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CMECNE

STD Screening in Pregnancy: CDC Recommendations

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. List the recommended screening tests for all pregnant women
2. Discuss the risk factors for Hepatitis C infection

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Dec 31 2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

CLINICAL ACTIONS:  

Pregnant women are considered a ‘special population’ by the CDC. Due to the potential burden to pregnant women, offspring and partners, providers should ask all pregnant women and their partners about STDs, and ensure counseling, screening and treatment are available.

SPECIFIC STDs: 
HIV
SYPHILIS
HEPATITIS B
CHLAMYDIA
GONORRHEA
HEPATITIS C
BACTERIAL VAGINOSIS
TRICHOMONAS
HSV-2

SCREENING RECOMMENDATIONS INFOGRAPHIC

Recommended Screening Tests for ALL Pregnant Women

HIV

  • ‘Opt-out screening’ – screen at first prenatal visit after notifying patient of the need to be screened, unless patient declines
    • Screen in prepregnancy or as early as possible in pregnancy
  • If patient declines, address concerns and discuss the following
    • A previous negative HIV test does not mean patient is still negative
    • Health benefit not only to patient but to fetus/offspring as treatment available to reduce perinatal transmission
  • Retest in the 3rd trimester (before 36 weeks, if possible) if at high risk
    • Illicit drug use
    • STD during pregnancy
    • Multiple sex partners during pregnancy
    • Live in areas of high HIV incidence
    • Receiving care in facilities with an HIV incidence in pregnant women ≥1/1,000 per year
    • Partner has HIV
    • Signs or symptoms of acute HIV infection
      • Fever | Lymphadenopathy | Skin rash | Myalgias | Arthralgias | Headache | Oral Ulcers | Leukopenia | Thrombocytopenia | Elevated transaminase
  • Rapid HIV testing should be performed on any woman in labor who has not been screened during pregnancy, unless she declines
    • If rapid HIV test positive, antiretroviral prophylaxis should be administered prior to receiving confirmatory test results
    • AAP recommends expedited HIV testing as soon as possible after birth for infants born to women with unknown HIV status
  • NOTE: The USPSTF (June 2019) continues to recommend screening for HIV infection in all pregnant persons, including those who present in labor or at delivery whose HIV status is unknown. (A recommendation)

SYPHILIS

  • Serologic tests should be performed at first prenatal visit
  • If access to prenatal care is suboptimal, rapid plasma reagin (RPR) test and treatment should be performed at time of pregnancy confirmation
  • Retest in the 3rd trimester (around 28 – 32 weeks) and at delivery if the patient:
    • Is at high risk for syphilis
    • Lives in areas of high syphilis morbidity
    • Is previously untested
    • Has a positive screening test in the first trimester
  • Test any woman who delivers a stillborn or in the case of infant death
    • Untreated syphilis has a 40% infant death rate
  • Do NOT discharge neonate if serologic status is unknown
    • Newborn infection may not be immediately obvious
    • Within a few weeks may develop
      • (1) developmental delay
      • (2) seizures
      • (3) birth defects such as bone deformation, blindness and deafness

Note: In September 2018, the USPSTF reaffirmed previous guidance and “recommends early screening for syphilis infection in all pregnant women.” (Grade A – Offer or Provide this Service)

HEPATITIS B (HBV)

  • Test for hepatitis B surface antigen (HBsAg) at the first prenatal visit regardless of previous testing or vaccination
  • At time of admission for delivery, retest if patient:
    • Is at high risk – more than one sex partner in previous 6 months, evaluation or treatment for STD, injection-drug use, HBsAG-positive sex partner
    • Was not screened prenatally
    • Has clinical hepatitis
  • Always do HBsAg testing prior to giving the HBV vaccine to avoid misinterpretation
  • Report HBsAg positive women to local or state health departments to ensure they are entered into a case management program to arrange access to appropriate vaccinations for contacts and prophylaxis for infants
    • If HBsAg positive, test for hepatitis B virus deoxyribonucleic acid (HBV DNA) to guide the use of antiviral medication to prevent perinatal transmission
    • If HBV DNA >200,000 IU/mL (7.6 log10 IU/mL): The American Association for the Study of Liver Diseases suggests antiviral therapy during pregnancy to further reduce perinatal HBV transmission

Recommended Screening Tests for Pregnant Women at Risk

CHLAMYDIA 

  • Test all pregnant women who are <25 years old for Chlamydia trachomatis at the first prenatal visit
  • Test all older women if at high risk:
    • More than one sex partner
    • A sex partner with concurrent partners or has an STD
  • Retest in the 3rd trimester to prevent maternal postnatal complications and chlamydia infection in the neonate
  • Test of cure by NAAT 3 to 4 weeks after treatment and retest within 3 months

GONORRHEA 

  • Test all pregnant women who are <25 years old for N. gonorrhoeae at the first prenatal visit
  • Test all older women if at high risk:
    • More than one sex partner
    • A sex partner with concurrent partners or has an STD
    • Inconsistent condom use in non-monogamous relationships
    • Previous or co-existing sexually transmitted infections
    • Exchanging sex for money or drugs
    • Consider consulting local public health authorities for further guidance on identifying those at high risk related to geographic location 
  • Treat all positive patients immediately and retest in 3 months
  • Retest in the 3rd trimester to prevent maternal postnatal complications and chlamydia infection in the neonate

