General Considerations
An estimated two million pregnant women are infected with sexually transmitted diseases (STDs) each year in the United States. These STDs are common complications in pregnancy. Physiologic—including immunologic and hormonal—changes during pregnancy may alter susceptibility to infection.
STDs can cause significant maternal and fetal complications. Adverse pregnancy outcomes directly and indirectly attributable to STDs include ectopic pregnancy, spontaneous abortion, fetal demise, perinatal infections, intrauterine growth restriction, congenital abnormalities, premature rupture of membranes, preterm birth, chorioamnionitis, puerperal infections, low-birth-weight infants, and neonatal infections. The immunologic mechanisms involved in STDs and adverse pregnancy outcomes are not well understood. Inflammatory cytokines, in response to infection, may be involved in the pathogenesis of preterm premature rupture of membranes and preterm labor, as well as adverse fetal conditions.
Diagnosis and management of STDs in pregnancy may decrease maternal and fetal morbidity and mortality. Most STDs are commonly asymptomatic or present with nonspecific symptoms; without a high index of suspicion and low threshold for testing, a substantial number of STDs will be missed, potentially leading to adverse perinatal outcomes. Therefore, obtaining a complete STD history and performing appropriate screening studies of the pregnant patient at the first prenatal visit are essential.
STDs routinely screened for in pregnancy include syphilis, hepatitis B, HIV, and chlamydia. Leading authorities differ regarding STD screening recommendations in pregnancy (see Table 22–1). These variations arise from different risk stratification, cost-benefit, and prevention strategies. Of note, the Centers for Disease Control and Prevention (CDC) recommends chlamydia screening for all pregnant women at the first prenatal visit, whereas the American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG), in their 2002 Guidelines for Perinatal Care, recommend chlamydia testing only in high-risk pregnant women, given that evidence of prevention of adverse effects through screening in pregnancy is limited. High-risk individuals may be defined by numerous criteria, depending on the specific STD in consideration (see Table 22–1). Additionally, gonorrhea and hepatitis C testing are also recommended by the CDC for at-risk women during the first prenatal visit.
| CDC | ACOG | |
|---|---|---|
| First prenatal visit | HIV | HIV |
| Syphilis | Syphilis | |
| Hepatitis B | Hepatitis B | |
| Chlamydia | Pap smear | |
| Pap smeara | ||
| Trichomoniasisb | ||
| First prenatal visit (high-risk)c | Gonorrhea | Gonorrhea |
| Hepatitis C | Hepatitis C | |
| Bacterial vaginosis | Chlamydia | |
| Third trimester | Chlamydia (<25 y) | Chlamydia (<25 y) |
| Third trimester (high-risk)c | HIV (before 36 wk) | HIV (before 36 wk) |
| Syphilis (at 28 wk) | Syphilis | |
| Gonorrhea | Hepatitis B | |
| Chlamydia | Gonorrhea | |
| Delivery (high-risk)c | HIV | HIV |
| Syphilis | ||
| Hepatitis B |
Testing for STDs, including HIV, syphilis, hepatitis B, chlamydia, and gonorrhea, should be repeated in the third trimester in any woman at high risk for acquiring these infections. Both the CDC and ACOG recommend that women younger than 25 years of age, regardless of risk profile, be retested for Chlamydia trachomatis in the third trimester.
Screening for bacterial vaginosis is not recommended as a routine component of prenatal care. Clinicians may consider such evaluation and treatment if indicated at the first prenatal visit for asymptomatic women with a history of preterm birth in order to potentially lower the risk of preterm premature rupture of membranes and low-birth-weight infants. Routine screening for Trichomonas vaginalis in asymptomatic pregnant women is not recommended.
In light of physiologic changes during pregnancy affecting the pharmacokinetics of medical therapy, drug exposure of the fetus, and breast-feeding safety considerations, treatment of STDs in pregnant and postpartum women may vary from guidelines for nonpregnant women (see Table 22–2). In addition, special concerns relating to the potential for transmission of some viral STDs need to be considered in determining the safety of breast-feeding (see Table 22–3).
