Clinical Practice Guidelines Antenatal care - Module I

Maternal health screening

Page last updated: 02 April 2013

HIV

NICE recommendation

Pregnant women should be offered screening for HIV infection early in antenatal care because appropriate antenatal interventions can reduce mother-to-child transmission of HIV infection. [A]

A system of clear referral paths should be established in each unit or department so that pregnant women who are diagnosed with an HIV infection are managed and treated by the appropriate specialist teams. [D]

Research questions

1. What is the prevalence of HIV infection in pregnant women in Australia? (Informed narrative)
2. What is the prevalence of congenitally acquired HIV infection in Australia? (Informed narrative)
3. What is the diagnostic accuracy of screening tests for HIV infection? (Informed Recommendation 11)
4. What benefits would result from screening for HIV in pregnancy? (Informed Recommendation 11)
5. What are the harms of not screening for HIV in pregnancy? (Informed Recommendation 11)
6. What are the harms of screening for HIV in pregnancy? (Informed Recommendation 11)
7. What are the additional needs of Aboriginal or Torres Strait Islander women? (Informed narrative)

Search Strategy

Databases searched: Medline; Embase; Australasian Medical Index; ATSIhealth; Google Scholar; Cochrane Database
Date of search: November 2010
Limits: English language
Publication dates for search: January 2003 – November 2010

Review findings

1. 2 level III-2 studies and 1 level IV study used as basis of narrative on Australian prevalence.
2. 1 level III-2 study used as basis for narrative on prevalence of congenital HIV.
3. 3 level III-2 studies support the accuracy of diagnostic tests.
4. 1 level I study, 1 level III-2 study, 1 level IV study and 5 clinical practice guidelines support routine testing of all women in pregnancy due to the availability of effective interventions to prevent mother-to-child transmission.
5. 1 level III-2 study and 1 level IV study identify lack of treatment as a harm arising from not screening.
6. 3 level III-2 studies, 2 level IV studies and 1 clinical practice guideline found no significant harms from antiretroviral therapy during pregnancy.
7. 1 level III-2, 4 level IV and 1 clinical practice guideline informed the narrative. Advice on screening in rural and remote areas also provided by Working Group for Aboriginal and Torres Strait Islander Women’s Antenatal Care.

Current available evidence supports the 2003 NICE recommendations for HIV screening in first trimester of pregnancy.
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EAC recommendation

11. Routinely offer and recommend HIV testing at the first antenatal visit as effective interventions are available to reduce the risk of mother-to-child transmission.

Evidence supporting recommendations (see Section 8.1.5)

Briand et al 2009; Butlerys et al 2004; Chappel et al 2009; Chou et al 2005; Giles et al 2008; Horvath et al 2009; Kourtis et al 2007; Pai et al 2007; Read & Newell 2005; Samson & King 1998; Tepper et al 2009; Townsend et al 2009; Volmink et al 2007; Wiysonge et al 2005; 2011

Grading of evidence — Recommendation 11

Evidence base - B
Consistency - B
Clinical impact - B
Generalisablity - B
Applicability - B
Recommendation - B

Hepatitis B

NICE recommendation

Serological screening for hepatitis B virus should be offered to pregnant women so that effective postnatal intervention can be offered to infected women to decrease the risk of mother-to-child transmission. [A]

Research questions

1. What are the interventions to reduce mother-to-child transmission of hepatitis B virus? (Informed Recommendation 12)
2. What are the additional considerations for Aboriginal and Torres Strait Islander women? (Informed narrative)

Search Strategy

Databases searched: Medline; Embase; Australasian Medical Index; ATSIhealth; Google Scholar; Cochrane Database
Date of search: November 2010
Limits: English language
Publication dates for search: January 2003 – November 2010

Review findings

1. The 2 level I studies and 3 level IV studies identified support the NICE recommendation. This recommendation is also in accord with United States clinical practice guidelines and the Australian Immunisation Handbook.
2. 1 level IV study was identified. No additional considerations were identified by the Working Group for Aboriginal and Torres Strait Islander Women’s Antenatal Care.

