CDC Zika Health Advisory: Prolonged IgM response and Testing Results in Pregnancy

SUMMARY:

On May 5, 2017, the CDC released an urgent public health advisory regarding prolonged IgM response and subsequent consequences related to Zika testing in pregnancy. Based on emerging data, it appears that IgM may remain in the system > 12 weeks, therefore complicating estimates as to when infection may have occurred, particularly in asymptomatic individuals

KEY POINTS:

Promptly test any pregnant women with concurrent NAT and serologic testing as soon as possible through 12 weeks after symptom onset if they become symptomatic during their pregnancy or if a sexual partner tests positive for Zika virus infection

Asymptomatic pregnant women living in or frequently traveling to areas with Zika virus transmission

• Consider Zika NAT testing at least once per trimester in addition to IgM testing as previously recommended
• Consider Zika NAT testing if performing amniocentesis
• Consider IgM testing to determine baseline Zika virus IgM levels as part of preconception counseling
• Counsel pregnant women each trimester on the limitations of IgM and NAT testing
• Interpreting Zika NAT results:
  • Positive – may indicate recent infection
  • Negative – does not rule out recent infection as viral RNA declines over time

The CDC has not changed guidance for symptomatic individuals at this time.  The Advisory states:

Although IgM persistence could affect IgM test interpretation for all infected people, it would have the greatest effect on clinical management of pregnant women with a history of living in or traveling to areas with Zika virus transmission before conception. Pregnant women who test positive for IgM antibody may have been infected with Zika virus and developed an IgM response before conception.

Learn More – Primary Sources:

CDC: Prolonged IgM Antibody Response in People Infected with Zika Virus: Implications for Interpreting Serologic Testing Results for Pregnant Women

CDC Guidance for Non-Pregnant Patients and Available Diagnostic Tests for Zika Virus

Zika virus disease is a nationally notifiable condition:

Healthcare providers should report suspected Zika virus disease cases to their state, local, or territorial health department to facilitate diagnosis and mitigate risk of local transmission. State, local, and territorial health departments should report laboratory-confirmed and probable cases to CDC.

CLINICAL ACTIONS:

The following is a summary of CDC testing protocols.  For detailed protocols and information, the CDC resource pages can be found in the Learn More – Primary Sources section below

Testing Guidance for Non-Pregnant patients

Symptomatic individuals with possible exposure to Zika virus

• CDC defines ‘exposure’ to Zika virus as travel or residency in an area of active Zika virus transmission or sexual intercourse without a condom with a parter who has lived in or traveled to such an area
• Concurrent testing of serum and urine by Zika virus ribonucleic acid (RNA) nucleic acid testing (NAT) and Zika virus and dengue virus IgM testing of serum is recommended
• NAT testing is dependent on the timing of specimen collection
  • NAT testing should be performed on specimens collected <14 days after symptom onset
    • NAT testing is not recommended on specimens collected ≥ 14 days after symptom onset
  • Zika virus and dengue virus IgM serology testing should be performed on NAT negative samples collected <14 days after onset of symptoms or on samples collected ≥14 days after onset of symptoms

SYNOPSIS:

Testing for Zika virus is available using molecular and serological assays. Typical symptoms include acute onset of fever, with maculopapular rash, arthralgia, myalgia, headache, conjunctivitis. Differential diagnosis of such symptoms is broad and include group A strep, rubella, measles and other viral diseases. Therefore, to identify those at risk for Zika virus, it is essential to take a travel and sexual history of all patients presenting with the above symptoms and to stay current with CDC updates as to high Zika virus transmission areas.

KEY POINTS:

Tests for Zika virus include the following

Molecular Testing: Triplex Real-time RT-PCR Assay (rRT-PCR)

• A molecular test designed to detect Zika virus, Dengue virus and Chikungunya virus RNA
• FDA is currently allowing its use under an Emergency Use Athoriziation
• RNA can be detected in the acute phase, and up to 14 days post symptoms in urine
• If clinically indicated, amniocentesis and CSF specimens may be tested alongside patient-matched serum sample

Antibody Detection Methods: Zika virus IgM

• Antibody testing not required if there is a a positive rRT-PCR result
• Due to cross reactivity, symptomatic individuals should be tested for anti-Zika and anti-Dengue IgM and where clinically relevant, anti-chikungunya IgM

