Key Highlights from the ASCCP Management Consensus Guidelines for Abnormal Cervical Cancer Screening Results

SUMMARY:

ASCCP released new guidance to inform assessment and treatment of abnormal cervical cancer screening results. The overarching theme reflects a ‘risk-based’ strategy, rather than rigid focus on a particular result. Risk tables have been generated to assist the clinician and guide practice. This is a consensus document with input from ACOG, ACS, SGO and multiple other professional organizations, including those affiliated with laboratory medicine.

The executive summary states

New data indicate that a patient’s risk of developing cervical precancer or cancer can be estimated using current screening test results and previous screening test and biopsy results, while considering personal factors such as age and immunosuppression

For a given current results and history combination, the immediate CIN 3+ risk is examined

If this risk is 4% or greater, immediate management via colposcopy or treatment is indicated

If the immediate risk is less than 4%, the 5-year CIN 3+ risk is examined to determine whether patients should return in 1, 3, or 5 years

Routine screening applies only to asymptomatic individuals who do not require surveillance for prior abnormal screening results

KEY POINTS:

  • Recommendations (colposcopy and treatment vs surveillance) are based on risk for CIN 3+
    • Risk determined by prior history as well as screen results
    • Risk tables also address ‘unknown history’ scenario
  • Deferral of colposcopy: Low risk for CIN 3+ (risk defined by tables)
    • Repeat HPV testing or cotesting at 1 year
    • At the 1-year follow-up test, referral to colposcopy if still abnormal
  • Expansion of expedited treatment category (biopsy not needed prior to therapy), for example, in nonpregnant patients ≥25 years, expedited treatment is
    • Preferred: CIN 3+ risk is ≥60%
    • Preferred: HPV 16–positive HSIL cytology and never or rarely screened patients with HPV-positive HSIL regardless of HPV genotype
    • Acceptable: CIN 3+ risk is between 25% and 60%
    • Shared decision making is important in the context of “impact on pregnancy outcomes”
  • Excisional treatment
    • Preferred over ablation for HSIL (CIN 2 or CIN 3) in the US
    • Recommended for AIS
  • CIN 1
    • Observation is preferred vs treatment
    • Treatment acceptable with persistent CIN 1 results >2 years
  • Lower Anogenital Squamous Terminology (LAST)/World Health Organization (WHO) recommendations for reporting histologic HSIL
    • Include HSIL (CIN 2) and HSIL (CIN 3) (i.e., include CIN 2 and 3 qualifiers)
  • Reflex cytology
    • Should be performed on all positive HPV tests, regardless of genotype
    • If HPV 16 and 18 testing is positive but additional laboratory testing of the same sample is not feasible, proceed directly to colposcopy
  • Surveillance recommendations following histologic HSIL, CIN 2, CIN 3, or AIS
    • Continue surveillance with HPV testing or cotesting at 3-year intervals for at least 25 years (recommended)
    • >25 years is acceptable “for as long as the patient’s life expectancy and ability to be screened are not significantly compromised by serious health issues”
  • HPV assays
    • The ASCCP consensus document states the following in reference to HPV tests

Human papilloma virus assays that are Food and Drug Administration (FDA)-approved for screening should be used for management according to their regulatory approval in the United States

Note: All HPV testing in this document refers to testing for high-risk HPV types only

For all management indications, HPV mRNA and HPV DNA tests without FDA approval for primary screening alone should only be used as a cotest with cytology, unless sufficient, exceptionally rigorous data are available to support primary HPV testing in management

Learn More – Primary Sources:

2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors

Risk Estimates Supporting the 2019 ASCCP Risk-Based Management Consensus Guidelines

ACOG Practice Advisory: Updated Guidelines for Management of Cervical Cancer Screening Abnormalities

ASCCP Management Web App (free but requires sign in)

Cervical Cancer Screening Guidelines: The Role of Pap and HPV

SUMMARY:

The USPSTF, based on latest evidence, has released final guidelines for cervical cancer screening (August 2018). The final recommendations now include ‘HPV only’ as an option for women 30 to 65 years of age.

