Managing Sexually Transmitted Infections in Pregnant Women

Nadi K Gupta; Christine A Bowman

Disclosures

Women's Health. 2012;8(3):313-321. 

In This Article

Bacterial Infections

C. trachomatis

C. trachomatis is an obligate intracellular bacterium of which there are several serotypes. It is the most common bacterial STI in the UK, with the highest rates in patients under 25 years of age. Furthermore, results from the National Chlamydia Screening Programme demonstrated a high level of asymptomatic infection.[101] Complications in women include pelvic inflammatory disease, ectopic pregnancy and infertility. Chlamydia, like other acute bacterial and viral STIs, is associated with increased risk of both HIV transmission and acquisition.[2]

Untreated cervical chlamydia during pregnancy is associated with an increased risk of preterm delivery and premature rupture of membranes.[3] Mother-to-child transmission occurs at the time of vaginal birth and may result in ophthalmia neonatorum and pneumonitis in the infant and postpartum endometritis in the mother.

Nucleic acid amplification testing is the gold standard diagnostic method and offers high sensitivity (90–95%) and specificity. Endocervical or vaginal swabs are the specimens of choice and are of equivalent sensitivity.

Treatment of Chlamydia During Pregnancy Erythromycin is safe for use in pregnancy but has a significant side-effect profile and is less efficacious (<95%) than azithromycin. The WHO recommends the use of azithromycin in pregnancy. The British National Formulary recommends the use of azithromycin in pregnant women only if no alternative is available, although the data that are available support its safety. When compared with erythromycin, meta-analysis showed amoxycillin to have a similar cure rate and a better side-effect profile.[4] However, penicillin has been shown to induce chlamydial latency in vitro. Tetracyclines are contraindicated in pregnancy because of the risk of bone and dental abnormalities in the infant.

Recommended regimens for chlamydia during pregnancy can be found in Box 1.

Contact tracing of sexual partners must be pursued and patients should be advised to avoid any – including condom protected – sexual intercourse for at least 7 days after both the patient and their sexual partner(s) have completed treatment. A repeat swab for test of cure is recommended for all pregnant women 6 weeks after treatment.[102] It is the authors' practice to rescreen in the third trimester.

Gonorrhea

Gonorrhea is caused by the Gram-negative diplococcus N. gonorrhoeae. It is the second most common bacterial STI in the UK.[101] Up to 50% of women may be asymptomatic and may not present until complications such as pelvic inflammatory disease are present.[5] Gonorrhea is associated with serious sequelae such as infertility, ectopic pregnancy, chronic pelvic pain and disseminated gonococcal infection.

Preterm delivery, premature rupture of membranes, chorioamnionitis and postpartum infection are more common in pregnant women with untreated gonorrhea.[6] Gonorrhea is transmitted to the newborn from the mothers' genital tract during birth and can cause ophthalmia neonatorum and systemic neonatal infection.

Diagnosis is often made using nucleic acid amplification testing. These are highly sensitive tests (>96%).[7,8] Endocervical and vaginal swabs are of equivalent sensitivity.[9] False positives may occur, however. Confirmatory culture for gonococcus is essential to allow antimicrobial sensitivity testing, which is of paramount importance given increasing antibiotic resistance.

Treatment of Gonorrhea During Pregnancy There is growing concern regarding the resistance and decreasing sensitivity of the gonococcus to many classes of antibiotics. Patients with gonorrhea frequently have concomitant infection with chlamydia. Intramuscular (im.) ceftriaxone plus cotreatment with azithromycin is now the first-line recommended treatment. Azithromycin is recommended as cotreatment irrespective of the results of chlamydia testing in order to prevent the emergence of cephalosporin resistance.[10] There is evidence to suggest synergy between azithromycin and cephalosporins.[11] Furthermore, pharyngeal gonorrhea may be more effectively eradicated with azithromycin cotreatment.[12]

Oral cefixime plus cotreatment with azithromycin is an alternative to im. ceftriaxone. In 2010, 6.3% of gonococcal isolates demonstrated decreased susceptibility to cefixime and in 2009, 0.3% to ceftriaxone.[101] A total of 35.7% of isolates were resistant to ciprofloxacin in 2010.[101] Moreover, quinolones are contraindicated in pregnancy.

