Practical obstetrics info for your women's healthcare practice

STI Screening in Pregnancy: CDC Recommendations

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 STIs, and ensure counseling, screening and treatment are available.

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

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
    • STI 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
  • 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

Learn More – Primary Sources:

CDC: Sexually Transmitted Infections Treatment Guidelines 2021

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

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 consider screening young men in high prevalence clinical settings e.g. adolescent clinics, correctional facilities, STI/sexual health clinic
    • 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) at sites of contact (urethra, rectum)and every 3-6 months if at higher risk e.g. MSM on PrEP, HIV infection, or if they or their sex partners have multiple partners
    • Transgender and Gender Diverse Persons screening adapted based on anatomy
  • 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 sexually active MSM | 3 to 6 months if at increased risk
    • 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 (born in high endemic area, 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

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 Hepatitis C
  • Increased risk for Hepatitis B includes 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 all adults (except where prevalence is < 0.1%)

Learn More – Primary Sources:

CDC: Sexually Transmitted Infections Treatment Guidelines 2021

CDC: A Guide to Taking a Sexual History

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

USPSTF: Screening for Hepatitis B Virus Infection in Adolescents and Adults

Map: Prevalence of hepatitis B virus infection

USPSTF: Screening for Chlamydia and Gonorrhea