Controversies in the Management of Isolated Congenital Atrioventricular Block.

Congenital atrioventricular block (CAVB) affects approximately 2% of fetuses of mothers with anti-Ro or anti-La antibodies, regardless of maternal rheumatologic symptoms. Anti-Ro and anti-La antibodies are antinuclear antibodies commonly found in autoimmune diseases. Congenital atrioventricular block is associated with a relatively high fetal morbidity and mortality, particularly more advanced degrees of block. There is significant controversy surrounding surveillance of anti-Ro/La-positive pregnancies and treatment of fetuses diagnosed with CAVB. Studies of dexamethasone in the treatment of CAVB have yielded conflicting results, with most suggesting only a limited potential benefit in first- and seconddegree CAVB and in cases complicated by fetal hydrops. Larger prospective studies are needed to further evaluate the efficacy of intravenous immunoglobulin in the treatment of CAVB and of intravenous immunoglobulin and hydroxychloroquine in the prevention of CAVB in fetuses of at-risk mothers. Surveillance and treatment regimens should be determined on a case-by-case basis, taking into consideration the degree of CAVB, costs, and potential adverse effects of treatment.

Influenza and tetanus, diphtheria, and acellular pertussis vaccinations during pregnancy.

UNLABELLED: Vaccinations in pregnancy are an important aspect of prenatal care and of improving not only maternal health but also neonatal outcomes. Only 2 vaccines are specifically recommended during pregnancy: influenza and tetanus, diphtheria, and acellular pertussis (Tdap). Because influenza illness disproportionately affects pregnant women compared with other populations, annual prevention of influenza illness is recommended for all women who will be pregnant during influenza season (October to May). Influenza vaccination has been recently reported to also result in decreased febrile respiratory illnesses in the newborn, likely through passive antibody transfer. Pertussis infection rates are rising in the United States as vaccine-induced immunity wanes, with the mortality burden primarily seen in infants aged <6 months. Pertussis immunization with Tdap is now recommended for all pregnant women during the late second (>20 weeks) or third trimester with the intent to both protect the pregnant woman and provide passive antibody to the infant before vaccination at 2 months of age. Provider support for these recommendations regarding both annual influenza vaccination and postpartum Tdap vaccination during pregnancy is critical to ensuring vaccine delivery and improving both maternal and fetal health. The article reviews the epidemiology and clinical aspects of influenza and pertussis infection with particular attention to pregnancy and recommendations for vaccination in these women. TARGET AUDIENCE: Obstetricians and gynecologists, ophthalmologists, neurologists, family physicians, emergency room physicians LEARNING OBJECTIVES: After completing this CME activity, obstetricians and gynecologists should be better able to analyze how influenza infection disproportionally affects pregnant women. Assess how influenza vaccination improves maternal and likely neonatal outcomes. Evaluate pertussis infection and immunity in adults, and counsel pregnant women as to the benefits of Tdap vaccination, particularly for the infant.