Recommended regimens for gonorrhea during pregnancy can be found in Box 2 .

Partner notification must be pursued and patients are advised to abstain from sexual intercourse until they and their partners have been successfully treated. A test of cure is recommended 1 week after treatment in all cases in view of concerns regarding emerging resistance. It is the authors' practice to advise repeat screening in the third trimester.

Syphilis

Syphilis is caused by the spirochete Treponema pallidum. The incubation period of primary syphilis is 9–90 days. The primary ulcer (chancre) usually occurs at the site of inoculation, which is usually the genital or perianal area. The lesion is classically solitary and painless but can be multiple and painful. The primary chancre spontaneously resolves after a few weeks and may go unnoticed. Secondary syphilis develops 4–8 weeks later. It has a wide variety of presentations and may mimic many other diseases and may be easily misdiagnosed as glandular fever or another similar viral illness. Clinical features of secondary syphilis include rash, lymphadenopathy, mouth ulcers, fever and malaise. The symptoms and signs resolve without treatment. Long-term complications of untreated syphilis are neurological disease, cardiovascular disease and gummata (granulomatous skin lesions).

There has been a marked increase in the number of cases of early syphilis observed since the late 1990s. There were a total of 2318 cases of early infectious syphilis diagnosed in England in 2010, albeit predominantly in men who have sex with men.[101] However, antepartum syphilis can have devastating consequences, resulting in preterm labor, polyhydramnios, hydrops, fetal death and congenital syphilis. Syphilis may be transmitted to the baby via the transplacental route at any stage of pregnancy.

In view of the potential profound adverse effects of syphilis during pregnancy it is recommended that all pregnant women in the UK are screened for syphilis at the initial antenatal appointment. Repeat serological testing may be indicated in women at high risk of syphilis, for example, those with sexual partners from high-risk groups or commercial sex workers.

Diagnosis and staging of disease is based on history, clinical examination and serology. Serology involves treponemal-specific tests and nontreponemal tests. Treponemal-specific tests include treponemal enzyme immunoassay to detect IgG and IgM and T. pallidum particle agglutination. These tests are specific for T. pallidum and are reported as positive or negative.

The nontreponemal tests include the Venereal Disease Research Laboratory test and rapid plasma reagin. Nontreponemal test titers usually correlate with disease activity. False positives can occur in many conditions including pregnancy.

Treatment of Syphilis During Pregnancy The clinical management of syphilis should be lead by a genitourinary medicine clinician. All patients diagnosed with syphilis should have their HIV test repeated. Treatment of syphilis in pregnancy should be with parenteral penicillin appropriate for the stage of syphilis. Pregnant women with early-stage syphilis and higher Venereal Disease Research Laboratory test result have a higher risk of having an infant with congenital syphilis after adequate treatment of maternal syphilis.[13,14] Treatment in the last trimester is also associated with increased likelihood of congenital infection.[13–16] Parenteral penicillin is the drug of choice as there are higher failure rates with nonpenicillin alternatives. Nonpenicillin alternatives include ceftriaxone, erythromycin and azithromycin. Penicillin desensitization should be considered in those patients reporting penicillin allergy.[17]

The Jarisch–Herxheimer reaction may occur just as for nonpregnant women. This may cause uterine contractions and fetal heart rate decelerations, which spontaneously resolve within 24 h. Steroids are not effective in reducing these effects and are usually only initiated 24 h prior to antibiotic therapy for cardiovascular syphilis, neurosyphilis or ophthalmological involvement in order to prevent complications arising from acute local inflammation.

Recommended regimens for syphilis during pregnancy can be found in Box 3.

Partner notification is essential. Management should involve close liaison between genitourinary medicine, obstetrics and pediatrics. Both the mother and baby require close monitoring and follow-up.

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