PRNT (Plaque Reduction Neutralization Test) to confirm antibodies

• Works by quantifying the antibodies that neutralize the virus
• Positive or equivocal IgM results must be confirmed with an antibody neutralization assay to rule out false positives (previous and not recent infection)
• Not necessary with positive rRT-PCR which is definitive
• Test is performed by the CDC or CDC approved lab
• PRNT may not be able to provide definitive determination of the specific virus causing the recent infection

Learn More – Primary Sources:

CDC: Zika Virus

CDC: Areas with Risk of  Zika

 

Trichomoniasis: CDC Diagnosis and Treatment Guidelines

SYNOPSIS: 

Trichomoniasis is the most prevalent nonviral sexually transmitted infection worldwide.  The U.S. population-based T. vaginalis prevalence is 2.1% among females and 0.5% among males, with the highest rates among Black females (9.6%) and Black males (3.6%), compared with non-Hispanic White women (0.8%) and Hispanic women (1.4%) The majority of persons who have trichomoniasis (70%–85%) either have minimal or no genital symptoms, and untreated infections might last from months to years, however, data are lacking on whether screening and treatment for asymptomatic trichomoniasis is beneficial. Decisions about screening might be informed by local epidemiology of T. vaginalis infection rates. 

CLINICAL ACTIONS: 

Male: Urethritis| Epididymitis | Prostatitis 

Women: Vaginal Discharge| Vulvar Irritation 

Diagnostic testing for T. vaginalis should be performed in women seeking care for vaginal discharge (yellow-green, with or without irritation). Screening might be considered for women receiving care in high-prevalence settings.

Diagnosis 

• Perform nucleic acid amplification testing (NAAT), which detects T. vaginalis genetic material, is highly sensitive and which is three to five times more likely to identify T. vaginalis infections than wet-mount microscopy, a method with poor sensitivity
• Culture was considered the gold standard before molecular testing and is less sensitive than newer tests
• If wet preparations are used, despite lower sensitivities, slides should be evaluated immediately as sensitivity declines with time
• If negative, consider follow up with a NAAT to make sure infection is truly not present
• T. vaginalis may be an incidental finding on a Pap test, neither conventional nor liquid-based Pap tests are considered diagnostic tests for Trichomoniasis, because false negatives and false positives can occur

KEY POINTS:

The nitroimidazoles are the only class of antimicrobial medications known to be effective against T. vaginalis infections. Of these drugs, metronidazole and tinidazole have been cleared by FDA for the oral or parenteral treatment of trichomoniasis.

The CDC recommends the following

• Women
  • Metronidazole 500 mg 2 times/day for 7 days
• Men
  • Metronidazole 2 g orally in a single dose

• Alternative regimen for men and women
  • Tinidazole 2 g orally in a single dose

Note: ACOG also recommends metronidazole 500 mg orally twice a day for 7 days as the recommended treatment option with tinidazole, 2 g orally in a single dose as the alternative regimen 

• Alcohol consumption should be avoided during treatment with nitroimidazoles
  • To reduce the possibility of a disulfiram-like reaction, abstinence from alcohol use should continue for 24 hours after completion of metronidazole or 72 hours after completion of tinidazole
• Providers should advise persons infected with T. vaginalis to abstain from sex until they and their sex partners are treated (i.e., when therapy has been completed and any symptoms have resolved)
  • Testing for other STDs including HIV should be performed in persons infected with T. vaginalis
• Retest for T. vaginalis is recommended for all sexually active women within 3 months following initial treatment
  • Testing by NAAT can be conducted as soon as 2 weeks after treatment
• Treat current partners to avoid reinfection and further transmission
  • Partners should be advised to abstain from intercourse until they and their sex partners have been adequately treated and any symptoms have resolved
  • In States where legally allowed (see learn more below), consider Expedited Partner Therapy (EPT) which allows the patient herself to provide medications to her partner when there are limited public health services to treat a partner, or concern that the partner will not have access to treatment

Pregnancy

• T. vaginalis infection is associated with two to threefold increased risk for HIV acquisition, preterm birth, and other adverse pregnancy outcomes among pregnant women
  • However, some trials have not shown improvement in perinatal morbidity with treatment
• Symptomatic pregnant women, regardless of pregnancy stage, should be tested and considered for treatment with metronidazole
  • Tinidazole should be avoided for pregnant women
• The benefit of routine screening for T. vaginalis in asymptomatic pregnant women has not been established

HIV

• Among women with HIV infection, up to 53% are also infected with T. vaginalis which has been associated with an increased risk for PID
• Routine screening of asymptomatic women with HIV infection for T. vaginalis is recommended on entry to care, and then annually
  • Pregnant women, including those who are asymptomatic, should be screened and treated as necessary because T. vaginalis infection is a risk factor for vertical HIV transmission
• The recommended regimen in the setting of HIV is as follows
  • Metronidazole 500 mg twice daily for 7 days
• Retest in 3 months with NAAT

