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Practice Advisory: Updated Interim Guidance for Care of Women of Reproductive Age During a Zika Virus Outbreak

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* Update (June 23, 2016)

From the
Centers for Disease Control and Prevention: Testing for Zika virus infection using real-time reverse-transcription polymerase chain reaction (rRT-PCR) molecular assays is now commercially available. When requesting Zika rRT-PCR testing from a commercial laboratory, providers should be aware that commercial laboratories performing rRT-PCR currently do not also offer Zika IgM enzyme-linked immunosorbent assay (ELISA) or confirmatory serologic testing (plaque reduction neutralization test, or PRNT). Therefore, if possible, providers should store a serum aliquot for subsequent Zika IgM ELISA testing if the rRT-PCR assay is negative. Otherwise, collection of an additional serum sample may be necessary.

 

  • rRT-PCR (molecular) testing should be performed for patients possibly exposed to Zika virus who have symptoms consistent with Zika virus infection.
  • Providers who request molecular testing for Zika virus infection from a commercial testing laboratory are advised to retain and store in a refrigerator (2-8°C) an aliquot of the patient's serum for subsequent Zika IgM ELISA testing if the rRT-PCR is negative.
  • For specimens that are rRT-PCR negative from the commercial laboratory and no stored serum specimen is available, another serum specimen should be collected within 12 weeks of symptom onset for Zika IgM ELISA testing.
  • Appropriate samples for molecular testing are serum samples collected <7 days and urine samples collected <14 days after symptom onset. Urine should always be collected with a patient-matched serum specimen.

 

Regardless of whether a provider requests testing from a commercial or non-commercial laboratory, ACOG encourages providers to be aware of how the laboratory performs Zika testing so that providers can retain or collect additional serum specimens as needed. 

* Update (June 10, 2016)

Because Zika Virus may be found in both urine and blood, the Centers for Disease Control and Prevention now recommends sending both urine and blood samples for PCR testing. If the PCR is negative, IgM testing should be performed; depending on the lab performing the test, providers may need to send a new blood sample for IgM testing.

(March 31, 2016)

This is an update and replacement of ACOG’s and SMFM's Practice Advisory released on February 12, 2016. Zika continues to be an area of evolving care and practice. Recommendations below are based on limited data. Fellows should check periodically for revisions and updates on ACOG’s Practice Advisories webpage and Zika webpages (www.acog.org/zika and http://immunizationforwomen.org/providers/Zika-Virus-Updates), CDC’s web site, and SMFM’s web site. ACOG and SMFM will communicate important changes and updates to this guidance.

On March 25, 2016, CDC issued updated Interim Guidelines for Health Care Providers Caring for Pregnant Women and Women of Reproductive Age with Possible Zika Virus (ZIKV) Exposure. This Practice Advisory reiterates the prevention strategies to minimize exposure to Zika and summarizes the current guidance for management of pregnant women who have been exposed and women of reproductive age.

Summary of Updated Guidance:

  • Women diagnosed with ZIKV disease should wait at least 8 weeks after symptom onset to attempt pregnancy. Men diagnosed with ZIKV disease should wait at least 6 months after symptom onset to attempt pregnancy. Asymptomatic women and men with possible exposure to ZIKV should wait at least 8 weeks after exposure before attempting pregnancy.
  • Consideration of amniocentesis has been removed from the CDC recommended testing algorithm. A decision regarding amniocentesis should be individualized for each clinical scenario on a case by case basis as with other congenital infections.
  • Prevention of unintended pregnancies in the context of a ZIKV outbreak is especially important as an approach to reducing the likelihood of congenital infections.
  • Adherence to Standard Precautions is necessary to protect health care providers and patients in labor and delivery settings from transmission of ZIKV. The appropriate use of personal protective equipment is important for all health care providers to minimize the risk of transmission of infectious pathogens through exposure to blood and body fluids. There is no evidence that contact precautions or respiratory isolation of ZIKV infected patients is warranted.
  • CDC established the U.S. Zika Pregnancy Registry and is collaborating with state, tribal, local, and territorial health departments to collect information about ZIKV infection during pregnancy and congenital ZIKV infection. Obstetrician–gynecologists and other health care providers are asked to report laboratory-confirmed cases of ZIKV to their state, tribal, local, or territorial health department and should notify state, tribal, local, or territorial health department staff or CDC registry staff of adverse events.
  • CDC maintains a 24/7 clinical consultation service for health care providers evaluating and caring for pregnant women and infants with possible ZIKV infection. Call CDC's Zika Pregnancy Hotline for Healthcare Providers at 770-488-7100 or e-mail zikamch@cdc.gov for any concerns related to clinical management.
  • ZIKV testing is performed at the CDC Arbovirus Diagnostic Laboratory and a few state health departments. Contact your state health department (ACOG members only) to facilitate testing using this list provided by CDC.

