Audrey Steenbeek

Antibiotic prophylaxis in obstetric procedures.

Abstract Objective To review the evidence and provide recommendations on antibiotic prophylaxis for obstetrical procedures. Outcomes Outcomes evaluated include need and effectiveness of antibiotics to prevent infections in obstetrical procedures. Evidence Published literature was retrieved through searches of Medline and The Cochrane Library on the topic of antibiotic prophylaxis in obstetrical procedures. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and articles published from January 1978 to June 2009 were incorporated in the guideline. Current guidelines published by the American College of Obstetrics and Gynecology were also incorporated. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the Society of Obstetricians and Gynaecologists of Canada under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1). Benefits, Harms, and Costs Implementation of this guideline should reduce the cost and harm resulting from the administration of antibiotics when they are not required and the harm resulting from failure to administer antibiotics when they would be beneficial. Summary Statements 1. Available evidence does not support the use of prophylactic antibiotics to reduce infectious morbidity following operative vaginal delivery. (II-1) 2. There is insufficient evidence to argue for or against the use of prophylactic antibiotics to reduce infectious morbidity for manual removal of the placenta. (III) 3. There is insufficient evidence to argue for or against the use of prophylactic antibiotics at the time of postpartum dilatation and curettage for retained products of conception. (III) 4. Available evidence does not support the use of prophylactic antibiotics to reduce infectious morbidity following elective or emergency cerclage. (II-3) Recommendations 1. All women undergoing elective or emergency Caesarean section should receive antibiotic prophylaxis. (I-A) 2. The choice of antibiotic for Caesarean section should be a single dose of a first-generation cephalosporin. If the patient has a penicillin allergy, clindamycin or erythromycin can be used. (I-A) 3. The timing of prophylactic antibiotics for Caesarean section should be 15 to 60minutes prior to skin incision. No additional doses are recommended. (I-A) 4. If an open abdominal procedure is lengthy (>3hours) or estimated blood loss is greater than 1500mL, an additional dose of the prophylactic antibiotic may be given 3 to 4hours after the initial dose. (III-L) 5. Prophylactic antibiotics may be considered for the reduction of infectious morbidity associated with repair of third and fourth degree perineal injury. (I-B) 6. In patients with morbid obesity (BMI>35), doubling the antibiotic dose may be considered. (III-B) 7. Antibiotics should not be administered solely to prevent endocarditis for patients who undergo an obstetrical procedure of any kind. (III-E

Screening and Management of Bacterial Vaginosis in Pregnancy

OBJECTIVE To review the evidence and provide recommendations on screening for and management of bacterial vaginosis in pregnancy. OPTIONS The clinical practice options considered in formulating the guideline. OUTCOMES Outcomes evaluated include antibiotic treatment efficacy and cure rates, and the influence of the treatment of bacterial vaginosis on the rates of adverse pregnancy outcomes such as preterm labour and delivery and preterm premature rupture of membranes. EVIDENCE Medline, EMBASE, CINAHL, and Cochrane databases were searched for articles, published in English before the end of June 2007 on the topic of bacterial vaginosis in pregnancy. VALUES The evidence obtained was rated using the criteria developed by the Canadian Task Force on Preventive Health Care. BENEFITS, HARMS, AND COSTS Guideline implementation will assist the practitioner in developing an approach to the diagnosis and treatment of bacterial vaginosis in pregnant women. Patients will benefit from appropriate management of this condition. VALIDATION These guidelines have been prepared by the Infectious Diseases Committee of the SOGC, and approved by the Executive and Council of the SOGC. SPONSORS The Society of Obstetricians and Gynaecologists of Canada.

Management Guidelines for Obstetric Patients and Neonates Born to Mothers With Suspected or Probable Severe Acute Respiratory Syndrome (SARS)