Learn More – Primary Sources:

CDC: Trichomoniasis Treatment Guidelines

CDC: Trichomoniasis Fact Sheet for Your Patients

CDC: Expedited Partner Therapy 

ACOG Practice Bulletin 215: Vaginitis in Nonpregnant Patients

Gonorrhea: CDC Diagnosis and Treatment Guidelines

CLINICAL ACTIONS:

Annual screening for gonococcal infection (GC) (N. gonorrhoeae) is recommended for all sexually active women aged <25 years and for older women at increased risk for infection (e.g., those who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has a sexually transmitted infection).

Diagnosis

• Perform nucleic acid amplification testing (NAAT), which detects genetic material of N. gonorrhoeae
  • More sensitive than culture
  • Faster results than culture
  • Easy to obtain from a vaginal swab
  • Currently approved for genital (vaginal, endocervical) and urine samples
  • Can NOT determine antibiotic resistance

          OR

• Culture for N. gonorrhoeae
  • Requires endocervical swab, not vaginal
  • Available for rectal, oropharyngeal, and conjunctival gonococcal infection

NOTE: Obtain BOTH NAAT and culture in the case of treatment failure to determine bacterial susceptibility to antibiotics

SYNOPSIS:

Specific microbiologic diagnosis of infection with N. gonorrhoeae should be performed in all persons at risk for, or suspected to have, gonorrhea. A specific diagnosis can potentially reduce complications, reinfections, and transmission. The CDC no longer recommends combination therapy for uncomplicated GC

KEY POINTS:

For Uncomplicated Gonococcal Infections of the Cervix, Urethra and Rectum

• <150 kg (300 lb): Ceftriaxone 500 mg IM as a single dose
•  ≥150 kg (300 lb): 1 g of IM ceftriaxone
• If chlamydial infection has not been excluded
  • Treat for chlamydia with doxycycline 100 mg orally twice daily for 7 days
  • During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia

If Ceftriaxone is Unavailable

• Gentamicin 240 mg IM as a single dose plus azithromycin 2 g orally as a single dose or
• Cefixime 800 mg orally as a single dose | If treating with cefixime, and chlamydial infection has not been excluded, providers should treat for chlamydia with doxycycline 100 mg orally twice daily for 7 days | During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia

Uncomplicated Gonococcal Infections of the Pharynx

• <150 kg (300 lb): Ceftriaxone 500 mg IM as a single dose
•  ≥150 kg (300 lb): 1 g of IM ceftriaxone
• If chlamydial infection has not been excluded
  • Treat for chlamydia with doxycycline 100 mg orally twice daily for 7 days
  • During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia

Note: No reliable alternative treatments are available for pharyngeal gonorrhea

Additional Notes

• Instruct patient to abstain from sexual activity for 7 days after treatment and until all sex partners are adequately treated (7 days after receiving treatment and resolution of symptoms, if present)
• Test for other STIs, including chlamydia, syphilis and HIV
• A test-of-cure is not needed for persons who receive a diagnosis of uncomplicated urogenital or rectal gonorrhea who are treated with any of the recommended or alternative regimens
• In the case of pharyngeal gonorrhea treated with an alternative regimen, the patient should return 14 days after treatment for a test-of cure using either culture or NAAT
  • If NAAT positive, do a confirmatory culture and antimicrobial susceptibility testing
• Retest after 3 months
  • Recurrence may not be treatment failure but rather reinfection
  • In States where legally allowed (see learn more below), consider Expedited Partner Therapy (EPT) which allows the patient herself to provide medications to her partner when there are limited public health services to treat a partner, or concern that the partner will not have access to treatment
• Treat women with HIV with the same recommended regimen
• Consult infectious disease specialist in case of allergies to cephalosporin

Learn More – Primary Sources:

CDC: Gonococcal Infections in Adolescents and Adults

Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020

Chlamydia: CDC Recommendations for Diagnosis and Treatment

CLINICAL ACTIONS:

Annual screening of all sexually active women aged <25 years for chlamydia is recommended, as is screening of older women at increased risk for infection (e.g., those who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has an STD).

