Washington, DC – In the United States, preterm birth is the leading cause of neonatal mortality. The American College of Obstetricians and Gynecologists (ACOG) is dedicated to fighting this statistic on every front. Thus in a new Committee Opinion released today, along with a series of Interim Updates, ACOG outlines expanded uses of antenatal corticosteroids to combat negative outcomes of preterm birth. The most significant document among these, “Antenatal Corticosteroid Therapy for Fetal Maturation,” overviews the many instances where corticosteroids can be successfully administered in advance of preterm birth to improve newborn outcomes. A number of Practice Bulletins also underwent focused changes to support the Committee Opinion. The materials comprehensively address preterm birth, providing resources to guide women’s health care providers in multiple clinical contexts at every step. All of these documents are a part of ACOG’s efforts to ensure a healthy mother has a healthy baby.
As ACOG continues its commitment to improving and applying the current best practices in obstetrical care, dedicated and focused attention on preterm birth and associated outcomes are an essential component. Likewise, ACOG supports and encourages investment in learning, solutions, and strategies for women’s health care providers that will help eliminate instances of preterm birth.
In addition to the long-standing recommendation to administer corticosteroids for women between 24 and 34 weeks pregnant anticipated to go into imminent preterm labor, the Committee Opinion includes new recommendations that support the administration of antenatal corticosteroids in certain populations during the late preterm birth period, or between 34 and 37 weeks of gestation. This recommendation comes on the heels of significant Antenatal Late Preterm Steroids (ALPS) trial, published earlier this year. The document also re-emphasizes ACOG’s recommendation to consider antenatal corticosteroids for pregnant women at risk of preterm delivery starting at 23 weeks of gestation, based on a family’s decision regarding resuscitation.
Once administered, over the next two to seven days, the antenatal corticosteroids help accelerate the maturation of a fetus’ lungs, increasing the likelihood of successful and independent function outside the womb. Recent data have shown that corticosteroids can also have long-term effect on preterm infant outcomes. Data from NICHD Neonatal Research Network indicated a reduction in death and neurodevelopmental impairment in infants (18-22 months) who were born at 23-25 weeks and whose mothers received antenatal corticosteroids, as compared to similar preterm infants whose mothers did not receive corticosteroids.
“Providing women’s health care providers with evidence-based techniques to successfully manage instances of preterm birth is a top priority for ACOG,” said one of the Committee Opinion authors, Dr. Yasser El-Sayed, MD, FACOG. “Through the new committee opinion we are expanding an existing therapy, based on recent data, to improve outcomes in more clinical settings. It’s an important step in getting more mothers and babies the care they need to be healthy.”
Dr. El-Sayed also underscored the need for continued surveillance and quality improvement strategies to optimize the administration of antenatal corticosteroids, saying, “There is a need to increase the awareness and use of existing and expanded therapies to improve preterm birth outcomes, including quality initiatives that ensure adherence with best practices. We must also continue to press for more research evaluating preterm birth therapies among specific populations and long term outcomes.”
This new Committee Opinion replaces ACOG’s Practice Advisory on Antenatal Corticosteroid Administration in the Late Preterm Period, originally issued on April 4, 2016. Importantly, ACOG has issued a series of Interim Updates, or limited, focused revisions, to align existing documents with the new Committee Opinion. This includes updates to Practice Bulletin 169, “Multifetal Gestations: Twin, Triplet and Higher-Order Multifetal Pregnancies,” Practice Bulletin 170, “Critical Care in Pregnancy,” “Practice Bulletin 171: Management of Preterm Labor,” and Practice Bulletin 172, “Premature Rupture of Membranes.”
The Committee Opinion, “Antenatal Corticosteroid Therapy for Fetal Maturation,” and updated versions of Practice Bulletin #169, “Multifetal Gestations: Twin, Triplet and Higher-Order Multifetal Pregnancies,” Practice Bulletin #170, “Critical Care in Pregnancy,” Practice Bulletin #171, “Management of Preterm Labor,” and Practice Bulletin #172, “Premature Rupture of Membranes,” are available in the October 2016 issue of Obstetrics and Gynecology.
For more information and resources visit acog.org/More-Info/AntenatalCorticosteroids.