Abstract Objective This document summarizes the limited experience of SARS in pregnancy and suggests guidelines for management. Outcomes Cases reported from Asia suggest that maternal and fetal outcomes are worsened by SARS during pregnancy. Evidence Medline was searched for relevant articles published in English from 2000 to 2007. Case reports were reviewed and expert opinion sought. Values Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care. Sponsors The Society of Obstetricians and Gynaecologists of Canada. Recommendations 1. All hospitals should have infection control systems in place to ensure that alerts regarding changes in exposure risk factors for SARS or other potentially serious communicable diseases are conveyed promptly to clinical units, including the labour and delivery unit. (III-C) 2. At times of SARS outbreaks, all pregnant patients being assessed or admitted to the hospital should be screened for symptoms of and risk factors for SARS. (III-C) 3. Upon arrival in the labour triage unit, pregnant patients with suspected and probable SARS should be placed in a negative pressure isolation room with at least 6 air exchanges per hour. All labour and delivery units caring for suspected and probable SARS should have available at least one room in which patients can safely labour and deliver while in need of airborne isolation. (III-C) 4. If possible, labour and delivery (including operative delivery or Caesarean section) should be managed in a designated negative pressure isolation room, by designated personnel with specialized infection control preparation and protective gear. (III-C) 5. Either regional or general anaesthesia may be appropriate for delivery of patients with SARS. (III-C) 6. Neonates of mothers with SARS should be isolated in a designated unit until the infant has been well for 10 days, or until the mother’s period of isolation is complete. The mother should not breastfeed during this period. (III-C) 7. A multidisciplinary team, consisting of obstetricians, nurses, pediatricians, infection control specialists, respiratory therapists, and anaesthesiologists, should be identified in each unit and be responsible for the unit organization and implementation of SARS management protocols. (III-C) 8. Staff caring for pregnant SARS patients should not care for other pregnant patients. Staff caring for pregnant SARS patients should be actively monitored for fever and other symptoms of SARS. Such individuals should not work in the presence of any SARS symptoms within 10 days of exposure to a SARS patient. (III-C) 9. All health care personnel, trainees, and support staff should be trained in infection control management and containment to prevent spread of the SARS virus. (III-A) 10. Regional health authorities in conjunction with hospital staff should consider designating specific facilities or health care units, including primary, secondary, or tertiary health care centres, to care for patients with SARS or similar illnesses. (III-A)

Management guidelines for obstetric patients and neonates born to mothers with suspected or probable severe acute respiratory syndrome (SARS): No. 225, April 2009

This document summarizes the limited experience of SARS in pregnancy and suggests guidelines for management.

Immunisation pendant la grossesse

Resume Objectif Analyser les resultats et offrir des recommandations quant a l’immunisation pendant la grossesse. Issues Parmi les issues evaluees, on trouve l’efficacite de l’immunisation, les risques et les avantages pour la mere et le fœtus. Resultats Des recherches ont ete menees dans les bases de donnees Medline et Cochrane en vue d’en tirer les articles, publies avant juillet 2007, portant sur l’immunisation pendant la grossesse. Valeurs Les donnees obtenues ont ete analysees et evaluees par le comite sur les maladies infectieuses de la Societe des obstetriciens et gynecologues du Canada (SOGC), sous la supervision des auteurs principaux, et des recommandations ont ete formulees conformement aux lignes directrices etablies par le Groupe d’etude canadien sur les soins de sante preventifs. Avantages, desavantages et couts La mise en œuvre des recommandations de la presente directive clinique devrait mener a une meilleure immunisation des femmes enceintes et des femmes qui allaitent, a une attenuation du risque d’immunisation contre-indiquee et a une meilleure prevention de la maladie. Recommandations 1. Avant de proceder a l’immunisation de toute femme en âge de procreer, le fournisseur de soins devrait chercher a ecarter la presence possible d’une grossesse chez celle-ci. (III-A) 2. Les fournisseurs de soins devraient obtenir les antecedents quant a l’immunisation de toutes les femmes qui les consultent afin d’obtenir des soins prenatals. (III-A) 3. En general, les vaccins a virus vivant et/ou a virus vivant-attenue sont contre-indiques pendant la grossesse, et ce, en raison de la presence d’un risque (essentiellement theorique) pour le fœtus. (II-3B) 4. Les femmes qui ont recu, par inadvertance, une immunisation au moyen de vaccins vivants ou vivants-attenues pendant la grossesse ne devraient pas etre avisees de proceder a une interruption de grossesse motivee par la presence d’un risque de teratogenicite. (II-2A) 5. Les femmes n’etant pas enceintes qui ont ete immunisees au moyen d’un vaccin vivant ou vivant-attenue devraient etre avisees de reporter la grossesse pendant au moins quatre semaines. (III-B) 6. L’administration de vaccins viraux inactives, de vaccins bacteriens et de toxoides pendant la grossesse est consideree comme etant sure. (II-1A) 7. Les femmes qui allaitent peuvent tout de meme etre immunisees (immunisation passive-active, vaccins vivants ou morts). (II-1A) 8. Les femmes enceintes devraient se voir offrir le vaccin antigrippal lorsque leur grossesse coincide avec la saison de la grippe. (II-1A)