EAC recommendation

12. Routinely offer and recommend hepatitis B virus testing at the first antenatal visit as effective postnatal intervention can reduce the risk of mother-to-child transmission.
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Evidence supporting recommendation (see Section 8.2.5)

Cowan et al 2006; Jensen et al 2003; Lin & Vickery 2009; Summers et al 1987

Grading of evidence — Recommendation 12

Evidence base - A
Consistency - A
Clinical impact - A
Generalisablity - A
Applicability - A
Recommendation - A

Hepatitis C

NICE recommendation

Pregnant women should not be offered routine screening for hepatitis C virus because there is insufficient evidence on its effectiveness and cost effectiveness. [C]

Research questions

1. What is the diagnostic value and clinical effectiveness of screening for hepatitis C? (Informed Recommendation 13)
2. What are the additional considerations for Aboriginal and Torres Strait Islander women? (No studies identified)

Search Strategy

Databases searched: Medline; Embase; Australasian Medical Index; ATSIhealth; Google Scholar; Cochrane Database
Date of search: November 2010
Limits: English language
Publication dates for search: January 2003 – November 2010

Review findings

1. 3 level III-2, 1 level III-3 and 5 level IV studies were identified in this review.
2. No evidence identified. Advice given by Working Group for Aboriginal and Torres Strait Islander Women’s Antenatal Care.

The evidence does not suggest a change to the NICE recommendation, which is consistent with DoHA recommendations for hepatitis screening and the advice of Hepatitis Australia.

EAC recommendation

13. Do not routinely offer pregnant women hepatitis C testing.

Evidence supporting recommendation (see Section 8.3.5)

Hutchinson et al 2004; Lui et al 2009; Pembrey et al 2003; 2005; Prasad et al 2007
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Grading of evidence — Recommendation 13

Evidence base - C
Consistency - B
Clinical impact - C
Generalisablity - C
Applicability - B
Recommendation - C

Rubella

NICE recommendation

Rubella susceptibility screening should be offered early in antenatal care to identify women at risk of contracting rubella infection and to enable vaccination in the postnatal period for the protection of future pregnancies. [B]

Research questions

1. What is the prevalence of rubella susceptibility in pregnant women? (Informed narrative)
2. Does screening pregnant women for rubella immunity lead to improved maternal and perinatal outcomes? (Informed Recommendations 14 and 15)
3. What are the additional considerations for Aboriginal and Torres Strait Islander women? (Informed narrative)

Search Strategy

Databases searched: Medline; Embase; Australasian Medical Index; ATSIhealth; Google Scholar; Cochrane Database
Date of search: November 2010
Limits: English language
Publication dates for search: January 2003 – November 2010

Review findings

1. 1 level IV study informed discussion of prevalence of non-immunity.
2. Recent evidence on screening (3 level II studies) focused on the risk of the risk of congenital rubella syndrome (CRS) for women inadvertently vaccinated during pregnancy or just prior to conception and found this to be very low.
3. 1 level IV study informed discussion of non-immunity among Aboriginal and Torres Strait Islander women.
There was insufficient new evidence to change the NICE recommendation.

EAC recommendations

14. Routinely offer women testing for rubella immunity at the first antenatal visit to identify women at risk of contracting rubella and enable postnatal vaccination to protect future pregnancies.
15. Inform women who have been vaccinated against rubella before they were aware of the pregnancy that the baby is highly unlikely to have been affected by the vaccine.

Evidence supporting recommendations (see Section 8.4.5)

Recommendation 14 — Grageot-Keros & Enders 1997; Grillner et al 1983; Miller et al 1982
Recommendation 15 — Badilla et al 2007; Bar-Oz et al 2004; Hamkar et al 2006

Grading of evidence — Recommendation 14

Evidence base - B
Consistency - A
Clinical impact - B
Generalisablity - A
Applicability - A
Recommendation - B
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Grading of evidence — Recommendation 15

Evidence base - A
Consistency - A
Clinical impact - B
Generalisablity - A
Applicability - A
Recommendation - A