USPSTF recommends the following

Women ages 21 to 65 years – Recommendation Grade A (offer or provide this service)

21 to 29 years

  • The USPSTF recommends screening for cervical cancer every 3 years with cervical cytology alone

30 to 65 years

  • The USPSTF recommends screening
    • Every 3 years with cervical cytology alone or
    • Every 5 years with high-risk human papillomavirus (hrHPV) testing alone or
    • Every 5 years with hrHPV testing in combination with cytology (cotesting)

Women older than age 65 years – Recommendation Grade D (discourage the use of this service)

  • The USPSTF recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer

Women younger than age 21 years – Recommendation Grade D (discourage the use of this service)

  • The USPSTF recommends against screening for cervical cancer in women younger than age 21 years

Women who have had a hysterectomy – Recommendation Grade D (discourage the use of this service)

  • The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and do not have a history of a high-grade precancerous lesion (i.e., cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer

KEY POINTS:

  • The first three recommendations (not the recommendation related to hysterectomy) apply to women who have a cervix, regardless of their sexual history or HPV vaccination status
  • None of these recommendations apply to women who have been diagnosed with a high-grade precancerous cervical lesion or cervical cancer
  • These recommendations also do not apply to women with in utero exposure to diethylstilbestrol or women who have a compromised immune system (e.g., women living with HIV)

ACOG Practice Advisory Update (August 2018)

  • The ACOG Practice Advisory Update (endorsed by SGO and ASCCP) states

ACOG affirms its current cervical cancer screening guidelines, which encompass all three cervical cancer screening strategies (cervical cytology alone, hrHPV testing alone, and co-testing). It is appropriate to counsel average-risk women aged 30– 65 years regarding all three strategies so that they can select their preferred option.

  • The ACOG Practice Advisory Update refers to the Interim Clinical Guidance for primary hrHPV testing, based on expert panel (Obstetrics & Gynecology, 2015) evidence review
  • Panel Representation included
    • SGO | ASCCP | ACOG |ACS | American Society of Cytopathology | College of American Pathologists | American Society for Clinical Pathology
  • The ACOG Practice Advisory Update summarizes the expert opinion as follows
    • Preferred: Co-testing (cervical cytology and hrHPV testing) every 5 years
    • Acceptable: Screening with cervical cytology alone every 3 years
    • Can be considered: HrHPV testing alone as an alternative screening strategy (re-screen not more frequently than every 3 years)

American Cancer Society (2020)

  • 25 to 65 years of age
    • ‘Primary’ HPV testing every 5 years 
  • If HPV testing is not available, other acceptable screening methods 
    • HPV and cervical cytology every 5 years or
    • Cervical cytology along every 3 years
  • Women >65: Stop screening if patient meets the following criteria
    • Regular screening in the past 10 years with normal results and no history of CIN2 or higher in the past 25 years
  • Total hysterectomy
    • Stop screening (unless surgery was for cervical cancer or pre-cancer)
  • Supra-cervical hysterectomy
    • Continue screening
  • Patients who have had HPV vaccine
    • Continue to screen based on guidelines

Learn More – Primary Sources:

Screening for Cervical Cancer: US Preventive Services Task Force Recommendation Statement

ACOG Practice Advisory: Cervical Cancer Screening (Update)

Use of Primary High-Risk Human Papillomavirus Testing for Cervical Cancer Screening: Interim Clinical Guidance (Obstetrics & Gynecology, 2015) 

The American Cancer Society Guidelines for the Prevention and Early Detection of Cervical Cancer

Trichomoniasis: CDC Diagnosis and Treatment Guidelines

CLINICAL ACTIONS

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

SYNOPSIS:

Trichomoniasis is the most prevalent nonviral sexually transmitted infection in the United States.  T. vaginalis infection affects >11% of women aged ≥40 years and infection rates reflect health disparities: 13% of black women are affected compared with 1.8% of non-Hispanic white women. While some infected women will present with vaginitis, the majority of those infected (70%-80%) will have minimal or no symptoms. Screening asymptomatic women may be done in high risk settings (such as an STD clinic), 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.

