Am Fam Physician. 2007;76:265-270, 272.
Clinical ContextPregnant women with STIs can transmit the
infection to their children, resulting in significant morbidity and mortality. C. trachomatis can cause neonatal pneumonitis and maternal endometritis. Neisseria gonorrhea
can result in ophthalmia neonatorum, neonatal systemic infection, and
maternal endometritis.
Syphilis is associated with maternal hydramnios,
spontaneous abortion, preterm delivery, fetal hydrops, fetal distress,
stillbirth, and neonatal syphilis. Trichomonas vaginalis has been linked to preterm delivery, low birth weight, maternal vaginitis, and possible increased
risk for HIV transmission.
In the August 4, 2006, issue of MMWR Recommendations and Reports, Workowski and Berman described guidelines for
screening for and
treatment of STIs in pregnancy.
In the current review, Majeroni and Ukkadam detail the current
recommendations for screening for and treatment of STIs in pregnant
women in the United States.
Study HighlightsScreening recommendationsAll pregnant women should be screened for HIV, HBV, syphilis, and C. trachomatis.Women with risk factors should be tested for N. gonorrhea and hepatitis C virus (HCV).Women at risk (eg, those < 25 years and those with multiple sex partners) should be rescreened in the third trimester.Screening is not recommended for HSV, human papillomavirus (HPV), trichomoniasis, or bacterial vaginosis.HIV testing is recommended at first prenatal visitRisk
factors include previous STIs, prostitution for money or drugs,
multiple sex partners during pregnancy, illicit drug use, or high-risk
or HIV-positive sex partners.Screening test is enzyme immunoassay for HIV antibodies, confirmed by Western blot or immunofluorescence assay.Treatment includes highly active antiretroviral therapy to reduce viral load.Efavirenz is not used because of teratogenicity in animals.In women who do not take antiretrovirals, elective cesarean
delivery at 38 weeks can decrease transmission risk.The updated treatment guidelines are available at the AIDSinfo Web site: http://aidsinfo.nih.gov/.HBVHBsAg
test can detect acute and chronic infections, and IgM antibody to
hepatitis B core antigen indicates acute or recent infection.HBV vaccine is recommended for unvaccinated pregnant women needing STI treatment.Infants of mothers positive for HBsAg need hepatitis B immune globulin and vaccine at birth.Additional treatment guidelines are provided by the CDC.SyphilisScreening tests are rapid plasma reagin or Venereal Disease Research Laboratories test.Treatment failure is more likely if fetal ultrasound shows syphilis findings.Treatment is 2.4 million units of intramuscular benzathine penicillin G, although best treatment is unclear.C. trachomatisNucleic acid amplification test on cervical or urine specimens has high sensitivity and specificity.Preferred treatment is single 1-g dose of oral azithromycin, but there are no long-term safety studies.Testing should be repeated 3 weeks after treatment completion.N. gonorrheaRisk factors are new or multiple sex partners.Tests include culture on Thayer-Martin media and nucleic acid amplification test on cervical or urine specimen.Preferred treatment is 400 mg of oral cefixime or 125 mg of intramuscular ceftriaxone.HCVAnti-HCV
antibody test is recommended for women at risk (eg, those with history
of injectable drug use, recurrent exposure to blood products, or
pre-1992 blood transfusion or organ transplant).HSV vertical transmission risk is higher if acquired by women near delivery timeScreening occurs by patient history or observed lesions.Tests include culture or polymerase chain reaction assay of lesion.Treatment
with acyclovir or valacyclovir starting at 36 weeks'' gestation reduces
recurrence of lesions and viral shedding at delivery.HPVBiopsy can be done if visual diagnosis unclear, treatment ineffective, or lesions pigmented, ulcerated, fixed, or bleeding.Treatment is weekly topical trichloroacetic acid, 80% to 90%.T. vaginalisScreening of asymptomatic women is not needed; testing of symptomatic women includes saline wet mount or culture.Metronidazole
as single 2-g oral dose or twice-daily 500 mg for 1 week after the
first trimester, does not decrease preterm delivery.Bacterial vaginosis is more common in sexually active women but is not STIScreening and treatment in asymptomatic women does not decrease pregnancy complications.
Pearls for PracticeAll pregnant women should be screened for HIV, HBV, syphilis, and C. trachomatis. Women with risk factors should be screened for N gonorrhea
and HCV. Screen for trichomoniasis, HPV, HSV infection, or bacterial
vaginosis is not recommended. Women at risk should be rescreened in the
third trimester.Treatments of STIs in pregnancy include azithromycin for chlamydia,
cefixime or ceftriaxone for gonorrhea, acyclovir for HSV infection,
highly active antiretroviral therapy for HIV, trichloroacetic acid for
HPV, benzathine penicillin G for syphilis, and metronidazole for
trichomoniasis.
More abstracts about the Recommendations for Screening, Treatment of STIs During Pregnancy