Chlamydia

NICE recommendation

Pregnant women should not be offered routine screening for asymptomatic chlamydia because there is insufficient evidence on its effectiveness and cost effectiveness. However, this policy is likely to change with the implementation of the national opportunistic chlamydia screening programme. [C]

Research questions

1. What is the diagnostic value and effectiveness of the following screening methods in identifying genital chlamydia: age, urine testing, endocervical swabs, serum antibody testing, history? (Informed Recommendation 16)
2. What are the additional needs of Aboriginal and Torres Strait Islander women? (Informed narrative)

Search Strategy

Databases searched: Medline; Embase; Australasian Medical Index; ATSIhealth; Google Scholar; Cochrane Database
Date of search: November 2010
Limits: English language
Publication dates for search: January 2003 – November 2010

Review findings

1. 1 level II study, 1 level III-1 study and 3 level IV studies investigated the diagnostic accuracy of tests and an additional 1 level I, 2 level III-2 studies and 8 level IV studies provided information on prevalence.
2. 1 level I and 4 level IV studies informed discussion of Aboriginal and Torres Strait Islander women in the narrative. Additional advice was also sought from the Working Group for Aboriginal and Torres Strait Islander Women’s Antenatal Care.

No high quality evidence suggested a change to the NICE recommendation. Additional information from systematic reviews, modelling and prevalence studies suggest screening of specific populations.

EAC recommendation

16. Do not routinely offer chlamydia testing to all women as part of antenatal care.
Routinely offer chlamydia testing at the first antenatal visit to pregnant women younger than 25 years.

Evidence supporting recommendation (see Section 8.1.5)

Bilardi et al 2010; Black-Payne et al 1990; Chen et al 2009; Cheney & Wray 2008; Cohen et al 1990; Macmillan et al 1985; Martin et al 1997; Regan et al 2008; Rivlin et al 1997; Ryan et al 1990

Grading of evidence — Recommendation 16

Evidence base - C
Consistency - C
Clinical impact - C
Generalisablity - B
Applicability - C
Recommendation - C
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Syphilis

NICE recommendation

Screening for syphilis should be offered to all pregnant women at an early stage in antenatal care because treatment of syphilis is beneficial to the mother and fetus. [B]

Research questions

1. What is the prevalence of syphilis in pregnant women in Australia? (Informed narrative)
2. What are the diagnostic tests available for detection of syphilis infection and how do they compare in terms of specificity, sensitivity, and cost-effectiveness? (Informed narrative)
3. What are the available interventions for managing women who are infected with syphilis? (Informed Recommendation 17)
4. What are the additional considerations for Aboriginal and Torres Strait Islander women? (Informed narrative)

Search Strategy

Databases searched: Medline; Embase; Australasian Medical Index; ATSIhealth; Google Scholar; Cochrane Database Date of search: November 2010
Limits: English language
Publication dates for search: January 2003 – November 2010

Review findings

1. 1 level IV study informed discussion of prevalence in the narrative.
2. 2 level II and 3 level III-2 studies confirmed the diagnostic accuracy of tests for syphilis and informed the narrative.
3. 2 level I studies, 1 level II study, 2 level III-2 studies and 1 level III-3 study confirmed the effectiveness of treatment for syphilis.
4. 1 level IV study informed the narrative.

The new evidence did not warrant changing the NICE recommendation.

EAC recommendation

17. Routinely offer and recommend syphilis testing at the first antenatal visit as treating syphilis benefits both mother and baby.

Evidence supporting recommendation (see Section 8.6.5)

Abyad 1995; Cameron et al 1997; Connor et al 2000; Duthie et al 1990; Garland & Kelly 1989; Hurtig et al 1998; Villar & Bergsjo 1997; Walker 2001; Wolff et al 2009

Grading of evidence — Recommendation 17

Evidence base - B
Consistency - B
Clinical impact - B
Generalisablity - B
Applicability - B
Recommendation - B

Asymptomatic bacteriuria

NICE recommendation

Women should be offered routine screening for asymptomatic bacteriuria by midstream urine culture early in pregnancy. Identification and treatment of asymptomatic bacteriuria reduces the risk of pyelonephritis. [no grading; area for further research]
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Research questions

