Despite substantial progress in prevention of perinatal group B streptococcal (GBS) disease since the 1990s, GBS remains the leading cause of early-onset neonatal sepsis in the United States In 1996, CDC, in collaboration with relevant professional societies, published guidelines for the prevention of perinatal group B streptococcal disease (CDC Prevention of perinatal group B streptococcal disease: a public health perspective MMWR 1996;45[No RR-7]); those guidelines were updated and republished in 2002 (CDC Prevention of perinatal group B streptococcal disease: revised guidelines from CDC MMWR 2002;51[No RR-11]) In June 2009, a meeting of clinical and public health representatives was held to reevaluate prevention strategies on the basis of data collected after the issuance of the 2002 guidelines This report presents CDC's updated guidelines, which have been endorsed by the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the American College of Nurse-Midwives, the American Academy of Family Physicians, and the American Society for Microbiology The recommendations were made on the basis of available evidence when such evidence was sufficient and on expert opinion when available evidence was insufficient The key changes in the 2010 guidelines include the following: • expanded recommendations on laboratory methods for the identification of GBS, • clarification of the colony-count threshold required for reporting GBS detected in the urine of pregnant women, • updated algorithms for GBS screening and intrapartum chemoprophylaxis for women with preterm labor or preterm premature rupture of membranes, • a change in the recommended dose of penicillin-G for chemoprophylaxis, • updated prophylaxis regimens for women with penicillin allergy, and • a revised algorithm for management of newborns with respect to risk for early-onset GBS disease Universal screening at 35-37 weeks' gestation for maternal GBS colonization and use of intrapartum antibiotic prophylaxis has resulted in substantial reductions in the burden of early-onset GBS disease among newborns Although early-onset GBS disease has become relatively uncommon in recent years, the rates of maternal GBS colonization (and therefore the risk for early-onset GBS disease in the absence of intrapartum antibiotic prophylaxis) remain unchanged since the 1970s Continued efforts are needed to sustain and improve on the progress achieved in the prevention of GBS disease There also is a need to monitor for potential adverse consequences of intrapartum antibiotic prophylaxis (eg, emergence of bacterial antimicrobial resistance or increased incidence or severity of non-GBS neonatal pathogens) In the absence of a licensed GBS vaccine, universal screening and intrapartum antibiotic prophylaxis continue to be the cornerstones of early-onset GBS disease prevention

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Prevention of perinatal group B streptococcal disease. Revised guidelines from CDC.

Background Monochorionic twin pregnancies complicated by severe twin-to-twin transfusion syndrome at midgestation can be treated by either serial amnioreduction (removal of large volumes of amniotic fluid) or selective fetoscopic laser coagulation of the communicating vessels on the chorionic plate. We conducted a randomized trial to compare the efficacy and safety of these two treatments. Methods Pregnant women with severe twin-to-twin transfusion syndrome before 26 weeks of gestation were randomly assigned to laser therapy or amnioreduction. We assessed perinatal survival of at least one twin (a prespecified primary outcome), survival of at least one twin at six months of age, and survival without neurologic complications at six months of age on the basis of the number of pregnancies or the number of fetuses or infants, as appropriate. Results The study was concluded early, after 72 women had been assigned to the laser group and 70 to the amnioreduction group, because a planned interim analysis demonstr...

https://www.nejm.org/doi/pdf/10.1056/NEJMoa032597

Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome

Background—The goal of this statement is to review available literature and to put forth a scientific statement on the current practice of fetal cardiac medicine, including the diagnosis and manage...

