© Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION 40 Sexually Transmitted Infections During Pregnancy Ahmed S. Latif and Sharon Moses Sexually transmitted infections (STIs) in pregnancy may surgery has led to a reduction in febrile morbidity rates result in adverse pregnancy outcomes, fetal infection, neo- (Qvistad et al. 1983; Crowley et al. 2001). If screening natal infection, and a broad range of social consequences. is not practical, many clinics and practitioners routinely Adverse pregnancy outcomes include ectopic pregnancy, treat all women receiving surgical abortion for chlamydia miscarriage, and stillbirth, congenital and perinatal infec- presumptively and, in high prevalence areas, would treat tions, and maternal puerperal infections. Infection before for gonorrhea as well. pregnancy can lead to ectopic pregnancy and infertility, Intrauterine infection may be the result of hema- and infection during pregnancy can cause miscarriage, togenous or ascending infection. For example, con- chorioamnionitis, preterm delivery, small-for-dates in- genital syphilis Treponema pallidum is hematogenously fants, and congenital infection. The susceptibility to in- spread in the mother’s blood and invades the placenta fection is increased during pregnancy, and the clinical and fetal tissues. Such infection produces characteristic manifestations of some STIs are altered during pregnancy. histologic changes in the placenta. Ascending infec- STIs present at delivery can cause maternal puerperal in- tion from the cervix and vagina may occur through fection and neonatal infections. intact or compromised fetal membranes and can cause chorioamnionitis and amniotic fluid infection. HIV and hepatitis B, in contrast, are hematogenously dis- PREGNANCY-RELATED COMPLICATIONS seminated in the mother but do not pass the placental OF STIS barrier. Vertical transmission occurs in these cases at Although fertility-related complications are not the parturition, through exposure to blood and secretions. specific focus of this chapter, they are the among most Fetal loss, prematurity, and preterm rupture of critical and costly complications of unprotected sexual membranes, low birth weight, and a variety of perina- intercourse and STI. Ectopic pregnancy and infertility are tal complications occur more frequently in pregnant recognized complications of salpingitis; the most com- women with reproductive tract infections, including mon causes of salpingitis are Neisseria gonorrhoeae and STIs and bacterial vaginosis. Chlamydia trachomatis. The risk of ectopic pregnancy Intrauterine or perinatally transmitted STIs can increases 10-fold following an episode of salpingitis. Both have severely debilitating effects on pregnant women, chlamydial and gonococcal infection can cause salpingitis, their partners, and their fetuses, and are among the top resulting in tubal obstruction, a major cause of infertility. causes of disability-adjusted life years lost in developing Postabortal infections following surgical termina- countries. All pregnant women and their sex partners tions are substantially increased in women with co- should be asked about STIs, counseled about the pos- existent chlamydia, gonorrhea, or bacterial vaginosis. sibility of perinatal infections, and ensured access to Screening and treating women for these infections pre- treatment, if needed. 377 86755_CH40_FINAL.indd 377 3/1/11 3:26 PM © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION 378 Chapter 40: Sexually Transmitted Infections During Pregnancy SCREENING FOR STIS IN PREGNANCY Pregnant women identified as HIV infected should be staged with CD4 and viral load testing, as well as The antenatal care visit provides an opportunity for for opportunistic infections. As soon as possible, they screening pregnant women for STIs and for providing should be apprised of the potential options available to critically important surveillance data to STI and perina- them. Three options are (1) term delivery with appropri- tal program managers. The infections that are screened ate antiretroviral prenatal and perinatal intervention, will depend on the prevalence of infections in the com- which reduces vertical transmission to <2%; (2) term munity in which the pregnant woman lives and on the delivery without antiretroviral therapy, which carries a individual woman’s risk for acquiring infection. Screen- 30% risk of vertical transmission; and (3) pregnancy ing tests are available for most STIs; however, the range termination. Women should also be apprised that cur- of tests available in resource-constrained settings may rent data suggest that pregnancy during HIV infection be limited. Generally, comprehensive testing is recom- does not result in increased adverse HIV-related events