1. What is the diagnostic accuracy of screening tests for asymptomatic bacteriuria? (Informed Recommendation 18)
2. What benefits would result from screening for asymptomatic bacteriuria? (Informed Recommendation 18)
3. What are the harms of not screening for asymptomatic bacteriuria? (No studies identified)
4. What are the additional considerations for Aboriginal and Torres Strait Islander women? (Informed narrative)

Search Strategy

Databases searched: Medline, EMBASE, MIDIRS, CINAHL, BNI, SIGLE, JBI, CENTRAL, COCHRANE, PsycINFO, LILACS, DARE, CONTROLLED TRIALS, CONFERENCE PROCEEDINGS, NDLTD, APAIS – ATSIhealth, Health Collection, Health Source, Nursing Academic Edition, AHRQ, ISI Web of Knowledge, TRIP, MD Consult, HTA, NHS EED, Scopus, Google Scholar, Academic OneFile, MEDNAR, ANZCTR
Date of search: December 2010
Limits: Female/women, human
Publication dates for search: January 2003 – December 2010

Review findings

1. 1 level I study, 3 level II studies, 3 level III-2 studies and 5 level IV studies supported the accuracy of urine culture.
2. The NICE recommendation is supported by a Cochrane review and an analysis of cost-effectivness and cost-benefit of screening. No additional specific studies were identified which indicated benefits from screening. 1 level III-2 study found that urine cultures are of little clinical importance for predicting preterm labour.
3. No studies identified.
4. 1 level IV study identified challenges with screening for Aboriginal women in remote communities. The Working Group for Aboriginal and Torres Strait Islander Women’s Antenatal care also provided advice on testing in rural and remote areas.

The evidence supports the NICE recommendation.

EAC recommendations

18. Routinely offer and recommend testing for asymptomatic bacteriuria early in pregnancy as treatment is effective and reduces the risk of pyelonephritis.
19. Use urine culture testing wherever possible as it is the most accurate means of detecting asymptomatic bacteriuria.

Evidence supporting recommendations (see Section 8.7.5)


Recommendation 18 — Rouse et al 1995; Smaill & Vasquez 2007
Recommendation 19 — Bookallil et al 2005; Deville et al 2004; Eigbefoh et al 2008; Karabulut 2007; Mignini et al 2009; Teppa & Roberts 2005

Grading of evidence — Recommendation 18

Evidence base = A
Consistency - A
Clinical impact - C
Generalisablity - A
Applicability - A
Recommendation - A

Grading of evidence — Recommendation 19

Evidence base - A
Consistency - A
Clinical impact - C
Generalisablity - A
Applicability - A
Recommendation - A
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Asymptomatic bacterial vaginosis

NICE recommendation

Pregnant women should not be offered routine screening for bacterial vaginosis because the evidence suggests that the identification and treatment of asymptomatic bacterial vaginosis does not lower the risk for preterm birth and other adverse reproductive outcomes. [A]

Research questions

1. What is the diagnostic accuracy of screening tests for asymptomatic bacterial vaginosis? (Informed narrative)
2. What benefits would result from screening for asymptomatic bacterial vaginosis? (Informed Recommendation 20)
3. What are the harms of not screening for asymptomatic bacterial vaginosis? (Informed Recommendation 20)
4. What are the additional considerations for Aboriginal and Torres Strait Islander women? (No studies identified)

Search Strategy

Databases searched: Medline, EMBASE, MIDIRS, CINAHL, BNI, SIGLE, JBI, CENTRAL, COCHRANE, PsycINFO, LILACS, DARE, CONTROLLED TRIALS, CONFERENCE PROCEEDINGS, NDLTD, APAIS – ATSIhealth, Health Collection, Health
Source, Nursing Academic Edition, AHRQ, ISI Web of Knowledge, TRIP, MD Consult, HTA, NHS EED, Scopus, Google Scholar, Academic OneFile, MEDNAR, ANZCTR
Date of search: December 2010
Limits: English language
Publication dates for search: January 2003 – December 2010

Review findings

1. 9 level III-2 studies discussed tests for asymptomatic bacterial vaginosis and suggested that Gram stains were effective.
2. 1 level I, 1 level III-1, I level III-2 and I level III-3 study suggested that the general population seems to lack any clear clinical benefit from screening and treatment for asymptomatic bacterial vaginosis during pregnancy.
3. 1 level I study suggested that, although a subgroup of high-risk women may benefit from screening and treatment for bacterial vaginosis in pregnancy, a sizeable group would receive either no benefit or may experience harm.
4. No relevant studies identified.