| Disease | Treatment Regimen |
|---|---|
| Bacterial vaginosis | Metronidazole, 500 mg PO twice daily for 7 d |
| or | |
| Clindamycin, 300 mg PO twice daily for 7 d | |
| or | |
| Metronidazole, 250 mg PO 3 times daily for 7 d | |
| Chancroid | Azithromycin, 1 g PO in a single dose |
| or | |
| Ceftriaxone, 250 mg IM in a single dose | |
| or | |
| Erythromycin base, 500 mg PO 3 times daily for 7 d | |
| Chlamydiaa | Azithromycin, 1 g PO in a single dose |
| or | |
| Amoxicillin, 500 mg PO 3 times daily for 7 d | |
| Cytomegalovirus | Supportive care |
| Genital herpes | Acyclovir, 400 mg PO 3 times daily for 7–14 d (first episode) |
| Acyclovir, 400 mg PO 3 times daily for 5 d (recurrent episode) | |
| Acyclovir, 400 mg PO 3 times daily (suppression after 36 wk) | |
| Alternative regimen (for women in whom adherence is an issue): valacyclovir, 500 mg daily | |
| Genital warts | Cryotherapy and trichloroacetic acid |
| Gonorrheab | Cefpodoxime, 400 mg PO in a single dose |
| or | |
| Ceftriaxone, 125 mg IM in a single dose | |
| Alternate regimen (for women who cannot tolerate a cephalosporin: spectinomycin, 2 g IM as a single dose | |
| Granuloma inguinale | Erythromycin base, 500 mg PO 4 times daily for at least 3 wk ± parenteral aminoglycoside |
| Hepatitis A | Immunoprophylaxis (immune serum globulin and hepatitis A vaccine) as needed |
| Hepatitis B | Immunoprophylaxis (HBIG and hepatitis B vaccine) as needed |
| Lymphogranuloma venereum | Erythromycin base, 500 mg PO 4 times daily for 21 d |
| Molluscum contagiosum | Curettage, cryotherapy, chemical cauterization, or laser therapies |
| Pediculosis pubis | Permethrin 1% cream rinse to affected areas, washed off after 10 min |
| or | |
| Pyrethrins with piperonyl butoxide to affected area, washed off after 10 min | |
| Scabies | Permethrin cream (5%) to all areas of body from neck down, washed off after 8–14 h |
| Syphilisc | Benzathine penicillin G, 2.4 million units IM in a single dose (primary, secondary, early latent) |
| Benzathine penicillin G, 7.2 million units total, 2.4 million units IM once weekly for 3 weeks (late latent or latent of unknown duration) | |
| Trichomoniasis | Metronidazole, 2 g PO in a single dose |
Cervical Infections
- • Genital chlamydia infection is most often asymptomatic.
- • Adverse pregnancy outcomes include postpartum endometritis, ophthalmia neonatorum, and neonatal pneumonia.
C trachomatis infection in pregnancy has been associated with various complications, including postpartum endometritis, spontaneous abortion, and possibly preterm labor and delivery. Neonatal infections include conjunctivitis, otitis media, and pneumonia. The prevalence of chlamydia in pregnant women ranges between approximately 3% and 14%. Pregnant women infected with C trachomatis may present with vaginal discharge, spotting, dysuria, and pelvic pain. However, most women are asymptomatic. Pelvic examination may reveal findings consistent with cervicitis. Induced endocervical bleeding is also predictive of cervical infection in pregnancy.
Nucleic acid amplification tests (NAATs) are the standard diagnostic method for evaluation of chlamydial infection, because these techniques are more sensitive than culture and antigen-based assays. (For more detailed discussion, see Chapter 13.)
Doxycycline and ofloxacin, first-line treatments for chlamydial infection in nonpregnant women, are contraindicated in pregnancy. Instead, azithromycin and amoxicillin are recommended (see Table 22–2). Repeat testing for C trachomatis 3 weeks after completion of therapy is recommended for all pregnant women.
- • Almost half of all gonorrhea infections are asymptomatic.
- • Adverse pregnancy outcomes include preterm labor, postpartum infection, ophthalmia neonatorum, and neonatal sepsis.
The clinical course of Neisseria gonorrhoeae infection during pregnancy is similar to that in nonpregnant women. The prevalence of gonorrhea in pregnancy is approximately 1–10%. Almost half of infections are asymptomatic. Gonorrhea infection during pregnancy has been associated with pelvic inflammatory disease, predominantly in the first trimester before the chorion fuses with the decidua and obliterates the uterine cavity. Later in pregnancy, N gonorrhoeae is associated with premature rupture of membranes, preterm labor, chorioamnionitis, and postpartum infection. Gonococcal conjunctivitis (ophthalmia neonatorum), the most common manifestation of perinatal infection, is usually transmitted during delivery. If untreated, this condition may lead to corneal perforation and panophthalmitis. Other more rare neonatal infections include meningitis, disseminated sepsis with arthritis, and genital and rectal infections.
Pregnant women infected with N gonorrhoeae may present with vaginal discharge, spotting, dysuria, or pelvic pain or be asymptomatic. Pelvic examination may reveal mucopurulent cervicitis, similar to that found in chlamydial infection, as well as urethral and rectal findings. A detailed examination of skin, pharynx, rectum, and joints should be performed when disseminated infection is suspected. Hospitalization and parenteral antibiotics are recommended for women with disseminated infection during pregnancy.
NAATs are the current standard diagnostic method for evaluation of gonorrhea infection, because these techniques are more sensitive than culture and direct microscopy. (For more detailed discussion, see Chapter 16.)
Pregnant women infected with gonorrhea should be treated with a recommended or alternate cephalosporin (see Table 22–2). They should not be treated with quinolones or tetracyclines, because these antibiotics are not recommended for use during pregnancy. Women who cannot tolerate a cephalosporin should be administered a single, intramuscular 2-g dose of spectinomycin. If recent chlamydia testing was not performed, it is recommended that pregnant women receive presumptive treatment for chlamydia. Although some authorities propose retesting women 3 months after treatment, given the adverse outcomes associated with gonorrhea in pregnancy it is reasonable to consider retesting 3–4 weeks after completion of treatment in pregnancy.
Mucopurulent cervicitis may be associated not only with chlamydia and gonorrhea but also with Mycoplasma genitalium, trichomoniasis, and genital herpes simplex virus (HSV) infection. Additionally, mucopurulent cervical discharge should be clearly distinguished from the normal increases in cervical mucous often seen during pregnancy. Inflammation of the cervix should be distinguished from the normal condition of the zone of ectopy (or ectropion) that results from the symmetric extension of the columnar cervical epithelium over the os and is frequently observed in high-estrogen states (eg, pregnancy, adolescence, and use of oral contraceptives). Patients with purulent cervical discharge may have either gonococcal or chlamydial infection, or both. The presence of mucopurulent discharge along with ulcerations and erythema of the ectocervix may indicate HSV infection. Other noninfectious causes of cervicitis include systemic illnesses such as autoimmune diseases, neoplasia, and mechanical or chemical trauma.
Vaginal Infections
- • Bacterial vaginosis may be associated with preterm labor and preterm premature rupture of membranes.
- • Testing may be conducted at the first prenatal visit in asymptomatic women who are at high risk for preterm delivery.
Bacterial vaginosis has been associated with adverse pregnancy outcomes, including spontaneous abortion in the first and second trimesters, preterm labor, preterm premature rupture of membranes, preterm delivery, low-birth-weight infants, chorioamnionitis, postpartum endometritis, and postcesarean wound infections. Current evidence does not support routine screening for bacterial vaginosis during pregnancy in the general population. However, screening at the first prenatal visit is recommended for patients who are at high risk of preterm delivery (eg, those with a history of a previous preterm delivery or preterm premature rupture of membranes).
Most cases (50–75%) of bacterial vaginosis are asymptomatic or mild. Clinical presentation may include a fishy or ammonia-like odor of vaginal discharge, and thin, gray-white, nonclumping, homogenous vaginal discharge. Dysuria and dyspareunia are rare, and pruritus and inflammation are absent. The discharge associated with bacterial vaginosis originates from the vagina rather than the cervix.
The “gold standard” for diagnosis of bacterial vaginosis remains the Gram stain. This method distinguishes bacterial vaginosis from various categories of abnormal vaginal flora. Amsel criteria are used to make the diagnosis in clinical settings. Recently introduced point-of-care tests may be less reliable forms of diagnostic screening tests. (For further discussion, see Chapter 11.)
Both oral metronidazole and oral clindamycin are recommended for treatment of bacterial vaginosis in pregnant women (see Table 22–2). Clindamycin cream is not recommended during pregnancy because increased adverse pregnancy outcomes were observed in trials using this therapy. Given that treatment of bacterial vaginosis in asymptomatic pregnant women who are at high risk for preterm delivery might prevent adverse pregnancy outcomes, a follow-up evaluation 1 month after completion of treatment should be considered to evaluate whether therapy was effective.
