The American College of Obstetricians and Gynecologists (the College) makes the following recommendations regarding clinical guidelines and standardization of practice to improve outcomes:Protocols and checklists should be recognized as guides to the management of a clinical situation or process of care that will apply to most patients. For any patient whose care cannot be managed by standardized protocols because of clinically valid reasons, the physician should document in the medical record why the protocol or checklist is not being followed.
This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publications may not reflect the most recent evidence. Any updates to this document can be found on acog.org or by calling the ACOG Resource Center.
Although new ACOG guidelines were largely based on research using self-report measures, self-reported PA is often higher than accelerometry.8 Findings here may therefore represent an overestimation of women meeting PA guidelines. As NHANES ceased to oversample pregnant women during the study period, this study combined data from 2007 to 2014, preventing analysis of trends. It was also unable to identify women for whom PA was contraindicated.
The American College of Obstetricians and Gynecologists (ACOG) joins ASCCP and the Society of Gynecologic Oncology (SGO) in endorsing the U.S. Preventive Services Task Force (USPSTF) cervical cancer screening recommendations 1 , which replace ACOG Practice Bulletin No. 168, Cervical Cancer Screening and Prevention, as well as the 2012 ASCCP cervical cancer screening guidelines 2 .
The American College of Obstetricians and Gynecologists (ACOG), is the nation's leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, ACOG 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. www.acog.org
CDC, AAP, ACOG, ASM, the American College of Nurse-Midwives, and the American Academy of Family Physicians have worked together on GBS prevention for many years and new guidance represents both progress and continued collaboration between these groups. These organizations remain committed to working together to protect newborns from GBS disease. CDC will continue to stay engaged actively in evaluating guidelines implementation along with impact and trends in disease burden. CDC will also continue to build the evidence base relevant to maternal GBS vaccination.
Group B streptococcus (GBS) is the leading cause of newborn infection 1. The primary risk factor for neo-natal GBS EOD is maternal colonization of the genitourinary and gastrointestinal tracts. Vertical transmission usually occurs during labor or after rupture of membranes 2. Implementation of national guidelines for intrapartum antibiotic prophylaxis has resulted in a reduction in the incidence of GBS EOD of more than 80%, from 1.8 newborns per 1,000 live births in the 1990s to 0.23 newborns per 1,000 live births in 2015 3.
A recent CDC survey from 10 states participating in the Active Bacterial Core Surveillance demonstrated that, although use of NAAT-based assays for GBS screening has increased since the last perinatal guidelines were published in 2010, reported use overall remained low in 2016. With more than 93% of 544 laboratories responding to the survey, only 18.7% reported using GBS NAATs for screening. Thirty-nine percent of laboratories used NAAT for antepartum screening only, 22% for intrapartum only, and 17% for both, with 21% not specifying their use context 51. Almost all (97.4%) laboratories reporting GBS NAAT use were hospital or clinic-based, compared with 12.6% use in commercial or private laboratories. In addition, 82% of laboratories using NAAT for antepartum GBS screening reported using an enrichment step before the assay was performed 51.
Current ACOG guidelines recommend proceeding to delivery if PPROM occurs at or beyond 34 0/7 weeks of gestation 78. If expectant management is being considered, an initial GBS culture should be obtained, and a latency antibiotic regimen that incorporates agents active against GBS should be started. If a woman with PPROM has or is suspected of having intraamniotic infection, administration of broad-spectrum intrapartum antibiotics, including an agent that provides antimicrobial coverage against GBS, is recommended 75.
When a woman reports a penicillin allergy, the recommended antibiotic for intrapartum antibiotic prophylaxis, if she is colonized with GBS, is based on her risk of a severe reaction (ie, anaphylaxis or non-immunoglobulin E [IgE]-mediated reaction such as Stevens Johnson syndrome) and the susceptibility of the GBS isolate to clindamycin Figure 3. It has been demonstrated that the two prenatal assessments most commonly omitted in following GBS guidelines are determination of the nature of the penicillin allergy and evaluation of susceptibility of a GBS isolate to clindamycin 84 85.
In an earlier version of the GBS prophylaxis guidelines, erythromycin and clindamycin were listed as alternative therapies for use in women at high risk of anaphylaxis to penicillin 36. However, as rates of GBS resistance to erythromycin have continued to increase (up to 44.8%), the use of erythromycin is no longer recommended 3 20 93 103. In addition, erythromycin does not cross the placenta well and does not produce therapeutic drug levels in either amniotic fluid or fetal blood, reinforcing that it is a poor choice for intrapartum GBS prophylaxis 105.
Outcomes associated with immersion in water during labor and birth in women colonized with GBS are not well studied. International guidelines suggest that immersion in water during labor or birth is not contraindicated for women colonized with GBS who have been offered the appropriate intrapartum antibiotic prophylaxis if no other contraindications to water immersion are present 77. The American College of Obstetricians and Gynecologists recommends that immersion in water during the first stage of labor may be offered to healthy women at term who have uncomplicated pregnancies 136.
The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-Info/GBS.
You and your ob-gyn should work together to develop a nutrition and exercise plan. If you are gaining less than what the guidelines suggest, and if your fetus is growing well, gaining less than the recommended guidelines can have benefits. If your fetus is not growing well, changes may need to be made to your diet and exercise plan.
Food Sources of Select Nutrients
Examples of foods that are good sources of important nutrients.
www.dietaryguidelines.gov/resources/2020-2025-dietary-guidelines-online-materials/food-sources-select-nutrients
Based on these studies, the Society of Radiologists in Ultrasound Multispecialty Panel on Early First Trimester Diagnosis of Miscarriage and Exclusion of a Viable Intrauterine Pregnancy created guidelines that are considerably more conservative than past recommendations and also have stricter cutoffs than the studies on which they are based 14 Table 1. The authors of the guidelines report that the stricter cutoffs are needed to account for interobserver variability; however, this already was accounted for in the original study through its use of multiple ultrasonographers 12 15. Other important limitations in the development of these guidelines should be recognized. For example, there were few cases at or near the measurements ultimately identified as decision boundaries. Similarly, the time between observing a gestational sac and expecting to see a yolk sac or embryo was increased from 7 days or more in the clinical study 13 to 14 days in the guidelines 14. The basis of this recommendation is unclear.
Other health care organizations also have published guidelines for preeclampsia prevention using low-dose aspirin based on risk factors. Published in 2011, the World Health Organization guideline recommended that low-dose aspirin (75 mg/day) be initiated before 20 weeks of gestation for women at high risk of preeclampsia; eg, women with a history of preeclampsia, diabetes, chronic hypertension, renal disease, autoimmune disease, and multiple gestations 3. The National Institute of Health and Care Excellence published a quality statement, Antenatal Assessment of Pre-eclampsia Risk, in July 2013 that asked health care providers to prescribe low-dose aspirin (75 mg/day) to pregnant women at increased risk of preeclampsia at the first prenatal visit, to be taken daily from 12 weeks of gestation until birth 4. The degree of risk of preeclampsia was based on the presence of one or more high-risk factors (hypertensive disease in previous pregnancy, chronic kidney disease autoimmune disease, type 1 or type 2 diabetes, and chronic hypertension) or more than one moderate-risk factor (first pregnancy, maternal age of 40 years or older, a body mass index greater than 35, family history of preeclampsia, and multiple pregnancy) 4.
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