The recent evidence supports the NICE recommendation.

EAC recommendation

20. Do not routinely offer pregnant women testing for bacterial vaginosis.

Evidence supporting recommendation (see Section 8.8.5)


McDonald et al 2007; Nygren et al 2008

Grading of evidence — Recommendation 20

Evidence base - B
Consistency - B
Clinical impact - B
Generalisablity - B
Applicability - B
Recommendation - B
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Vitamin D

NICE recommendation

All women should be informed at the booking appointment about the importance for their own and their baby’s health of maintaining adequate vitamin D stores during pregnancy and whilst breastfeeding. In order to achieve
this, women may choose to take 10 micrograms of vitamin D per day, as found in the Healthy Start multivitamin supplement. Particular care should be taken to enquire as to whether women at greatest risk are following advice to take this daily supplement. These include:
  • women of South Asian, African, Caribbean or Middle Eastern family origin
  • women who have limited exposure to sunlight, such as women who are predominantly housebound, or usually remain covered when outdoors
  • women who eat a diet particularly low in vitamin D, such as women who consume no oily fish, eggs, meat, vitamin D-fortified margarine or breakfast cereal
  • women with a pre-pregnancy body mass index above 30 kg/m2. [no grading; area for further research]

Research questions

1. Who should be screened for vitamin D deficiency? (Informed Consensus-based recommendation viii)

Search Strategy

Databases searched: Medline; Embase; Australasian Medical Index; ATSIhealth; Google Scholar; Cochrane Database
Date of search: November 2010
Limits: English language
Publication dates for search: January 2003 – November 2010

Review findings

1. Although 3 level I studies, 11 level II studies, 1 level III-2, 1 level III-3 and 5 level IV studies were identified, there is an absence of high quality evidence supporting a demonstrable reduction in morbidity or mortality from vitamin D supplementation. However, there is a growing international trend towards screening and/or recommending supplementation in pregnancy, due to the growing awareness of vitamin D deficiency and its sequelae.

Consensus-based recommendation

viii. Offer vitamin D screening to women with limited exposure to sunlight (eg because they are predominantly indoors or usually protected from the sun when outdoors), or who have dark skin or a pre-pregnancy BMI of >30, as they may be at increased risk of vitamin D deficiency and may benefit from supplementation for their long-term health. Base decisions about whether to offer screening on these factors, season and climate.

Chromosomal abnormalities

NICE recommendation

All pregnant women should be offered screening for Down’s syndrome. Women should understand that it is their choice to embark on screening for Down’s syndrome.

Screening for Down’s syndrome should be performed by the end of the first trimester (13 weeks 6 days), but provision should be made to allow later screening (which could be as late as 20 weeks 0 days) for women booking later in pregnancy.
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The ‘combined test’ (nuchal translucency, beta-human chorionic gonadotrophin, pregnancy-associated plasma protein-A) should be offered to screen for Down’s syndrome between 11 weeks 0 days and 13 weeks 6 days. For women who book later in pregnancy the most clinically and cost-effective serum screening test (triple or quadruple test) should be offered between 15 weeks 0 days and 20 weeks 0 days.

When it is not possible to measure nuchal translucency, owing to fetal position or raised body mass index, women should be offered serum screening (triple or quadruple test) between 15 weeks 0 days and 20 weeks 0 days.

Information about screening for Down’s syndrome should be given to pregnant women at the first contact with a healthcare professional. This will provide the opportunity for further discussion before embarking on screening. (Refer to Section 3.3 for more information about giving antenatal information). Specific information should include:
  • the screening pathway for both screen-positive and screen-negative results
  • the decisions that need to be made at each point along the pathway and their consequences
  • the fact that screening does not provide a definitive diagnosis and a full explanation of the risk score obtained following testing
  • information about chorionic villus sampling and amniocentesis
  • balanced and accurate information about Down’s syndrome.
If a woman receives a screen-positive result for Down’s syndrome, she should have rapid access to appropriate counselling by trained staff.

