the mother has received perinatal AZT treatment, infants should receive oral AZT for a total of 4-6 weeks, then commence co- trimoxazole as prophylaxis against pneumocystis pneumonia, until the infant’s HIV status has been determined (i).
(Health gain notation - 2 "likely to be beneficial")
 i. Sharland M, Gibb D, Tudor-Williams G, Walters S, Novelli V. Paediatric HIV infection. Archives of Disease in Childhood. 1997; 76(4): 293-296
(Type V evidence - expert opinion)

Top

 4.8 MYCOPLASMA  
The Statements The Evidence
 4.8a. There is little evidence of association of mycoplasma during pregnancy in women with previous fetal loss and routine screening is unlikely to be beneficial(i).

(Health gain notation - 5 "unlikely to be beneficial")

 i. Chalmers I, Enkin M, Kierse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 546-547
(Type I evidence - systematic review. Summary in Enkin M, Kierse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. P. 119)
 4.9 RUBELLA  
The Statements The Evidence
 4.9a. Screening for Rubella antibodies in pregnancy followed by postpartum vaccination of seronegative women is good practice in reducing congenital anomaly in subsequent pregnancy(i).
(Health gain notation - 2 "likely to be beneficial")
 i. Chalmers I, Enkin M, Kierse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 541-542
(Type IV evidence - observational studies. Summary in Enkin M, Kierse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. pp. 117-119
4.10 SYPHILIS  
The Statements The Evidence
4.10a. The introduction of routine screening for, and treatment of, syphilis in pregnancy antedated randomised controlled trials. It remains currently good practice (i). Although the number of cases is very small in the United Kingdom (6 cases in 1996) there is evidence of an increase of syphilis among visitors to Eastern Europe(ii).

(Health gain notation - 2 "likely to be beneficial")

i. Chalmers I, Enkin M, Kierse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 538-539
(Type IV evidence - observational studies. Summary in Enkin M, Kierse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 116);
ii. College of Paediatrics and Child Health. Surveillance Unit 10th Annual Report. London: CPCH, 1996. p.22
(Type IV evidence - statistical information)

Top

4.11 THRUSH  
The Statements The Evidence
4.11a. Clotrimazole is beneficial in the treatment of vaginal candida infection and associated with better compliance and this should be used in preference to nystatin (i).
(Health gain notation - 1 "beneficial")
i. Young GL, Jewell MD. Topical treatment for vaginal candidiasis. Cochrane database of systematic reviews. Cochrane Library. 1997 Issue 4.
(Type I evidence - systematic review)
4.11b. Oral fluconazole is effective against candida infection but has not been tested in pregnancy and should be used with caution(i).
(Health gain notation - 4 "unknown")
i. British National Formulary.September 1996

(Type V evidence - expert opinion)

4.11c. There is no evidence of benefit in screening for, and treatment of, asymptomatic candidiasis (i).

(Health gain notation - 5 "unlikely to be beneficial")

i. Chalmers I, Enkin M, Kierse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 p. 543
(Type V evidence - expert opinion. Summary in Enkin M, Kierse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 79)
4.12 TOXOPLASMOSIS  
The Statements The Evidence
4.12a. There is a relatively low incidence of toxoplasmosis in the United Kingdom (1.8 per 1000 live births) which does not justify universal screening for toxoplasmosis during pregnancy(i,ii).

(Health gain notation - 3 "trade-off between beneficial and adverse effects")

 i. Chalmers I, Enkin M, Kierse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 547-548
(Type IV evidence - observational studies. Summary in Enkin M, Kierse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 119);
ii. Palmer, SR. Screening for toxoplasma infection in pregnancy. London: Department of Health, 1989
(Type V evidence - expert opinion)
4.13 TRICHOMONAS  
The Statements The Evidence
4.13a. Metronidazole remains the drug of choice for symptomatic trichomonal vaginitis in pregnancy. A single oral dose of Tinidazole is effective (93% of women were free of infection after 4 weeks) but should be avoided in the first trimester(i,ii).
(Health gain notation - 1 "beneficial")
caveat: warn patients about side effects and attempt to treat partners.
i. British National Formulary. September 1996
(Type V evidence - expert opinion);

ii. Gulmezoglu AM. Trichomoniasis treatment during pregnancy. Cochrane database of systematic reviews. Cochrane Library 1997 Issue 4.
(Type II evidence - single randomised controlled trial)

Top


Contents Home

Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk