MATERNAL AND EARLY CHILD HEALTH
Date of completion: 27.10.97
MATERNAL AND EARLY CHILD HEALTH |
|
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
(Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation)
| 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) |
| 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) |
| 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) |
| 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 |
| 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) |
| 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); 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 |
| 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) |
| 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) |
| 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. |
Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk