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IHS Primary Care Provider Newsletter THE IHS PRIMARY CARE PROVIDER A journal for health professionals working with American Indians and Alaska Natives February 2008 Volume 33 Number 2 STD Screening and Treatment in Pregnancy Sexually transmitted diseases (STD) are common among records system. women of childbearing age, and may be asymptomatic. The goals of STD screening during pregnancy are 1) early detection Note: Some states require specific counseling or written and treatment of infection; 2) prevention of maternal signed consent. complications; and 3) prevention of vertical transmission and neonatal disease. The Centers for Disease Control and Syphilis Prevention (CDC) 2006 STD Treatment Guidelines • Screen all pregnant women at first prenatal visit recommend screening pregnant women for STDs. The CDC with a non-treponemal test (VDRL or RPR), and if screening recommendations are incorporated into the positive, confirm with treponemal test (TP-PA or recommendations below. Note that these are screening FTA- ABS). recommendations for asymptomatic pregnant women. Women • Retest at 28 to 32 weeks and at delivery for women presenting with signs or symptoms of STDs should be living in areas with excess syphilis morbidity. examined, tested, and treated if an STD is suspected at any • Stat RPR should be done at delivery for women with time during pregnancy. This document is limited to an overview of STD screening and treatment guidelines and does no prenatal care. not address issues regarding diagnostic work-up, STD • No infant or mother should leave the hospital counseling, and/or partner management. Treatment of HIV, without having the maternal syphilis status including prophylaxis for HIV positive pregnant women, is documented at least once during pregnancy. beyond the scope of this document. • Any woman who delivers a stillborn after 20 weeks’ gestation should be tested for syphilis. STD Screening Recommendations by Disease HIV • Screen all pregnant women as early in the pregnancy In this Issue… as possible. Testing is voluntary but HIV 37 STD Screening and Treatment in Pregnancy information and testing should be offered to all 41 STD/HIV Training pregnant women in opt-out format. 42 The Thirteenth Annual Elders Issue • Re-test in third trimester in high risk women 42 Oral Health Risk Assessment Training (injection drug use, concurrent STDs, women with 43 New Educational Opportunities from the New multiple sex partners, domestic violence or abuse or Mexico Geriatric Education Center HIV-infected partners). 44 2008 Nurse Leadership in Native Care • Rapid HIV testing for women in labor if Conference undocumented HIV status. If rapid screen is 45 Save the Date: 2008 ELDP reactive, antiretroviral prophylaxis (with consent) 45 IHS Child Health Notes prior to confirmatory test results. 48 OB/GYN Chief Clinical Consultant’s Corner • Have linkages to HIV services/care and follow up in Digest place 58 Meetings of Interest • Document HIV screen was offered and/or completed 60 Position Vacancies in patient medical records or electronic medical Note: If a treponemal EIA test is used for syphilis • Retest in third trimester for women at continued risk screening all positive tests should be confirmed by a or if tested positive earlier in pregnancy non-treponemal test (RPR or VDRL). If the non- treponemal test is positive then syphilis is confirmed. Note: Urine or vaginal swab NAATs for gonorrhea If the non-treponemal test is negative a second have the advantage of being non-invasive and can be treponemal test should be done. If this is positive then obtained when a pelvic exam is not being done or syphilis is confirmed, if this is negative then the first when there is a risk to the pregnancy in taking treponemal EIA was a false positive. Contact your cervical specimens. local health department to find out about areas with excess syphilis morbidity where the risk for Hepatitis C congenital syphilis is high. • Screen at first prenatal visit in high risk women (history of IDU, history of blood transfusion or Hepatitis B organ transplantation before 1992). • Screen all pregnant women in first trimester with hepatitis B surface antigen (HBsAg) in each Bacterial Vaginosis pregnancy even if previously vaccinated or tested. • Screen women with a history of preterm labor and • Test/retest at time of admission to hospital for delivery at first prenatal visit. delivery in unscreened women and high risk women • Benefit of screening women at low risk for preterm (more than one sex partner prior six months, labor is unproven. concurrent STDs, recent or current injection drug users (IDU) or HBsAg-positive partner). Human Papillomavirus • No recommendation for routine HPV screening Note: Hepatitis B vaccine is safe in pregnancy. apart from work-up of abnormal Pap tests. Women who are at risk for hepatitis B should be • If the patient has not had a Pap in the past year, it vaccinated. HBsAg serologic testing should be done may be warranted to obtain a Pap test for cervical prior to starting the hepatitis B vaccine as transient