Other recommendations issued in the October Obstetrics & Gynecology:
Committee Opinion #675, Management of Vulvar Intraepithelial Neoplasia
Vulvar intraepithelial neoplasia (VIN) is an increasingly common problem, particularly among women in their 40s. Although spontaneous regression has been reported, VIN should be considered a premalignant condition. Immunization with the quadrivalent or 9-valent human papillomavirus vaccine, which is effective against human papillomavirus genotypes 6, 11, 16, and 18, and 6, 11, 16, 18, 31, 33, 45, 52, and 58, respectively, has been shown to decrease the risk of vulvar high-grade squamous intraepithelial lesion (HSIL) (VIN usual type) and should be recommended for girls aged 11–12 years with catch-up through age 26 years if not vaccinated in the target age. There are no screening strategies for the prevention of vulvar cancer through early detection of vulvar HSIL (VIN usual type). Detection is limited to visual assessment with confirmation by histopathology when needed. Treatment is recommended for all women with vulvar HSIL (VIN usual type). Because of the potential for occult invasion, wide local excision should be performed if cancer is suspected, even if biopsies show vulvar HSIL. When occult invasion is not a concern, vulvar HSIL (VIN usual type) can be treated with excision, laser ablation, or topical imiquimod (off-label use). Given the relatively slow rate of progression, women with a complete response to therapy and no new lesions at follow-up visits scheduled 6 months and 12 months after initial treatment should be monitored by visual inspection of the vulva annually thereafter.
Committee Opinion #676, Health Literacy to Promote Quality of Care
Health literacy is defined as the degree to which individuals have the capacity to obtain, process, and understand the basic health information and services they need to make appropriate health decisions. Multiple factors affect a patient’s understanding of health information, including cultural factors, a physician’s health knowledge and communication skills, the demands of the situation, the environment in which the health information is being conveyed, and time constraints. The responsibility for recognizing and addressing the problem of limited health literacy lies with all entities in the health care system, from primary care physicians to community-based or public health organizations. Because of the potential effect of health literacy on patient outcomes, obstetrician– gynecologists should take the appropriate steps to ensure that they communicate in an understandable manner so patients can make informed decisions about their health care.
Practice Bulletin #167, Gynecologic Care for Women and Adolescents With Human Immunodeficiency Virus
In the United States in 2013, there were an estimated 226,000 women and adolescents living with human immunodeficiency virus (HIV) infection. Women with HIV are living longer, healthier lives, so the need for routine and problem-focused gynecologic care has increased. The purpose of this document is to educate clinicians about basic health screening and care, family planning, prepregnancy care, and managing common gynecologic problems for women and adolescents who are infected with HIV. For information on screening guidelines, refer to the American College of Obstetricians and Gynecologists’ Committee Opinion No. 596, Routine Human Immunodeficiency Virus Screening.
Practice Bulletin #168, Cervical Cancer Screening and Prevention
The incidence of cervical cancer in the United States has decreased more than 50% in the past 30 years because of widespread screening. In 1975, the rate was 14.8 per 100,000 women. By 2011, it decreased to 6.7 per 100,000 women. Mortality from the disease has undergone a similar decrease from 5.55 per 100,000 women in 1975 to 2.3 per 100,000 women in 2011. The American Cancer Society (ACS) estimated that there would be 12,900 new cases of cervical cancer in the United States in 2015, with 4,100 deaths from the disease. Cervical cancer is much more common worldwide, particularly in countries without screening programs, with an estimated 527,624 new cases of the disease and 265,672 resultant deaths each year. When cervical cancer screening programs have been introduced into communities, marked reductions in cervical cancer incidence have followed. New technologies for cervical cancer screening continue to evolve, as do recommendations for managing the results. In addition, there are different risk–benefit considerations for women at different ages, as reflected in age specific screening recommendations. In 2011, the ACS, the American Society for Colposcopy and Cervical Pathology (ASCCP), and the American Society for Clinical Pathology (ASCP) updated their joint guidelines for cervical cancer screening, as did the U.S. Preventive Services Task Force (USPSTF). Subsequently, in 2015, ASCCP and the Society of Gynecologic Oncology (SGO) issued interim guidance for the use of a human papillomavirus (HPV) test for primary screening for cervical cancer that was approved in 2014 by the U.S. Food and Drug Administration (FDA). The purpose of this document is to provide a review of the best available evidence regarding the prevention and early detection of cervical cancer.