/pdf/diagnosis-and-treatment-of-fetal-cardiac-disease-a-1komqhwbxf.pdf

Diagnosis and Treatment of Fetal Cardiac Disease A Scientific Statement From the American Heart Association

Problem/condition The risk of death from complications of pregnancy has decreased approximately 99% during the twentieth century, from approximately 850 maternal deaths per 100,000 live births in 1900 to 7.5 in 1982. However, since 1982, no further decrease has occurred in maternal mortality in the United States. In addition, racial disparity in pregnancy-related mortality ratios persists; since 1940, mortality ratios among blacks have been at least three to four times higher than those for whites. The Healthy People 2000 objective for maternal mortality of no more than 3.3 maternal deaths per 100,000 live births was not achieved during the twentieth century; substantial improvements are needed to meet the same objective for Healthy People 2010. Reporting period covered This report summarizes surveillance data for pregnancy-related deaths in the United States for 1991-1999. Description of system The Pregnancy Mortality Surveillance System was initiated in 1987 by CDC in collaboration with state health departments and the American College of Obstetricians and Gynecologists Maternal Mortality Study Group. Health departments in the 50 states, the District of Columbia, and New York City provide CDC with copies of death certificates and available linked outcome records (i.e., birth certificates or fetal death certificates) of all deaths occurring during or within 1 year of pregnancy. State maternal mortality review committees, the media, and individual providers report a limited number of deaths not otherwise identified. Death certificates and relevant birth or fetal death certificates are reviewed by clinically experienced epidemiologists at CDC to determine whether they are pregnancy-related. Results During 1991-1999, a total of 4,200 deaths were determined to be pregnancy-related. The overall pregnancy-related mortality ratio was 11.8 deaths per 100,000 live births and ranged from 10.3 in 1991 to 13.2 in 1999. The pregnancy-related mortality ratio for black women was consistently higher than that for white women for every characteristic examined. Older women, particularly women aged >/= 35 years and women who received no prenatal care, were at increased risk for pregnancy-related death. The distribution of the causes of death differed by pregnancy outcome. Among women who died after a live birth (i.e., 60% of the deaths), the leading causes of death were embolism and pregnancy-induced hypertension. Interpretation The reported pregnancy-related mortality ratio has substantially increased during 1991-1999, probably because of improved ascertainment of pregnancy-related deaths. Black women continued to have a 3-4 times higher pregnancy-related mortality ratio than white women. In addition, pregnancy-related mortality has the largest racial disparity among the maternal and child health indicators. Reasons for this difference could not be determined from the available data. Public health actions Continued surveillance and additional studies should be conducted to monitor the magnitude of pregnancy-related mortality, to identify factors that contribute to the continuing racial disparity in pregnancy-related mortality, and to develop effective strategies to prevent pregnancy-related mortality for all women. In addition, CDC is working with state health departments, researchers, health-care providers, and other stakeholders to improve the ascertainment and classification of pregnancy-related deaths.

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Pregnancy-related mortality surveillance--United States, 1991--1999.

Group B streptococcus (GBS) remains a leading cause of serious neonatal infection despite great progress in perinatal GBS disease prevention in the 1990s. In 1996, CDC, in collaboration with other agencies, published guidelines for the prevention of perinatal group B streptococcal disease (CDC. Prevention of perinatal group B streptococcal disease: a public health perspective. MMWR 1996;45[RR-7]:1--24). Data collected after the issuance of the 1996 guidelines prompted reevaluation of prevention strategies at a meeting of clinical and public health representatives in November 2001. This report replaces CDC's 1996 guidelines. The recommendations are based on available evidence and expert opinion where sufficient evidence was lacking. Although many of the recommendations in the 2002 guidelines are the same as those in 1996, they include some key changes:

Prevention of perinatal group b streptococcal disease

Objective The purpose of this study was to evaluate the prognostic value of sonographic and clinical parameters to develop a staging classification of twin-twin transfusion syndrome (TTTS). Study design Severe TTTS was defined as the presence of polyhydramnios (maximum vertical pocket of > or = 8 cm) and oligohydramnios (maximum vertical pocket of Results A total of 80 of 108 referred patients met criteria for surgery, but only 65 were treated surgically: 48 with LPCV and 17 with umbilical cord ligation. Complete Doppler data were obtainable in 41 of 48 LPCV patients. Survival rates by stage for one or two fetuses were statistically different (chi-squared analysis = 12.9, df = 6, p = 0.044). Neither percent size discordance nor gestational age at diagnosis were predictive of outcome. Conclusion Staging of TTTS using the proposed criteria has prognostic significance. This staging system may allow comparison of outcome data of TTTS with different treatment modalities.