mended at an early prenatal visit (in the first trimester). or complications. Women who carry a pregnancy to Depending on the organism, the clinical setting, and term should be advised that 1–15% of seronegative in- risk profile, testing may be repeated during the third fants will become infected during breast-feeding if HIV- trimester as parturition approaches. Clinicians should infected women breast-feed their infants into the second not be deluded that once engaged in prenatal care, that year of life. patient’s risk disappears! Pregnant women who are HIV infected should be counseled concerning their options (either on-site or by referral), given appropriate antenatal treatment, and HIV TESTING advised not to breast-feed their infants if infant formula All pregnant women should be offered voluntary HIV is readily available and can be safely prepared. testing at the first antenatal visit. Repeat testing for HIV is advisable in the third trimester and at the time of delivery in women at greater risk for infection, including women SCREENING FOR SYphILIS that have an STI during pregnancy or have multiple sex- A serologic test for syphilis should be performed on all ual partners during pregnancy, those that have an HIV- pregnant women at the first prenatal visit. Where prenatal infected partner, those using illicit drugs, and those that care is not optimal, rapid plasma reagin (RPR)-card test live in or come from areas where HIV prevalence is high. screening should be performed, and if the test is reactive, HIV testing consent requirements are in transi- treatment should be given at the prenatal visit. Women tion, from the former “HIV testing exceptionalism” who are at high risk for syphilis, live in areas of excess that requires a separate consent process, to “normaliza- syphilis morbidity, were previously untested, or have posi- tion,” wherein HIV testing is routinely provided unless tive serology in the first trimester should be screened again practitioners are specifically asked not to test. Testing early in the third trimester (28 weeks gestation) and at de- should occur after the patient is notified that she will be livery. Ideally, women should be retested at delivery, and tested for HIV as part of the routine panel of prenatal infants should not be discharged from the hospital unless tests (Centers for Disease Control and Prevention 2010; the syphilis serologic status of the mother has been deter- American College of Obstetricians and Gynecologists mined at least one time during pregnancy and preferably 2003). For women who decline, providers should con- again at delivery. Any woman who delivers a stillborn tinue to strongly encourage testing and address concerns infant should be tested for syphilis. Congenital syphilis that pose obstacles to testing. Women who decline test- is considered in most areas to be a “sentinel public health ing because they have had a previous negative HIV test event” because it is 100% preventable through screening should be informed of the importance of retesting dur- and treatment. ing each pregnancy. The concept of incident infection should be reemphasized. Testing pregnant women is par- ESTING FOR EPATITIS IRUS NFECTION ticularly important, because antiretroviral and obstetric T H B V I interventions can reduce the risk of perinatal HIV trans- A serologic test for hepatitis B surface antigen (HBsAg) mission to below 2%. In settings where women present should be performed on all pregnant women at the first for delivery and their HIV status is undocumented, prenatal visit. HBsAg testing should be repeated late in rapid testing should be performed if available. pregnancy for women who are HBsAg negative but who 86755_CH40_FINAL.indd 378 3/1/11 3:26 PM © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION Papanicolaou Smear 379 are at high risk for HBV infection, including injection- women at risk or for women living in an area in which the drug users and women who have other STIs. prevalence of N. gonorrhoeae is high (Miller et al. 2003). Women who are HBsAg positive should be referred A repeat test should be performed during the third trimes- for assessment and medical management and for as- ter for those at continued risk. Testing can be performed sessment and vaccination of their sexual partners and by either culture (of endocervical secretions) or NAATs. household contacts. The hospital in which delivery is As with chlamydia, NAATs are highly sensitive, specific, planned and the provider who will care for the newborn and offer the widest range of testing specimen types and should be notified of the woman’s HBsAg result so that may be used with self-obtained vaginal swabs, endocervi- the neonate may be provided with immunoprophylaxis. cal swabs, vaginal swabs,