Background:

Zika was reported in May 2015 in South America and since then has spread throughout the Americas. The CDC and Pan American Health Organization (PAHO) web sites maintain and update the list of areas where ZIKV transmission has been identified.

The virus spreads to humans primarily through infected Aedes aegypti mosquitoes, however, it can also be transmitted sexually from an infected man to his sexual partners. Once a person is infected, the incubation period for the virus is approximately 3–14 days. This time frame is suggested based on limited experience from ZIKV cases as well as extrapolation from data on other flaviviruses. Symptoms of the disease are nonspecific but may include fever, rash, arthralgias, and conjunctivitis. It appears that only about one in five infected individuals will exhibit these symptoms and most of these will have mild symptoms. It is not known if pregnant women are at greater risk of infection than nonpregnant individuals.

Increasing evidence supports the link between ZIKV infection during pregnancy and adverse pregnancy outcomes such as pregnancy loss, microcephaly, and other brain and eye abnormalities. Transmission of Zika to the fetus has been documented in all trimesters; ZIKV RNA has been detected in fetal tissue from early missed abortions, amniotic fluid, term neonates, and the placenta. However, much is not yet known about ZIKV in pregnancy. Uncertainties include the incidence of ZIKV infection among pregnant women in areas of ZIKV transmission, the rate of vertical transmission and the rate with which infected fetuses manifest complications such as microcephaly or demise. However, one study utilizing modeling based on the ZIKV outbreak in French Polynesia suggested microcephaly would occur in 1% of babies born to mothers infected in the first trimester, and a recent cohort study from Brazil found abnormal outcomes including stillbirth, growth restriction, and microcephaly and other sonographic abnormalities in 29% of fetuses of Zika-infected mothers in all trimesters (Cauchemez, 2016, Brasil, 2016). Currently, there is no vaccine or treatment for this infection.

Prevention:

  • Avoiding exposure is best. When possible, pregnant women should delay travel to areas where Zika outbreaks are ongoing. Women considering pregnancy should discuss with their obstetric providers the advisability of travel. See the CDC and PAHO web sites for updated lists of affected countries and states. At this time, this travel warning pertains only to areas where local transmission of ZIKV is reported.
  • When traveling to areas where Zika has been reported, women should take all precautions to avoid mosquito bites including the use of EPA-approved bug spray with DEET, covering exposed skin, staying in air-conditioned or screened-in areas, and treating clothing with permethrin.
  • Providers should specifically communicate to pregnant women that when used as directed on the product label, EPA-registered insect repellents, particularly those with DEET and permethrin, can be used safely during pregnancy.
  • These protective measures should be followed both day and night as the Aedes aegypti mosquito (which carries ZIKV) bites primarily during the day as well as at dusk and dawn. Reapplication of insect repellant should be practiced as directed on the product label.

Evaluation and Management of Pregnant Women:*

Evaluation of pregnant women with a history of travel to an area with ongoing ZIKV transmission (detailed in Figure 1):

  • Recommend testing of pregnant women with clinical illness consistent with ZIKV disease (one or more of the following signs or symptoms: acute onset of fever, rash, arthralgia, conjunctivitis) during or within 2 weeks of travel, using ZIKV RT PCR and Zika IgM. Fetal management should be based on test results (see below).*
  • For women without clinical illness consistent with ZIKV disease during or within 2 weeks of travel: Offer testing to pregnant women 2–12 weeks after exposure (travel) with Zika IgM. Fetal management should be based on test results (see below).

Evaluation of pregnant women residing in an area with ongoing ZIKV virus transmission (detailed in Figure 2):

  • If clinical illness consistent with Zika is reported, test for infection with PCR and IgM. Fetal management should be based on test results (see below).*
  • If no clinical illness, obtain IgM at first visit and repeat in late second trimester given ongoing exposure. Fetal management should be based on test results (see below).

ZIKV testing is performed at the CDC Arbovirus Diagnostic Laboratory and a few state health departments. Contact your state health department (ACOG members only) to facilitate testing using this list provided by CDC.