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

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

Bacterial Vaginosis – CDC Diagnosis and Treatment Recommendations

CLINICAL ACTIONS:

Bacterial Vaginosis (BV) occurs when normal hydrogen peroxide producing Lactobacillus sp. is replaced by an overgrowth of facultative anaerobic bacteria. If a woman presents with symptoms, including vaginal discharge, irritation and malodor

  • Diagnose BV if 3 of the following (Amsel) clinical criteria are present
    • Homogeneous, thin, white discharge that smoothly coats the vaginal walls
    • More than 20% clue cells (e.g., vaginal epithelial cells studded with adherent coccobacilli) on saline microscopic examination
    • pH of vaginal fluid >4.5
    • Fishy odor of vaginal discharge before or after addition of 10% KOH (i.e., the whiff test),   OR
  • Gram stain with Nugent scoring is considered the gold standard to diagnose
      • Used in research settings; impractical for clinicians so Amsel criteria preferred clinically
      • Assigns a score to various bacterial concentrations seen on gram stain: 0-3 Normal | 4-6 Intermediate | 7-10 Bacterial vaginosis
  • Affirm VP III (Becton Dickinson, Sparks, MD), a DNA hybridization probe test for high concentrations of G. vaginalis
  • OSOM BV Blue test (Sekisui Diagnostics, Framingham, MA), which detects vaginal fluid sialidase activity, have acceptable performance characteristics compared with Gram stain
  • Nucleic Acid Amplification Tests (NAAT) are also available and “can be used as an alternative to clinical testing in settings where pH paper, KOH, and microscopy are not available”
  • Do NOT use Pap tests
  • Do NOT culture for G. vaginalis given normal vaginal flora is heterogenous

Vaginal wet mount with a clue cell

Vaginal wet mount with a NaCl preparation, showing a clue cell at bottom left, and two normal epithelial cells.

SYNOPSIS:

Bacterial Vaginosis (BV) is not caused by a single bacterium, but by high concentrations of facultative anaerobic bacteria (e.g., Prevotella sp. and Mobiluncus sp.), G. vaginalis, Ureaplasma, Mycoplasma, and numerous other anaerobes. BV is associated with multiple or new sex partners, lack of condom use and in particular lack of vaginal lactobacillus. Because BV is not an inflammatory condition, vulvar erythema and edema are not commonly seen, unlike candidiasis and trichomoniasis.

KEY POINTS:

Treatment is recommended for women with symptoms, including discharge, irritation and malodor and may reduce the risk for C. trachomatis, N. gonorrhoeae, T. vaginalis, HIV, and herpes simplex type 2.

Recommended CDC regimens include the following:

  • Metronidazole* 500 mg orally twice a day for 7 days OR
  • Metronidazole* gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days OR
  • Clindamycin** cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days

Alternative Regimens

  • Tinidazole* 2 g orally once daily for 2 days OR
  • Tinidazole* 1 g orally once daily for 5 days OR
  • Clindamycin** 300 mg orally twice daily for 7 days OR
  • Clindamycin** ovules 100 mg intravaginally once at bedtime for 3 days
  • Secnidazole 2 g orally in a single dose

*Alcohol consumption should be avoided during treatment with oral nitroimidazoles. To reduce the possibility of a disulfiram-like reaction, abstinence from alcohol use should continue for 24 hours after completion of metronidazole and 72 hours after completion of tinidazole.

**Clindamycin ovules use an oleaginous base that might weaken latex or rubber products (e.g., condoms and vaginal contraceptive diaphragms). Use of such products within 72 hours following treatment with clindamycin ovules is not recommended. 

