Caroline Paquet

Cytomegalovirus Infection in Pregnancy

OBJECTIVES To review the principles of prenatal diagnosis of congenital cytomegalovirus (CMV) infection and to describe the outcomes of the affected pregnancies. OUTCOMES Effective management of fetal infection following primary and secondary maternal CMV infection during pregnancy. Neonatal signs include intrauterine growth restriction (IUGR), microcephaly, hepatosplenomegaly, petechiae, jaundice, chorioretinitis, thrombocytopenia and anemia, and long-term sequelae consist of sensorineural hearing loss, mental retardation, delay of psychomotor development, and visual impairment. These guidelines provide a framework for diagnosis and management of suspected CMV infections. EVIDENCE Medline was searched for articles published in English from 1966 to 2009, using appropriate controlled vocabulary (congenital CMV infection) and key words (intrauterine growth restriction, microcephaly). Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated into the guideline. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice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. RECOMMENDATIONS The quality of evidence reported in this document has been assessed using the evaluation of evidence criteria in the Report of the Canadian Task Force on Preventive Health Care (Table 1). 1. Diagnosis of primary maternal cytomegalovirus (CMV) infection in pregnancy should be based on de-novo appearance of virus-specific IgG in the serum of a pregnant woman who was previously seronegative, or on detection of specific IgM antibody associated with low IgG avidity. (II-2A) 2. In case of primary maternal infection, parents should be informed about a 30% to 40% risk for intrauterine transmission and fetal infection, and a risk of 20% to 25% for development of sequelae postnatally if the fetus is infected. (II-2A) 3. The prenatal diagnosis of fetal CMV infection should be based on amniocentesis, which should be done at least 7 weeks after presumed time of maternal infection and after 21 weeks of gestation. This interval is important because it takes 5 to 7 weeks following fetal infection and subsequent replication of the virus in the kidney for a detectable quantity of the virus to be secreted to the amniotic fluid. (II-2A) 4. The diagnosis of secondary infection should be based on a significant rise of IgG antibody titre with or without the presence of IgM and high IgG avidity. In cases of proven secondary infection, amniocentesis may be considered, but the risk-benefit ratio is different because of the low transmission rate. (III-C) 5. Following a diagnosis of fetal CMV infection, serial ultrasound examinations should be performed every 2 to 4 weeks to detect sonographic abnormalities, which may aid in determining the prognosis of the fetus, although it is important to be aware that the absence of sonographic findings does not guarantee a normal outcome. (II-2B) 6. Quantitative determination of CMV DNA in the amniotic fluid may assist in predicting the fetal outcome. (II-3B) 7. Routine screening of pregnant women for CMV by serology testing is currently not recommended. (III-B) 8. Serologic testing for CMV may be considered for women who develop influenza-like illness during pregnancy or following detection of sonographic findings suggestive of CMV infection. (III-B) 9. Seronegative health care and child care workers may be offered serologic monitoring during pregnancy. Monitoring may also be considered for seronegative pregnant women who have a young child in day care. (III-B).