To diagnose a chlamydia infection:

• Obtain nucleic acid amplification testing (NAAT), which detects genetic material of C. trachomatis
  • Highly sensitive in first-catch urine samples and endocervical or vaginal swabs
  • Can be collected by a provider or a self-collected vaginal swab
  • Certain NAATs have been FDA-cleared for use on liquid-based cytology specimens (collected for Pap smears), however sensitivity may be lower than swabs

SYNOPSIS:

Chlamydial infection is the most frequently reported infectious disease in the United States, and prevalence is highest in persons aged ≤24 years. Several sequelae can result from C. trachomatis infection in women, the most serious of which include PID (pelvic inflammatory disease), ectopic pregnancy, and infertility. Some women who receive a diagnosis of uncomplicated cervical infection already have subclinical upper-reproductive–tract infection.

KEY POINTS:

Chlamydia treatment should be provided promptly for all persons testing positive for infection; treatment delays have been associated with complications

• Recommended Regimens
  • Azithromycin 1 g orally in a single dose or
  • Doxycycline 100 mg orally twice a day for 7 days

• Alternative Regimens
  • Erythromycin base 500 mg orally four times a day for 7 days or
  • Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days or
  • Levofloxacin 500 mg orally once daily for 7 days or
  • Ofloxacin 300 mg orally twice a day for 7 days

• Routine pharyngeal screening for chlamydia is not recommended, but if C. trachomatis is detected in an oropharyngeal specimen treat with azithromycin or doxycycline
• Directly observe patient receiving therapy when single dose therapy is given
• To minimize disease transmission to sex partners, persons treated for chlamydia should be instructed to abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen and resolution of symptoms if present
• To minimize risk for reinfection, patients also should be instructed to abstain from sexual intercourse until all of their sex partners are treated
• Persons who receive a diagnosis of chlamydia should be tested for HIV, gonococcal infection, and syphilis
• Test-of-cure to detect therapeutic failure is not advised unless therapeutic adherence is in question, symptoms persist, or reinfection is suspected
  • Chlamydial NAATs at <3 weeks after completion of therapy is not recommended because the continued presence of nonviable organisms can lead to false-positive results
• Retest after 3 months
  • Recurrence may not be treatment failure but rather reinfection
  • In States where legally allowed (see ‘Related OBG Topics’ below), consider Expedited Partner Therapy (EPT) which allows the patient herself to provide medications to her partner when there are limited public health services to treat a partner, or concern that the partner will not have access to treatment
• Treat women with HIV with the same recommended regimen

PREGNANCY AND CHLAMYDIAL INFECTION

Risks in pregnancy include preterm labor, premature rupture of membranes and low birth weight with neonates at risk for conjunctivitis (ophthalmia neonatorum) and pneumonia. It is therefore imperative to screen and treat pregnant women with the following:

• Recommended Regimens
  • Azithromycin 1 g orally in a single dose
• Alternative Regimens
  • Amoxicillin 500 mg orally three times a day for 7 days or
  • Erythromycin base 500 mg orally four times a day for 7 days or
  • Erythromycin base 250 mg orally four times a day for 14 days or
  • Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days or
  • Erythromycin ethylsuccinate 400 mg orally four times a day for 14 days

• Test-of-cure (preferably by NAAT) recommended at 3 to 4 weeks after completion of therapy and again after 3 months
• Diagnosis code: Chlamydia: A74.9  (pregnant) or A56.02 (nonpregnant)

Learn More – Primary Sources:

CDC: Chlamydial Infections in Adolescents and Adults

CDC: Chlamydia Fact Sheet for Your Patients

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
HEPATITIS C
CHLAMYDIA
GONORRHEA
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

• Cases of congenital syphilis have increased 10 fold in the past decade
• Syphilis during pregnancy can lead to
  • Stillbirth | Miscarriage | Infant death | Maternal and infant morbidity
• 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
    • Initial automated treponemal test (such as an enzyme-linked [EIA], chemiluminescence [CIA], or multiplex flow immunoassay [immunoblot])
    • Followed by a nontreponemal test
    • NOTE: 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)

• Screen during each pregnancy, preferably in the first trimester, regardless of vaccination status or history of testing
  • Use ‘triple panel’: Hepatitis B surface antigen (HBsAg), antibody to HBsAg, and total antibody to HBcAg (total anti-HBc)
• If patient underwent appropriately timed triple panel screening and has not had any new HBV exposures since triple panel screening, only HBsAg screening is required
• 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

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

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

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

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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

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 Clinical Practice Guideline 6: Viral Hepatitis in Pregnancy

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 and Testing for Hepatitis B Virus Infection: CDC Recommendations — United States, 2023

Vital Signs: Missed Opportunities for Preventing Congenital Syphilis — United States, 2022