The many uncertainties about ZIKV biology highlight the challenges of managing and counseling about exposures and infection in pregnancy. Referral to a maternal–fetal medicine or infectious disease specialist with expertise in pregnancy management is recommended (Peterson, 2016) and may be useful particularly for those pregnancies with demonstrated maternal infection or concerning fetal findings.

Finally, obstetrician–gynecologists will need to report pregnant women with any laboratory evidence of ZIKV infection (positive or inconclusive test results) to the state health department. They can expect follow up from health officials during the pregnancy and at the time of expected birth to collect surveillance data. In addition, any adverse outcome should be reported to the state health department. CDC registry staff will work with state health departments to assist with collection of information. Ob-gyns can also contact the CDC pregnancy hotline to discuss women with laboratory evidence of ZIKV infection. If they contact CDC for clinical consultation, registry staff will ensure that state, tribal, local, or territorial health departments are notified.

For questions about the registry please e-mail: ZikaPregnancy@cdc.gov or call 770-488-7100.

Fetal Evaluation:

Ultrasound examinations are recommended for those living in, or who have traveled to, areas with ongoing ZIKV exposure. It seems reasonable to obtain the first ultrasound 3–4 weeks after symptoms or exposure (for those who have traveled to ZIKV areas but have no symptoms) or at 18–20 weeks (or as soon as first seen thereafter) for those living in an area with ZIKV infection who have no symptoms.

  • Ultrasound examinations should focus on development of findings such as intracranial calcifications and microcephaly and other brain abnormalities, as those abnormalities have been most frequently reported in affected pregnancies.
  • After a first reassuring ultrasound, serial ultrasounds are recommended in the setting of maternal infection (positive or inconclusive IgM and/or PCR), perhaps as frequently as every 3–4 weeks, and obtaining an additional ultrasound could be considered even among those with exposure alone because the natural history of ZIKV in utero infection is not known, and the time from exposure and infection to clinical manifestations is uncertain. Therefore one reassuring ultrasound, particularly if obtained close to the time of infection or exposure, may not preclude later manifestations, and cases with delayed findings have been reported.
  • Those with travel history but no evidence of ZIKV infection by serologic testing may be appropriate for less frequent ultrasound screening or routine prenatal care. However, at present, data do not permit the identification of an evidence-based interval and/or identify which pregnancies can avoid serial ultrasound entirely. The CDC notes that negative IgM 2–12 weeks after travel cannot definitively rule out ZIKV infection, but may eliminate the need for serial ultrasounds.
  • When imaging raises suspicion for fetal infection, amniocentesis for ZIKV testing of amniotic fluid may be considered on a case by case basis. While it is assumed that assay performance on amniotic fluid is similar to that with maternal serum, this is not certain. Nor is it known how long after a pregnant woman becomes infected she can transmit the virus to the fetus, for what duration amniotic fluid will be PCR positive, or what the ability of the test is to determine the presence of fetal injury.

Neonatal Outcomes and Evaluation:

Guidelines for infants whose mothers have possible ZIKV infection are available.

An important feature of the CDC guidance is the recommendation that specimens obtained after ZIKV infection is suspected or diagnosed should be sent to pathology for further evaluation. This includes fetal remains and placental tissue that can be examined using ZIKV RT-PCR, histopathologic examination, and immunohistochemical staining. This testing is recommended to advance the understanding of Zika infection in pregnancy and provide insight to patient counseling in the setting of fetal loss.

Sexual Transmission:

Sexual transmission of ZIKV has been reported but the frequency and efficiency of this route of infection is uncertain. Additional studies are needed to characterize the risk of sexual transmission of ZIKV; as more information becomes available, recommendations will be updated. Based on limited data, there is a risk of sexual transmission through exposure to semen of males with ZIKV infection. Given the potential risks of maternal ZIKV infection, pregnant women whose male partners have traveled to countries in which ZIKV is reported or those who have ZIKV infection should consider using condoms or abstaining from sexual intercourse for the remainder of pregnancy.

Reproductive Counseling:

Obstetrician–gynecologists and other health care providers should discuss pregnancy intentions and reproductive options with all women of reproductive age for shared decision making. In the context of the ongoing ZIKV outbreak, preconception care should include a discussion of the signs and symptoms and the potential risks of ZIKV infection. Women and men who reside in an area with ongoing transmission of ZIKV without clinical illness consistent with ZIKV disease and who desire pregnancy should talk with their health care providers. Health care providers should discuss their patients’ reproductive life plans in the context of potential ZIKV exposure; resources are available here. The risk of adverse pregnancy and birth outcomes associated with ZIKV disease during pregnancy highlights the need to ensure that effective contraception is readily available for women and couples who live in or have recently traveled to areas with local ZIKV transmission and who do not desire pregnancy (Oduyebo, 2016). Prevention of unintended pregnancies in the context of a ZIKV outbreak is especially important as an approach to reducing the likelihood of congenital infections.