Antibiotic Prophylaxis in Gynaecologic Procedures

Abstract Objective To review the evidence and provide recommendations on antibiotic prophylaxis for gynaecologic procedures. Outcomes Outcomes evaluated include need and effectiveness of antibiotics to prevent infections in gynaecologic procedures. Evidence Medline and The Cochrane Library were searched for articles published between January 1978 and January 2011 on the topic of antibiotic prophylaxis in gynaecologic procedures. Results were restricted to systematic reviews, randomized control trials/ controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated in the guideline to June 2011. 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 quality of evidence obtained was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table 1). Benefits, harms, and costs Guideline implementation should result in a reduction of cost and related harm of administering antibiotics when not required and a reduction of infection and related morbidities when antibiotics have demonstrated a proven benefit. Recommendations 1. All women undergoing an abdominal or vaginal hysterectomy should receive antibiotic prophylaxis. (I-A) 2. All women undergoing laparoscopic hysterectomy or laparoscopically assisted vaginal hysterectomy should receive prophylactic antibiotics. (III-B) 3. The choice of antibiotic for hysterectomy should be a single dose of a first-generation cephalosporin. If patients are allergic to cephalosporin, then clindamycin, erythromycin, or metronidazole should be used. (I-A) 4. Prophylactic antibiotics should be administered 15 to 60 minutes prior to skin incision. No additional doses are recommended. (I-A) 5. If an open abdominal procedure is lengthy (e.g., > 3 hours), or if the estimated blood loss is > 1500 mL, an additional dose of the prophylactic antibiotic may be given 3 to 4 hours after the initial dose. (III-C) 6. Antibiotic prophylaxis is not recommended for laparoscopic procedures that involve no direct access from the abdominal cavity to the uterine cavity or vagina. (l-E) 7. All women undergoing surgery for pelvic organ prolapse and/or stress urinary incontinence should receive a single dose of firstgeneration cephalosporin. (III-B) 8. Antibiotic prophylaxis is not recommended for hysteroscopic surgery. (II-2D) 9. All women undergoing an induced (therapeutic) surgical abortion should receive prophylactic antibiotics to reduce the risk of postabortal infection. (I-A) 10. Prophylactic antibiotics are not suggested to reduce infectious morbidity following surgery for a missed or incomplete abortion. (I-E) 11. Antibiotic prophylaxis is not recommended for insertion of an intrauterine device. (I-E) However, health care professionals could consider screening for sexually transmitted infections in high-risk populations. (III-C) 12. There is insufficient evidence to support the use of antibiotic prophylaxis for an endometrial biopsy. (III-L) 13. The best method to prevent infection after hysterosalpingography is unknown. Women with dilated tubes found at the time of hysterosalpingography are at highest risk, and prophylactic antibiotics (e.g., doxycycline) should be given. (II-3B) 14. Antibiotic prophylaxis is not recommended for urodynamic studies in women at low risk, unless the incidence of urinary tract infection post-urodynamics is > 10%. (1-E) 15. In patients with morbid obesity (BMI > 35 kg/m2), doubling the antibiotic dose may be considered. (III-B) 16 Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary procedure. (III-E)

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

Guidelines for the Management of Herpes Simplex Virus in Pregnancy

OBJECTIVE To provide recommendations for the management of genital herpes infection in women who want to get pregnant or are pregnant and for the management of genital herpes in pregnancy and strategies to prevent transmission to the infant. OUTCOMES More effective management of complications of genital herpes in pregnancy and prevention of transmission of genital herpes from mother to infant. EVIDENCE Medline was searched for articles published in French or English related to genital herpes and pregnancy. Additional articles were identified through the references of these articles. All study types and recommendation reports were reviewed. VALUES Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care.

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.

Principles of human teratology: drug, chemical, and infectious exposure.

OBJECTIVE To provide a teratology update for prescription and non-prescription drugs and infections during pregnancy. OPTIONS Limited to teratology principles and possible common exposures during pregnancy. EVIDENCE A search of Medline and textbooks was conducted for information published to June 2006 on teratology exposure risks. This document represents an abstraction of the information. BENEFITS, HARMS, AND COSTS This consensus provides practitioners with a summary of information regarding teratology risks for drug, chemical, and infection exposures during pregnancy.

HIV Screening in Pregnancy

OBJECTIVE The purpose of this guideline is to provide recommendations to obstetric health care providers and to minimize practice variations for HIV screening, while taking provincial and territorial recommendations into account. OUTCOMES The risk of transmission of HIV from mother to fetus is significant if the mother is not treated. The primary outcome of screening for and treating HIV in pregnancy is a marked decrease in the rate of vertical transmission of HIV from mother to fetus. Secondary outcomes include confirmation of HIV infection in the woman, which allows optimization of her health and long-term management. EVIDENCE The Cochrane Library and Medline were searched for English-language articles published related to HIV screening and pregnancy. Additional articles were identified through the references of these articles. All study types were reviewed.