disease at the first prenatal visit. positive HBsAg tests can occur post vaccination. • Examination to assess for genital warts can be done during prenatal physical examination. Chlamydia • Screen all pregnant women at first prenatal visit. Note: the HPV vaccine is not recommended in • Retest in third trimester for at-risk women (ages 25 pregnancy. If the series is started prior to pregnancy, years or younger or who have new or multiple sex it should be discontinued for the duration of the partners or if tested positive earlier in pregnancy). pregnancy. Note: Urine or patient obtained vaginal swab Nucleic Trichomoniasis Acid Amplification Tests (NAATs) for chlamydia • Currently no CDC guidelines for screening have the advantage of being non-invasive and can be asymptomatic pregnant women. obtained when a pelvic exam is not being done or when there is a risk to the pregnancy in taking Herpes Simplex Virus cervical specimens. Because NAATS are the most sensitive testing technology to detect chlamydial • Insufficient evidence to recommend routine Type infection, they are recommended for screening. Specific HSV-2 serology screening. • Screen (HSV-2 Type Specific Serology) for HIV co- Gonorrhea infected women. • Screen at first prenatal visit for women ages 25 • Consider HSV Type Specific Serology if sex partner years or younger or women at risk (history of with HSV infection and pregnant women has no gonorrhea in prior two years, more than one sex history of HSV. partner in past year, partner with other partners, • Third trimester serial cultures for HSV are not commercial sex work, and drug use) or women recommended in asymptomatic women with a living in an area with high gonorrhea prevalence history of HSV. (certain geographic regions). African American • All pregnant women should be examined for women are also at higher risk for gonorrhea. evidence of genital herpes at the time of delivery. February 2008 THE IHS PROVIDER 38 Table 1. STD Screening Recommendations in Pregnancy and Time of Screening Gonorrhea • Ceftriaxone and Cefixime are the only recommended Time of Tests for All PregnantWomen (unless specific regimens. For patients with cephalosporin allergy, Screening risk group noted) anaphylaxis-type (IgE-mediated) penicillin allergy, First prenatal • x HIV visit • x Syphilis (RPR or VDRL). Always confirm a or other contraindication, CDC recommends positive RPR or VDRL with treponemal test considering desensitization. However, in the vast (TP-PA or FTA- ABS) majority of cases, this may not be feasible. • x Chlamydia • x Gonorrhea for women ages 25 years or younger Judicious use of azithromycin is a practical option if or women at risk (histo ry of gonorrhea in prior spectinomycin is not available or not indicated. If 2 years, more than one sex partner in past year, azithromcyin is used, a test-of-cure is prudent partner with other partners, commercial sex work and drug use) or women living in an area because efficacy data are limited and there are with high gonorrhea prevalence (certain concerns about emerging resistance. geographic regions). African American women • Cefixime tablets have not been available in the US are also at higher risk for gonorrhea. • x Hepatitis B surface antigen (HBsAg) since November 2002. An oral suspension • x Hepatitis C if high risk (history of IDU, history formulation is available. of blood transfusion or organ transplantation • Spectinomycin is an alternative regimen; however it before 1992) has not been manufactured in the US since January • x Bacterial Vaginosis if hi story of preterm labor and delivery 2006, and future availability is uncertain. • x Pap test if no Pap in prior year • Co-treatment for chlamydia infection is indicated • x Herpes (HSV-2 Type Specific Serology) for unless chlamydia infection is ruled out using HIV co-infected women and consider HSV Type Specific Serology if sex partner with HSV sensitive NAAT technology. infection and pregnant women has no history of HSV Pelvic Inflammatory Disease 28-32 weeks • x Syphilis if women lives in area with excess • Parenteral therapy in an inpatient setting is syphilis morbidity necessary because of risk of preterm delivery and Third • x HIV if high risk (IDU, concurrent STDs, maternal morbidity. Trimester multiple partners or HIV + partner) • Clindamycin plus Gentamicin are the recommended • x Chlamydia for women ages 25 years or younger regimen. or at risk (new or multiple partners) or if tested positive earlier in pregnancy • x Gonorrhea if continued risk or if tested positive Cervicitis earlier in pregnancy • Azithromycin is the drug of choice for presumptive During Labor • x HIV rapid testing if undocumented HIV status treatment. & Delivery • x Syphilis if women lives in area with excess • If local prevalence of gonorrhea is greater than 5%, syphilis morbidity co-treat for gonorrhea infection. • x Stat RPR if no prior prenatal care • x HBsAg on admission to delivery if no prior • Co-treat for bacterial vaginosis and/or screening or if high risk women (multiple trichomoniaisis if infection detected.
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