Women Avoiding Pregnancy:

When women do not plan a pregnancy, obstetrician–gynecologists and other health care providers should discuss strategies to prevent unintended pregnancy and provide counseling on family planning and the use of contraceptive methods. Safety, effectiveness, availability, and acceptability should be considered when selecting a contraceptive method.

Women Who Desire Pregnancy:

Women who are diagnosed with ZIKV disease should wait at least 8 weeks from symptom onset to attempt pregnancy, and men diagnosed with ZIKV disease should wait at least 6 months from symptom onset to attempt pregnancy. These are estimates derived from the upper limit estimate for ZIKAV incubation (14 days) and approximate tripling of the longest published duration of known viremia after symptom onset (11 days). Routine ZIKV testing (IgM or PCR) is not currently recommended for women or men with possible ZIKV exposure without clinical illness who are attempting pregnancy. It is important to note that it is not known whether a positive serologic ZIKV test result in an asymptomatic man would indicate presence of ZIKV in semen, or if a negative serologic ZIKV test result would preclude ZIKV presence in semen.

No instances of ZIKV transmission during fertility treatment have been documented, but transmission through donated gametes or embryos is theoretically possible, given that ZIKV can be present in semen and sexual transmission of ZIKV has occurred. See CDC’s Update: Interim Guidelines for Health Care Providers Caring for Women of Reproductive Age with Possible ZIKV Exposure.

Breastfeeding:

Although the presence of ZIKV in breast milk has been reported, it is in very small amounts and unlikely to be harmful for the neonate. Infection through oral intake is not known and any effects of neonatal infection, as with adults, are likely to be mild and of short-term consequence. The benefits of breastfeeding likely outweigh the potential neonatal risks. Therefore, the recommendation is that women should continue to breastfeed.

Infection Control Considerations:

ZIKV RNA has been detected in many body fluids, including blood, urine, saliva, and amniotic fluid. No health care-associated transmission associated with exposure to these bodily fluids has been documented; however, minimizing exposures to body fluids is important. CDC, ACOG and SMFM recommend Standard Precautions in health care settings to protect obstetrician–gynecologists and other health care providers and patients from infection with ZIKV as well as from blood-borne pathogens. This emphasizes what should already be usual and expected practice. Adherence to Standard Precautions, the basic infection prevention measures that apply to patient care in all heath care settings, is necessary to protect health care providers and patients in labor and delivery settings from transmission of ZIKV, as well as blood-borne pathogens, such as human immunodeficiency virus and hepatitis C. The appropriate use of personal protective equipment is important for all health care providers to minimize the risk of transmission of infectious pathogens through exposure to blood and body fluids. There is no evidence that contact precautions or respiratory isolation of ZIKV-infected patients is warranted. See CDC’s new guidelines on Infection Control and ZIKV: Considerations for Labor and Delivery Units.

FIGURE 1. Updated interim guidance: testing algorithm*,†,§,¶,** for a pregnant woman with possible Zika virus exposure,** not residing in an area with active Zika virus transmission

March 31 PA Figure 2 Via CDC

* Testing is recommended for pregnant women with clinical illness consistent with Zika virus disease, including one or more of the following signs or symptoms: acute onset of fever, rash, arthralgia, or conjunctivitis during or within 2 weeks of travel or possible sexual exposure. Testing includes Zika virus reverse transcription-polymerase chain reaction (RT-PCR), and Zika virus immunoglobulin M (IgM) and neutralizing antibodies on serum specimens. More information is available at http://www.aphl.org/Materials/CDCMemo_Zika_Chik_Deng_Testing_011916.pdf. Because of the overlap of symptoms and areas for which other viral illnesses are endemic, evaluate for possible dengue or chikungunya virus infection.

Testing can be offered to pregnant women without clinical illness consistent with Zika virus disease. If performed, testing should include Zika virus IgM, and if IgM test result is positive or indeterminate, neutralizing antibodies on serum specimens. Testing should be performed 2–12 weeks after travel.

