Indications for fetal surveillance
In June of 2021, the American College of Obstetrics and Gynecology and the Society for Maternal-Fetal Medicine published a joint committee opinion outlining indications for antepartum fetal surveillance. The document suggests surveillance for conditions for which stillbirth is reported to occur more frequently than 0.8 per 1,000 and which are associated with a relative risk (RR) for stillbirth of more than 2.0 compared with pregnancies without the condition. Initiating antenatal fetal surveillance at 32 0/7 weeks of gestation or later is appropriate for most at-risk patients. For pregnant individuals with multiple or particularly worrisome high-risk conditions, antenatal fetal surveillance might begin at an earlier gestational age when delivery would be considered for perinatal benefit. The joint document highlights that as with all testing and interventions, shared decision making between the pregnant individual and the clinician is critically important when considering or offering antenatal fetal surveillance for individuals with pregnancies at high risk for stillbirth. It is important to note that the guidance offered in the committee opinion should be construed only as suggestions, not as mandates or as all encompassing. There is a paucity of evidence for the efficacy of antenatal fetal surveillance and for evidence-based recommendations on the timing and frequency of fetal surveillance. For most conditions, recommendations for fetal surveillance are largely based on expert consensus and relevant observational studies. Some factors associated with an increased risk of stillbirth that are addressed in the document include in vitro fertilization, prepregnancy BMI, maternal age and single umbilical artery.
COVID-19 Vaccines
There are currently three COVID-19 vaccines authorized for use in the United States. Two are mRNA vaccines (Pfizer-BioNTech and Moderna), and one is an adenoviral-vector vaccine (Janssen/J&J). None of the currently authorized vaccines contain live virus. On August 23rd, 2021, the U.S. Food and Drug Administration granted full approval to the Pfizer-BioNTech coronavirus vaccine (now marketed as Comirnaty). The American College of Obstetrics and Gynecology, the Center for Disease Control and the Society for Maternal-Fetal Medicine recommend that all pregnant, postpartum and lactating individuals receive a COVID-19 vaccine or vaccine series. A discussion with a clinician is not a requirement prior to vaccination. COVID-19 vaccines may be administered simultaneously with other vaccines, including within 14 days of receipt of another vaccine. This includes vaccines routinely administered during pregnancy, such as influenza and Tdap.
Community spread of SARS-CoV-2 is increasing due to the Delta variant. Data suggest that vaccination is safe and effective for pregnant people. More than 139,000 people have received the COVID-19 vaccine during pregnancy and no safety concerns have been reported for vaccinated pregnant people or their babies. Data indicate that pregnancy is an independent risk factor for severe COVID-19 (3-fold increased risk for ICU admission, a 2.4-fold increased risk for needing ECMO, and a 1.7-fold increased risk of death due to COVID-19, compared with symptomatic nonpregnant individuals). Vaccination is the best method to reduce maternal and fetal complications of SARS-CoV-2 infection. The data regarding the vaccine’s effectiveness against SARS-CoV-2 mutations (variants) is ongoing.
COVID-19 Vaccine Boosters
Currently, the CDC is recommending that moderately to severely immunocompromised people receive an additional dose of an mRNA vaccine. The CDC list includes people who have been receiving active cancer treatment for tumors or cancers of the blood, received an organ transplant and are taking medications to suppress the immune system, as well as other conditions and treatments that suppress the immune system. Although full vaccination is still providing stable and highly effective protection against hospitalizations and severe outcomes, a decrease in vaccine effectiveness against SARS-CoV-2 infection over time has been observed. Because the current protection against severe disease, hospitalization and death could diminish in the months ahead, especially among those who are at higher risk for complications or were vaccinated during the earlier phases of the vaccine rollout, the U.S. Department of Health and Human Services (HHS) has developed a plan to begin offering booster shots beginning in September, with individuals receiving a booster shot 8 months after the 2nd vaccine dose. This plan is subject to the FDA conducting an independent evaluation and determination of the safety and effectiveness of a third dose of the COVID-19 vaccine and the CDC Advisory Committee on Immunization Practices issuing booster dose recommendations based on a thorough review of the evidence.
Meet our perinatologist… Richard Miller, MD
Dr. Richard Miller is one of our Maternal-Fetal Medicine specialists at New Jersey Perinatal Associates and is a valued member of our team. He grew up outside of Pittsburg, PA, where he began his path to medical school. Dr. Miller graduated from Georgetown University School of Medicine and completed his residency in Obstetrics and Gynecology at the National Naval Medical Center in Bethesda, Maryland. He completed his fellowship training in Maternal-Fetal Medicine at the University of North Carolina at Chapel Hill in 1991. Before moving to New Jersey, Dr. Miller spent four years as Director of the Division of Maternal-Fetal Medicine at the National Naval Medical Center and was a member of the faculty at the Uniformed Services University of the Health Sciences and the National Institutes of Health. His research interests include outcome-based analysis of prenatal care and prenatal diagnosis.