HEPATITIS C (HCV) 

  • The CDC has updated HepC guidelines (2020)
    • Hepatitis C screening at least once in a lifetime for all adults aged ≥18 years, except in settings where the prevalence of HCV infection (HCV RNA-positivity) is <0.1%
    • Hepatitis C screening for all pregnant women during each pregnancy, except in settings where the prevalence of HCV infection (HCV RNA-positivity) is <0.1%
  • USPSTF also calls for universal screening for HCV infection, including pregnancy

Screen Only if Symptomatic

Bacterial Vaginosis (BV)

  • Evidence does not support routine screening
  • Evaluate and screen symptomatic women
  • The USPSTF addresses BV screening during pregnancy and states the following

The USPSTF addresses BV screening during pregnancy and states the following
The USPSTF recommends against screening for bacterial vaginosis in pregnant persons not at increased risk for preterm delivery. (D recommendation)

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for bacterial vaginosis in pregnant persons at increased risk for preterm delivery. (I statement)

Trichomonas

  • Evidence does not support routine screening 
  • Evaluate and screen symptomatic women

HSV-2

  • Evidence does not support routine screening
  • In the absence of lesions during the 3rd trimester, routine cultures for HSV are not indicated for women in the 3rd trimester who have a history of recurrent genital herpes
  • Type-specific serologic tests may help identify pregnant women at risk for HSV and to help guide counseling regarding the risk of acquiring herpes during pregnancy

SYNOPSIS:

Recommendations for STD testing can vary based on certain considerations, including state laws. The CDC recommendations are considered broader, such that more women will potentially be screened, but are consistent with other CDC guidance with the intention of preventing adverse outcomes for pregnant women, partners and fetuses.

KEY POINTS:

  • All pregnant women and their partners should be asked about STDs and counseled regarding personal risks as well as pregnancy and outcomes
  • Pap Smears should be performed in pregnancy at the same frequency as nonpregnant women
    • Management of abnormal Pap tests differ in pregnancy

Screening at Delivery

SYPHILIS 

  • Select groups of pregnant women, including women who are at high risk for syphilis or live in areas of high syphilis morbidity
  • Pregnant women with no previously established status
  • Pregnant women who deliver a stillborn infant

HIV

  • Pregnant women not screened during pregnancy

HBV

  • Women admitted for delivery at a health care facility without documentation of HBsAg test results should have blood drawn and tested as soon as possible after admission
  • Women at high risk
    • Having had more than one sex partner during the previous 6 months, an HBsAg-positive sex partner, evaluation or treatment for a sexually transmitted disease, or recent or current injection-drug use
  • Women with signs or symptoms of hepatitis

Note: CDC recommends universal hepatitis B vaccination within 24 hours of birth for medically stable infants >2000 grams

  • Permissive language that allowed the vaccine to be delayed until after hospital discharge has been removed
  • Administer hepatitis B vaccination and hepatitis immune globulin regardless of birth weight within 12 hours of birth for infants born to hepatitis b-infected mothers

CHLAMYDIA

  • Pregnant women less than 25 years of age
  • Continued high risk
    • New or multiple sex partners, sex partner with concurrent partners, sex partners who have a sexually transmitted disease

GONORRHEA 

  • Continued high risk
    • Past or current injection-drug use, having had a blood transfusion before July 1992, receipt of an unregulated tattoo, having been on long-term hemodialysis, intranasal drug use, and other percutaneous exposures

Learn More – Primary Sources:

CDC: Pregnant Women – 2015 Sexually Transmitted Diseases Treatment Guidelines

CDC: Syphilis Fact Sheet (Detailed)

Current Perspectives on Prevention of Mother-to-Child Transmission of Syphilis

ACOG Committee Opinion 752: Prenatal and Perinatal Human Immunodeficiency Virus Testing: Expanded Recommendations

CDC: A Guide to Taking a Sexual History

CDC: Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices

ACOG Practice Advisory: Hepatitis B Prevention

CDC Recommendations for Hepatitis C Screening Among Adults — United States, 2020

Screening for Syphilis Infection in Pregnant Women: US Preventive Services Task Force Reaffirmation Recommendation Statement

Screening for HIV Infection: US Preventive Services Task Force Recommendation Statement

Screening for Hepatitis B Virus Infection in Pregnant Women: US Preventive Services Task Force Reaffirmation Recommendation Statement

USPSTF: Screening for Bacterial Vaginosis in Pregnant Persons to Prevent Preterm Delivery

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Related ObG Topics:

SMFM Releases Guidelines on Screening and Management of Hepatitis C in Pregnancy 
Gonorrhea: New CDC Diagnosis and Treatment Guidelines
Gonorrhea Treatment Pearls
Chlamydia: CDC Recommendations for Diagnosis and Treatment
Bacterial Vaginosis – CDC Diagnosis and Treatment Recommendations
Screening & Treatment of Gynecologic infections in the HIV-Positive Woman
Screening for Sexually Transmitted Diseases – Who, When and How Often?
Abnormal Pap in Pregnancy: Options and Follow Up
USPSTF Recommends Universal Screening for Hepatitis C
Practical obstetrics info for your women's healthcare practice

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This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

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Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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