Research questions

1. Which tests should be used to screen for chromosomal abnormalities? (Informed Recommendations 21 and 22)
2. What is the impact of maternal age on chromosomal screening and choice of test? (Inconsistent evidence)
3. Which tests are available/should be used in rural/remote locations? (Informed narrative)
4. Who should be offered prenatal testing? (Informed narrative)
5. What is the psychological impact of prenatal screening? (Informed Consensus-based recommendation ix)
6. What is the psychological impact of not offering prenatal screening? (No studies identified)
7. What counselling is required before and after screening? What constitutes informed consent? (Informed Consensus-based recommendations ix and x)
8. What additional information do pregnant women require regarding the results of their chromosomal screening tests? (Informed narrative)
9. What are the additional considerations for Aboriginal and Torres Strait Islander women? (No studies identified)

Search Strategy

Databases searched: Medline; Embase; Australasian Medical Index; ATSIhealth; Google Scholar; Cochrane Database
Date of search: January 2011
Limits: English language
Publication dates for search: January 2003 – January 2011

Review findings

1. The findings from 4 level I studies, 4 level II studies and 12 level III-2 studies suggest that nuchal translucency thickness scans before 12 weeks are more accurate. Adding biochemical markers will either improve detection of chromosomal abnormalities or not change it. The addition of first trimester screening may lead to reduced rates of invasive testing and fewer losses of normal pregnancies. Detailed ultrasound examination at early gestational age may not be superior to nuchal scan in screening for fetal abnormalities. Second trimester amniocentesis is safer than early amniocentesis. Amniocentesis at 13 weeks carries an increased risk of talipes equinovarus compared with chorionic villus sampling.
2. The evidence from 2 Level II studies, 22 Level III-2 studies, 2 Level III-3 studies and 2 Level IV studies was inconsistent regarding maternal age in relation to screening for chromosomal abnormalities and choice of test.
3. 2 Level III-2 studies suggested that interventions should be targeted at rural areas as there is unequal access to screening in these areas.
4. 2 level III-2 and 3 Level III-3 studies suggested that combining first trimester screening with screening in the second trimester is most effective.
5. 2 level I and 2 level II studies supported the need for counselling following screening.
6. No studies identified.
7. 1 level I study informed the narrative on the use of decision aids.
8. 1 level I study supported the provision of information about screening.
9. No relevant studies identified. Advice on information provision provided by the Working Group for Aboriginal and Torres Strait Islander Women’s Antenatal Care.

EAC recommendations

21. If a woman chooses to have the combined test (nuchal translucency thickness, free beta-human chorionic gonadotrophin, pregnancy associated plasma protein-A), make arrangements so that blood for biochemical analysis is collected between 9 weeks to 13 weeks 6 days and ultrasound assessment takes place between 11 weeks 0 days and 13 weeks 6 days.
22. If a woman chooses to have a diagnostic test for chromosomal abnormalities, base the choice of test on the gestation of pregnancy and the woman’s preferences. Chorionic villus sampling is safer before 14 weeks pregnancy. Amniocentesis is safe after 15 weeks.
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Evidence supporting recommendations (see Section 9.7)

McDonald et al 2007; Nygren et al 2008

Grading of evidence — Recommendation 21

Evidence base - B
Consistency - B
Clinical impact - A
Generalisablity - A
Applicability - B
Recommendation - B

Grading of evidence — Recommendation 22

Evidence base - B
Consistency - B
Clinical impact - A
Generalisablity - A
Applicability - B
Recommendation - B

Consensus-based recommendations

ix. At the first antenatal visit, give all women information about the purpose and implications of testing for chromosomal abnormalities to enable them to make informed choices about whether or not to have the tests.
x. Offer rapid access to appropriate counselling and ongoing support by trained health professionals to women who receive a diagnosis of fetal chromosomal abnormality.