Washington, DC — As new technologies for cervical cancer screening continue to improve, recommendations for ob-gyns and other women's health care providers must be updated in order to provide the best care for patients. Today, in a revised Practice Bulletin, the American College of Obstetricians and Gynecologists (ACOG) highlights a number of changes and updates for providers, including discussion regarding the role for cervical cancer screening with human papillomavirus (HPV) testing alone, HPV vaccination to include the new 9-valent vaccine, and revised guidelines for cervical cancer screening in HIV-positive women.
"Cervical cancer screening recommendations are always evolving just like the technology behind the screening tests," said David Chelmow, MD, who led the development of the Practice Bulletin, "Cervical Cancer Screening and Prevention." "Clarifying and updating our guidelines to reflect new screening methods and vaccinations are essential for women's health care providers."
Existing cervical cancer screening guidelines predate the U.S. Food and Drug Administration (FDA) approval of a currently marketed HPV test for the additional indication of primary cervical cancer screening. The Practice Bulletin provides interim guidance on the use of the FDA-approved HPV test for primary cervical cancer screening, which it states can be considered as an alternative to current cytology-based cancer screening methods (the Pap test) in women 25 years and older. Women younger than 25 years should continue to be screened with cytology alone. Additional guidance is included that addresses a number of important clinical issues not specified in the FDA product labeling for the test, including when to rescreen after a negative test result, how to manage positive test results, and when to stop screening in women with negative screening histories.
Due to widespread screening over the past 30 years, the incidence of and mortality from cervical cancer has decreased by more than 50%. HPV vaccination now allows the primary prevention of cervical cancer. The Practice Bulletin includes guidance on the use of the new 9-valent HPV vaccine, which covers an additional 5 high-risk strains of the virus compared with the quadrivalent HPV vaccine. Given the high degree of protection with any HPV vaccine (bivalent, quadrivalent, or 9-valent), current recommendations are for administration of whichever HPV vaccine is readily available to females aged 9-26 years. It is crucial that ob-gyns and other adolescent and women's health care providers educate parents and patients on the benefits, efficacy and safety of HPV vaccination.
The Practice Bulletin also clarifies and updates ACOG recommendations on cervical cancer screening in HIV-positive women, now allowing every three year Pap testing in women who have had three consecutive normal annual Pap tests, and use of every 3 year co-testing in women ages 30 and older.
Other recommendations issued in the January Obstetrics & Gynecology:
Committee Opinion #652, Interim Update, Magnesium Sulfate Use in Obstetrics
The U.S. Food and Drug Administration advises against the use of magnesium sulfate injections for more than 5-7 days to stop preterm labor in pregnant women. Based on this, the drug classification was changed from Category A to Category D, and the labeling was changed to include this new warning information. However, the U.S. Food and Drug Administration's change in classification addresses an unindicated and nonstandard use of magnesium sulfate in obstetric care. The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine continue to support the short-term (usually less than 48 hours) use of magnesium sulfate in obstetric care for appropriate conditions and for appropriate durations of treatment, which includes the prevention and treatment of seizures in women with preeclampsia or eclampsia, fetal neuroprotection before anticipated early preterm (less than 32 weeks of gestation) delivery, and short-term prolongation of pregnancy (up to 48 hours) to allow for the administration of antenatal corticosteroids in pregnant women who are at risk of preterm delivery within 7 days.
Practice Bulletin #158, Interim Update, Critical Care in Pregnancy
Critical care in pregnancy is a field that remains unevenly researched. Although there is a body of evidence to guide many recommendations in critical care, limited research specifically addresses obstetric critical care. The purpose of this document is to review the available evidence, propose strategies for care, and highlight the need for additional research. Much of the review will, of necessity, focus on general principles of critical care, extrapolating where possible to obstetric critical care.
Practice Bulletin #159, Interim Update, Management of Preterm Labor
Preterm birth is the leading cause of neonatal mortality and the most common reason for antenatal hospitalization (1-4). In the United States, approximately 12% of all live births occur before term, and preterm labor preceded approximately 50% of these preterm births (5, 6). Although the causes of preterm labor are not well understood, the burden of preterm births is clear-preterm births account for approximately 70% of neonatal deaths and 36% of infant deaths as well as 25-50% of cases of long-term neurologic impairment in children (7-9). A 2006 report from the Institute of Medicine estimated the annual cost of preterm birth in the United States to be $26.2 billion or more than $51,000 per premature infant (10). However, identifying women who will give birth preterm is an inexact process. The purpose of this document is to present the various methods proposed to manage preterm labor and to review the evidence for the roles of these methods in clinical practice. Identification and management of risk factors for preterm labor are not addressed in this document.
Practice Bulletin #160, Interim Update, Premature Rupture of Membranes
Preterm delivery occurs in approximately 12% of all births in the United States and is a major factor that contributes to perinatal morbidity and mortality (1, 2). Preterm premature rupture of membranes (PROM) complicates approximately 3% of all pregnancies in the United States (3). The optimal approach to clinical assessment and treatment of women with term and preterm PROM remains controversial. Management hinges on knowledge of gestational age and evaluation of the relative risks of delivery versus the risks of expectant management (eg, infection, abruptio placentae, and umbilical cord accident). The purpose of this document is to review the current understanding of this condition and to provide management guidelines that have been validated by appropriately conducted outcome-based research when available. Additional guidelines on the basis of consensus and expert opinion also are presented.
The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of approximately 58,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org