§ Laboratory evidence of maternal Zika virus infection: 1) Zika virus RNA detected by RT-PCR in any clinical specimen; or 2) positive Zika virus IgM with confirmatory neutralizing antibody titers that are ≥fourfold higher than dengue virus neutralizing antibody titers in serum. Testing is considered inconclusive if Zika virus neutralizing antibody titers are <fourfold higher than dengue virus neutralizing antibody titers.

Fetal abnormalities consistent with Zika virus disease include microcephaly, intracranial calcifications, and brain and eye abnormalities. Fetal ultrasounds might not detect abnormalities until late second or early third trimester of pregnancy.

** Possible exposure to Zika virus includes travel to an area with active Zika virus transmission (http://wwwnc.cdc.gov/travel/notices/), or sex (vaginal intercourse, anal intercourse, or fellatio) without a condom with a man who traveled to, or resided in, an area with active Zika virus transmission. Testing is not currently recommended for pregnant women with possible sexual exposure to Zika virus if both partners are asymptomatic.

Source: Petersen EE, Polen KN, Meaney-Delman D, et al. Update: Interim Guidance for Health Care Providers Caring for Women of Reproductive Age with Possible Zika Virus Exposure — United States, 2016. MMWR Morb Mortal Wkly Rep. ePub: 25 March 2016. DOI: http://dx.doi.org/10.15585/mmwr.mm6512e2er.

FIGURE 2. Updated interim guidance: testing algorithm*,†,§,¶,** for a pregnant women residing in an area with active Zika virus transmission,** with or without clinical illness †† consistent with Zika virus disease

March 31 PA Figure 2 Via CDC

* Tests for pregnant women with clinical illness consistent with Zika virus disease include Zika virus reverse transcription-polymerase chain reaction (RT-PCR), and Zika virus immunoglobulin M (IgM) and neutralizing antibodies on serum specimens. More information is available at http://www.aphl.org/Materials/CDCMemo_Zika_Chik_Deng_Testing_011916.pdf. Because of the overlap of symptoms and areas for which other viral illnesses are endemic, evaluate for possible dengue or chikungunya virus infection. If chikungunya or dengue virus RNA is detected, treat in accordance with existing guidelines. Timely recognition and supportive treatment for dengue virus infections can substantially lower the risk of medical complications and death. Repeat Zika virus testing during pregnancy is warranted if clinical illness consistent with Zika virus disease develops later in pregnancy.

Testing can be offered to pregnant women without clinical illness consistent with Zika virus disease. If performed, testing should include Zika virus IgM, and if IgM test result is positive or indeterminate, neutralizing antibodies on serum specimens. Results from serologic testing are challenging to interpret in areas where residents have had previous exposure to other flaviviruses (eg, dengue, yellow fever) because of cross-reactivity with other flaviviruses.

§ Laboratory evidence of maternal Zika virus infection: 1) Zika virus RNA detected by RT-PCR in any clinical specimen; or 2) positive Zika virus IgM with confirmatory neutralizing antibody titers that are ≥fourfold higher than dengue virus neutralizing antibody titers in serum. Testing would be considered inconclusive if Zika virus neutralizing antibody titers are <fourfold higher than dengue virus neutralizing antibody titer.

Fetal abnormalities consistent with Zika virus disease include microcephaly, intracranial calcifications, and brain and eye abnormalities. Fetal ultrasounds might not detect abnormalities until late second or early third trimester of pregnancy.

** http://wwwnc.cdc.gov/travel/notices/. Local health officials should determine when to implement testing of asymptomatic pregnant women based on information about levels of Zika virus transmission and laboratory capacity.

§§ Clinical illness is consistent with Zika virus disease if one or more signs or symptoms (acute onset of fever, rash, arthralgia, or conjunctivitis) are present.

Source: Petersen EE, Polen KN, Meaney-Delman D, et al. Update: Interim Guidance for Health Care Providers Caring for Women of Reproductive Age with Possible Zika Virus Exposure — United States, 2016. MMWR Morb Mortal Wkly Rep. ePub: 25 March 2016. DOI: http://dx.doi.org/10.15585/mmwr.mm6512e2er.

References

American College of Obstetricians and Gynecologists. Zika state contacts [after login]. Washington, DC: American College of Obstetricians and Gynecologists; 2016. Available at: https://www.acog.org/-/media/Departments/Members-Only/Zika-Virus/ZIKAContacts50StatesTerritories-2-9-16.pdf?dmc=1. Retrieved March 30, 2016.

American College of Obstetricians and Gynecologists. Available at: http://www.acog.org. Retrieved March 30, 2016.

American College of Obstetricians and Gynecologists. Immunization for women. Available at: http://www.immunizationforwomen.org. Retrieved March 30, 2016.