Staging of twin-twin transfusion syndrome.

pdf/quintero-et-al-2003-stage-based-treatment-of-twin-twin-1v6gaobr7b.pdf

Stage-based treatment of twin-twin transfusion syndrome

Objective

We have recently described a surgical technique for the treatment of twin-to-twin transfusion syndrome (TTTS) that allows precise identification of vascular anastomoses (selective laser photocoagulation of communicating vessels, or S-LPCV). The purpose of this study was to compare S-LPCV with the previous non-selective technique (NS-LPCV) that targeted all vessels crossing the dividing membrane.



Materials and Methods

Patients with TTTS were treated with NS-LPCV from May 1994 to June 1997 and with S-LPCV from July 1997 to December 1999. TTTS was defined as polyhydramnios of ≥8 cm maximum vertical pocket (MVP) in the recipient twin and oligohydramnios of ≤2 cm MVP in the donor twin. Outcome was measured as survival per number of pregnancies and per number of fetuses together with limited morbidity data.



Results

NS-LPCV was used in 18 patients and 74 were treated with S-LPCV. Three patients interrupted their pregnancies electively after surgery (S-LPCV) and were removed from further analysis. Survival of at least one fetus was higher in S-LPCV (83.1%) than in NS-LPCV (61.1%) (P = 0.04), mostly due to a lower rate of dual intra-uterine fetal demise in S-LPCV (5.6%) than in NS-LPCV (22%) (P = 0.05). There were more hydropic fetuses in the NS-LPCV group (27%) than in the S-LPCV group (5.4%), but this difference did not account for the results. There was no difference in the survival per number of fetuses between the two groups.



Conclusions

S-LPCV represents an important evolution in the surgical treatment of TTTS. The use of this technique by all centers should allow better comparison of fetal survival and morbidity rates. S-LPCV should be the standard technique in trials comparing amniocentesis versus laser for the treatment of severe TTTS. Copyright © 2000 International Society of Ultrasound in Obstetrics and Gynecology

Selective versus non-selective laser photocoagulation of placental vessels in twin-to-twin transfusion syndrome.

Selective photocoagulation of communicating vessels in the treatment of monochorionic twins with selective growth retardation

Objective. We have previously described the selective laser photocoagulation of communicating vessels (SLPCV) technique for the treatment of twin–twin transfusion syndrome (TTTS). Because TTTS is thought to result from a net transfer of blood from the donor twin to the recipient twin, we hypothesized that lasering the arteriovenous anastomoses from the donor to the recipient (AVDRs) first (sequential SLPCV or SQLPCV) would result in an improved hemodynamic status and decreased likelihood of intrauterine fetal demise of the donor twin (IUFD-D).Materials and methods. The diagnosis of TTTS was made by ultrasound showing the combined presence of a maximum vertical pocket ≥ 8 cm in one sac and ≤2 cm in the other in a monochorionic/diamniotic twin pregnancy. Triplet pregnancies and monoamniotic pregnancies were excluded. Severity of TTTS was assessed using the Quintero staging system. All vascular anastomoses were endoscopically identified and classified as AVDR (AV from donor to recipient), AVRD (AV from recip...

Patricia W. Bornick

Papers

Staging of twin-twin transfusion syndrome.

Stage-based treatment of twin-twin transfusion syndrome

Selective versus non-selective laser photocoagulation of placental vessels in twin-to-twin transfusion syndrome.

Selective photocoagulation of communicating vessels in the treatment of monochorionic twins with selective growth retardation

Sequential selective laser photocoagulation of communicating vessels in twin-twin transfusion syndrome.