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 STIs, and ensure counseling, screening and treatment are available.
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
Screening for syphilis infection is a 2-step process | Antepartum screening can be performed by manual nontreponemal antibody testing (e.g., RPR) by using the traditional syphilis screening algorithm or by treponemal antibody testing (e.g., immunoassays)
Traditional screening: Initial “nontreponemal” antibody test (ie, Venereal Disease Research Laboratory test or rapid plasma reagin [RPR] test) to detect biomarkers released from damage caused by syphilis infection, followed by a confirmatory “treponemal” antibody detection test (ie, fluorescent treponemal antibody absorption [FTA-ABS] or T pallidum particle agglutination test [TP-PA])
Reverse sequence screening algorithm: Automated treponemal test (such as an enzyme-linked [EIA], chemiluminescence [CIA], or multiplex flow immunoassay [immunoblot]) performed first, followed by a nontreponemal test
If the test results of the reverse sequence algorithm are discordant, a second treponemal test (preferably using a different treponemal antibody) is performed
Pregnant women with positive treponemal screening tests (e.g., EIA, CIA, or immunoblot) should have additional quantitative nontreponemal testing because titers are essential for monitoring treatment response
If access to prenatal care is suboptimal, RPR test and treatment should be performed at time of pregnancy confirmation
Serologic retesting in the 3rd trimester (28 weeks) and at delivery if the patient for patients at high risk including
Sex with multiple partners | Sex in conjunction with drug use or transactional sex
Late entry to prenatal care (i.e., first visit during the second trimester or later) or no prenatal care
Methamphetamine or heroin use
Incarceration of the woman or her partner
Unstable housing or homelessness
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
Developmental delay
Seizures
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 STI, 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 STI
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 STI
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 STI 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 STIs 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
Screening for Sexually Transmitted Infections – Who, When and How Often?
SYNOPSIS:
There are an estimated 2.8 million new chlamydia infections each year in the US and 1.5 million new cases of gonorrhea diagnosed. The highest rates of both gonorrhea and chlamydia are reported in women aged 15 to 24. Symptoms are vague and sequelae can include pelvic inflammatory disease, ectopic pregnancy and infertility. A full comprehensive sexual history may identify other risk factors to prompt more comprehensive screening for sexually transmitted infections
CLINICAL ACTIONS:
Sexually transmitted infections (STIs) are common with potential for serious long term outcomes, and remain a serious public health concern. Here, we outline the recommendations for screening for STIs by population:
Adults
Annual screening for gonorrhea and chlamydia is recommended for all sexually active women <25 years | evidence is insufficient for routine testing of gonorrhea and chlamydia in heterosexual men
Re-testing is recommended 3 months after treatment due to high re-infection rates
Screening is recommended for adults >25 years old at increased risk for infection (new partner, multiple partners, or a partner who has an STI
Consider testing for rectal chlamydia and pharyngeal gonorrhea based on sexual history practices
Annual testing is recommended for men who have sex with men (MSM) and every 3-6 months if at higher risk
Screening for syphilis is based on risk profile, with higher risk including history of incarceration, transactional sex work, geography, or male younger than 29 years old
Annual screening for syphilis is recommended in transgender and gender diverse persons
Screening for HIV should be performed in all adults aged 13-64 and who seek evaluation and treatment for STIs | Annual HIV screening is recommended for MSM with more than one sexual partner, with consideration for more frequent 3-6 month intervals for testing
Consider type-specific HSV serologic testing in patients presenting for an STI evaluation
Consider screening for trichomonas in high-prevalence settings or patients at higher risk for infection (multiple sex partners, transactional sex, drug misuse, or a history of STI or incarceration)
Adults at increased risk of Hepatitis B should be screened (more than one sex partner in the previous 6 months, evaluation or treatment for an STI, past or current injection-drug use, or a partner with Hepatitis B)
Screening for hepatitis C infection (HCV) should take include all adults over age 18 years except in settings with HCV positivity < 0.1%
All persons with risk factors (eg., persons with HIV, prior recipients of blood transfusions, persons who ever injected drugs and shared needles, and persons who are born to an HCV-infected mother) should be tested for HCV, with periodic testing while risk factors persist
Pregnant Patients
All pregnant patients less than 25, or older than 25 with risk factors, should be screened for gonorrhea and chlamydia and re-tested in the third trimester if at risk
Pregnant women should be screened at the first prenatal visit for HIV and syphilis
Repeat screening for syphilis and HIV is recommended at 28 weeks (see ‘Related ObG Topics’ for more on screening in pregnancy) | More states are mandating third trimester repeat syphilis screening due to increasing prevalence
Hepatits B screening with Hepatitis B surface antigen at first prenatal visit is recommended regardless of prior testing
All pregnant women should undergo screening for Hepatitis C
Persons living with HIV
At first HIV evaluation and annually afterwards, screen for
Gonorrhea
Chlamydia
Syphilis
Hepatitis B surface antigen and Hepatitis B immunity
Hepatitis C screening for all persons with HIV and subsequent annual testing for MSM
Specifically for women with HIV
Screen for trichomonas for women at first evaluation and annually afterwards
Women should be screened within 1 year of sexual activity with testing repeat 65 months later | 3 normal and consecutive pap tests, screening can be spaced out to every 3 yeras
The USPSTF 2021 update
…recommends screening for chlamydia in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection. (B recommendation)
…recommends screening for gonorrhea in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection. (B recommendation)
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men
KEY POINTS:
Screen sexually active women ≥25 for gonorrhea and chlamydia if at increased risk
More comprehensive screening for STIs include evaluation for trichomonas, syphilis, HIV, Hepatitis B and Hepaittis C
Increased risk for hepatitis B include those born in a region of high endemicity (see map in ‘Learn More – Primary Sources’ below), such as sub-Saharan Africa, East Asia, the Amazon, southern parts of Eastern and Central Europe or US-born persons not vaccinated with prevalence of Hepatitis B virus >8%
CDC has updated guidelines to recommend universal Hepatitis C screening in pregnant patients and all adults (except where prevalence is < 0.1%)
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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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Disclaimer
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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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