American College of Obstetricians and Gynecologists. Zika virus. Available at: http://www.acog.org/zika. Retrieved March 30, 2016.

American College of Obstetricians and Gynecologists. Zika virus updates. Available at: http://immunizationforwomen.org/providers/Zika-Virus-Updates. Retrieved March 30, 2016.

Brasil P, Pereira JP Jr, Raja Gabaglia C, Damasceno L, Wakimoto M, Ribeiro Nogueira RM, et al. Zika virus infection in pregnant women in Rio de Janeiro - preliminary report. N Engl J Med 2016; DOI: 10.1056/NEJMoa1602412.

Cauchemez S, Besnard M, Bompard P, Dub T, Guillemette-Artur P, Eyrolle-Guignot D, et al. Association between Zika virus and microcephaly in French Polynesia, 2013-15: a retrospective study. Lancet 2016; DOI: 10.1016/S0140-6736(16)00651-6.

Centers for Disease Control and Prevention. CDC recommendation for subsequent Zika IgM antibody testing. Health Alert Network. Atlanta (GA): CDC; 2016. Available at: http://emergency.cdc.gov/han/han00392.asp. Retrieved June 22, 2016.

Centers for Disease Control and Prevention. Preconception counseling: for women and men living in areas with ongoing spread of Zika virus who are interested in conceiving. Atlanta (GA): CDC; 2016. Available at: http://www.cdc.gov/zika/pdfs/preconception-counseling.pdf. Retrieved March 30, 2016.

Centers for Disease Control and Prevention. Recognizing, managing, and reporting Zika virus infections in travelers returning from Central America, South America, the Caribbean, and Mexico. CDC Health Advisory. Atlanta (GA): CDC; 2016. Available at: http://emergency.cdc.gov/han/han00385.asp. Retrieved March 30, 2016.

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Nasci RS, Wirtz RA, Brogdon WG. Protection against mosquitoes, ticks, and other arthropods. In: Centers for Disease Control and Prevention, editor. CDC health information for international travel 2016. New York (NY): Oxford University Press; 2016. Available at: http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/protection-against-mosquitoes-ticks-other-arthropods. Retrieved March 30, 2016.

Oduyebo T, Petersen EE, Rasmussen SA, Mead PS, Meaney-Delman D, Renquist CM, et al. Update: interim guidelines for health care providers caring for pregnant women and women of reproductive age with possible Zika virus exposure — United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65:122-7.

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Petersen EE, Polen KN, Meaney-Delman D, Ellington SR, Oduyebo T, Cohn A, et al. Update: interim guidance for health care providers caring for women of reproductive age with possible Zika virus exposure — United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65: DOI: http://dx.doi.org/10.15585/mmwr.mm6512e2er.

Petersen EE, Staples JE, Meaney-Delman D, Fischer M, Ellington SR, Callaghan WM, et al. Interim guidelines for pregnant women during a Zika virus outbreak - United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65:30-3.

Society for Maternal–Fetal Medicine. Zika virus recommendation. Available at: https://www.smfm.org/education/zika-virus-recommendation. Retrieved March 30, 2016.

Staples JE, Dziuban EJ, Fischer M, Cragan JD, Rasmussen SA, Cannon MJ, et al. Interim guidelines for the evaluation and testing of infants with possible congenital Zika virus infection - United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65:63-7.

Tepper NK, Goldberg HI, Vargas Bernal MI, Rivera B, Frey MT, Malave C, et al. Estimating contraceptive needs and increasing access to contraception in response to the Zika virus disease outbreak — Puerto Rico, 2016. MMWR Morb Mortal Wkly Rep 2016;65: DOI: http://dx.doi.org/10.15585/mmwr.mm6512e1er.


 

This Practice Advisory was developed by the American College of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine in collaboration with Laura E. Riley, MD, and Jeffrey L. Ecker, MD.

A Practice Advisory is issued when information on an emergent clinical issue (eg, clinical study, scientific report, draft regulation) is released that requires an immediate or rapid response, particularly if it is anticipated that it will generate a multitude of inquiries. A Practice Advisory is a brief, focused statement issued within 24–48 hours of the release of this evolving information and constitutes ACOG clinical guidance. A Practice Advisory is issued only online for Fellows but may also be used by patients and the media. Practice Advisories are reviewed periodically for reaffirmation, revision, withdrawal, or incorporation into other ACOG guidelines.

This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.

 


 

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 more than 57,000 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

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