Management of Group B Streptococcal Bacteriuria in Pregnancy

OBJECTIVE To provide information regarding the management of group B streptococcal (GBS) bacteriuria to midwives, nurses, and physicians who are providing obstetrical care. OUTCOMES The outcomes considered were neonatal GBS disease, preterm birth, pyelonephritis, chorioamnionitis, and recurrence of GBS colonization. EVIDENCE Medline, PubMed, and the Cochrane database were searched for articles published in English to December 2010 on the topic of GBS bacteriuria in pregnancy. Bacteriuria is defined in this clinical practice guideline as the presence of bacteria in urine, regardless of the number of colony-forming units per mL (CFU/mL). Low colony counts refer to < 100 000 CFU/mL, and high (significant) colony counts refer to ≥ 100 000 CFU/mL. Results were restricted to systematic reviews, randomized controlled trials, and relevant observational studies. Searches were updated on a regular basis and incorporated in the guideline to February 2011. 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 Recommendations were quantified using the evaluation of evidence guidelines developed by the Canadian Task Force on Preventive Health Care (Table). BENEFITS, HARMS, AND COSTS The recommendations in this guideline are designed to help clinicians identify pregnancies in which it is appropriate to treat GBS bacteriuria to optimize maternal and perinatal outcomes, to reduce the occurrences of antibiotic anaphylaxis, and to prevent increases in antibiotic resistance to GBS and non-GBS pathogens. No cost-benefit analysis is provided. RECOMMENDATIONS 1. Treatment of any bacteriuria with colony counts ≥ 100 000 CFU/mL in pregnancy is an accepted and recommended strategy and includes treatment with appropriate antibiotics. (II-2A) 2. Women with documented group B streptococcal bacteriuria (regardless of level of colony-forming units per mL) in the current pregnancy should be treated at the time of labour or rupture of membranes with appropriate intravenous antibiotics for the prevention of early-onset neonatal group B streptococcal disease. (II-2A) 3. Asymptomatic women with urinary group B streptococcal colony counts < 100 000 CFU/mL in pregnancy should not be treated with antibiotics for the prevention of adverse maternal and perinatal outcomes such as pyelonephritis, chorioamnionitis, or preterm birth. (II-2E) 4. Women with documented group B streptococcal bacteriuria should not be re-screened by genital tract culture or urinary culture in the third trimester, as they are presumed to be group B streptococcal colonized. (II-2D).

Vulvovaginitis: Screening for and Management of Trichomoniasis, Vulvovaginal Candidiasis, and Bacterial Vaginosis