  • Test all women with BV for HIV and other sexually transmitted diseases (STDs)
  • Follow-up visits are unnecessary if symptoms resolve
  • Routine treatment of sex partners in not recommended
  • Using a different recommended treatment regimen can be considered in women who have a recurrence
    • Retreatment with the same recommended regimen is an acceptable approach for treating persistent or recurrent BV after the first occurrence
  • Recurrent BV: At least 3 documented, separate episodes of BV in one year
    • 0.75% metronidazole gel twice weekly for 4–6 months has been shown to reduce recurrences, although this benefit might not persist when suppressive therapy is discontinued

BV and Preterm Birth

  • 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)

Learn More – Primary Sources:

Sexually Transmitted Infections Treatment Guidelines 2021

ACOG Practice Bulletin 215: Vaginitis in Nonpregnant Patients

NEJM Review: Bacterial Vaginosis and Desquamative Inflammatory Vaginitis

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

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

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
    • 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

Guidance Update: Professional Organizations Align on Cervical Cancer Screening

SUMMARY:

ACOG has joined ASCCP and the SGO in endorsing the USPSTF cervical cancer screening recommendations. The ACOG practice document states that

Consistent with prior guidance, screening should begin at age 21 years, and screening recommendations remain unchanged for average-risk individuals aged 21–29 years and those who are older than 65 years

Management of abnormal cervical cancer screening results should follow current ASCCP guidelines

CLINICAL ACTIONS: 

The USPSTF recommends the following (Grade A – “Offer or Provide this Service”) 

  • Begin screening at age 21
    • Screen every 3 years with cytology alone
    • Do not perform HPV testing routinely
  • Age 30 to 65 can be screened
    • Every 5 years ‘cotesting’ with cytology plus HPV
    • Every 3 years with cytology only
    • every 5 years with high-risk human papillomavirus (hrHPV) testing alone

The USPSTF recommends against the following (Grade D – Discourage the use of this service)

  • <21 years
    • Do not offer screening
  • >65 years
    • Do not offer screening in the setting of adequate prior screening and otherwise not at high risk for cervical cancer
  •  Do not offer screening following hysterectomy if
    • Cervix was removed and
    • There is no history of a high-grade precancerous lesion (ie, cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer

SYNOPSIS:

Cervical cancer rates in the United States are low due largely to access to effective screening.  Cervical cancer is believed with a high degree of certainty, to be the delayed consequence of infection with high risk or oncogenic human papillomavirus (HPV).  The majority of HPV infections are transient and do not progress to cervical cancer.  However, the consequences of missing precancerous or early cancerous lesions are potentially lethal and should be avoidable with appropriate screening.

KEY POINTS:

  • The goal of cervical cancer screening is to minimize harm and maximize benefit
  • Guidelines focus on increasing the age at which to begin screening, lengthening the screening interval and discontinuing screening women at low risk for future cervical cancer
  • The above action items refer to average risk women
  • Women at increased risk for cervical cancer require a higher level of surveillance and include those who are
    • Immunocompromised (HIV positive, organ transplant recipient, chronic steroid use)
    • Sex workers
    • Women with multiple partners or high risk partners
    • Women with a history of abnormal Pap smear  or precancerous genital conditions
    • Smokers
    • Women with a history of sexually transmitted diseases
  • ACOG has responded to the American Cancer Society (2020) recommendation that hrHPV testing in isolation every 5 years should be prioritized for women 25 to 65 years of age
    • hrHPV alone has demonstrated efficacy and efficiency
    • However, the ACOG Practice Advisory notes significant limitations regarding current healthcare infrastructure, including

Limited access to primary hrHPV testing is of particular concern in rural and under-resourced communities and among communities of color, which have disproportionately high rates of cervical cancer incidence, morbidity, and mortality

Although HPV self-sampling has the potential to greatly improve access to cervical cancer screening, and there is an increasing body of evidence to support its efficacy and utility, it is still investigational in the United States

  • Diagnosis Codes:
    • Z01.411 encounter for routine gyn exam with abnormal findings
    • Z01.412 encounter for routine gyn exam with normal findings
    • Z01.42 encounter for exam to confirm normal smear after history of abnormal cervical cytology

Learn More – Primary Sources:

ACOG: Updated Cervical Cancer Screening Guidelines

ASCCP Management Guidelines and Algorithms

USPSTF (2018): Cervical Cancer Screening

Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society

Locate a GYN Oncology Specialist:

Gyn Oncology Locator – SGO