OBJECTIVE To review the evidence and provide recommendations on screening for and management of vulvovaginal candidiasis, trichomoniasis, and bacterial vaginosis. OUTCOMES OUTCOMES evaluated include the efficacy of antibiotic treatment, cure rates for simple and complicated infections, and the implications of these conditions in pregnancy. EVIDENCE Published literature was retrieved through searches of MEDLINE, EMBASE, CINAHL, and The Cochrane Library in June 2013 using appropriate controlled vocabulary (e.g., vaginitis, trichomoniasis, vaginal candidiasis) and key words (bacterial vaginosis, yeast, candidiasis, trichomonas vaginalis, trichomoniasis, vaginitis, treatment). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to May 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, and national and international medical specialty societies. VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Summary Statements 1. Vulvovaginal candidiasis affects 75% of women at least once. Topical and oral antifungal azole medications are equally effective. (I) 2. Recurrent vulvovaginal candidiasis is defined as 4 or more episodes per year. (II-2) 3. Trichomonas vaginalis is a common non-viral sexually transmitted infection that is best detected by antigen testing using vaginal swabs collected and evaluated by immunoassay or nucleic acid amplification test. (II-2) 4. Cure rates are equal at up to 88% for trichomoniasis treated with oral metronidazole 2 g once or 500 mg twice daily for 7 days. Partner treatment, even without screening, enhances cure rates. (I-A) 5. Current evidence of the efficacy of alternative therapies for bacterial vaginosis (probiotics, vitamin C) is limited. (I) Recommendations 1. Following initial therapy, treatment success of recurrent vulvovaginal candidiasis is enhanced by maintenance of weekly oral fluconazole for up to 6 months. (II-2A) 2. Symptomatic vulvovaginal candidiasis treated with topical azoles may require longer courses of therapy to be resolved. (1-A) 3. Test of cure following treatment of trichomoniasis with oral metronidazole is not recommended. (I-D) 4. Higher-dose therapy may be needed for treatment-resistant cases of trichomoniasis. (I-A) 5. In pregnancy, treatment of symptomatic Trichomonas vaginalis with oral metronidazole is warranted for the prevention of preterm birth. (I-A) 6. Bacterial vaginosis should be diagnosed using either clinical (Amsels) or laboratory (Gram stain with objective scoring system) criteria. (II-2A) 7. Symptomatic bacterial vaginosis should be treated with oral metronidazole 500 mg twice daily for 7 days. Alternatives include vaginal metronidazole gel and oral or vaginal clindamycin cream. (I-A) 8. Longer courses of therapy for bacterial vaginosis are recommended for women with documented multiple recurrences. (I-A).

Best Practices to Minimize Risk of Infection With Intrauterine Device Insertion

BACKGROUND Intrauterine devices provide an extremely effective, long-term form of contraception that has the benefit of being reversible. Historically, the use of certain intrauterine devices was associated with increased risk of pelvic inflammatory disease. More recent evidence suggests that newer devices do not carry the same threat; however, certain risk factors can increase the possibility of infection. OBJECTIVES To review the risk of infection with the insertion of intrauterine devices and recommend strategies to prevent infection. OUTCOMES The outcomes considered were the risk of pelvic inflammatory disease, the impact of screening for bacterial vaginosis and sexually transmitted infections including chlamydia and gonorrhea; and the role of prophylactic antibiotics. EVIDENCE Published literature was retrieved through searches of PubMed, Embase, and The Cochrane Library on July 21, 2011, using appropriate controlled vocabulary (e.g., intrauterine devices, pelvic inflammatory disease) and key words (e.g., adnexitis, endometritis, IUD). An etiological filter was applied in PubMed. The search was limited to the years 2000 forward. There were no language restrictions. Grey (unpublished) literature was identified through searching the web sites of national and international medical specialty societies. VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table). Recommendations 1. All women requesting an intrauterine device should be counselled about the small increased risk of pelvic inflammatory disease in the first 20 days after insertion. (II-2A) 2. All women requesting an intrauterine device should be screened by both history and physical examination for their risk of sexually transmitted infection. Women at increased risk should be tested prior to or at the time of insertion; however, it is not necessary to delay insertion until results are returned. (II-2B) 3. Not enough current evidence is available to support routine screening for bacterial vaginosis at the time of insertion of an intrauterine device in asymptomatic women. (II-2C) 4. Routine use of prophylactic antibiotics is not recommended prior to intrauterine device insertion, although it may be used in certain high-risk situations. (I-C) 5. Standard practice includes cleansing the cervix and sterilizing any instruments that will be used prior to and during insertion of an intrauterine device. (III-C) 6. In treating mild to moderate pelvic inflammatory disease, it is not necessary to remove the intrauterine device during treatment unless the patient requests removal or there is no clinical improvement after 72 hours of appropriate antibiotic treatment. In cases of severe pelvic inflammatory disease, consideration can be given to removing the intrauterine device after an appropriate antibiotic regimen has been started. (I-B) 7. An intrauterine device is a safe, effective option for contraception in an HIV-positive woman. (I-B) 8. An intrauterine device can be considered a first-line contraceptive agent in adolescents. (I-A).