From the Guidelines
Pregnant women with STIs require prompt treatment to prevent complications for both mother and baby, and the most effective approach is to initiate antiretroviral therapy (ART) for HIV, daily suppressive therapy for herpes, and immediate treatment for syphilis, gonorrhea, and chlamydia, as outlined in the guidelines from the U.S. Centers for Disease Control and Prevention 1. For HIV, antiretroviral therapy (ART) should be initiated immediately, typically with regimens containing dolutegravir or raltegravir plus tenofovir/emtricitabine, continuing throughout pregnancy and postpartum, as this reduces maternal viral load and decreases transmission risk to less than 1% 1. Some key points to consider when managing STIs in pregnancy include:
- For herpes (HSV), daily suppressive therapy with acyclovir (400mg three times daily), valacyclovir (500mg twice daily), or famciclovir (250mg three times daily) starting at 36 weeks prevents outbreaks at delivery, and cesarean section is indicated for active genital lesions during labor 1.
- Syphilis requires immediate treatment with benzathine penicillin G, with dosing based on disease stage: 2.4 million units IM once for primary/secondary/early latent syphilis, or weekly for three weeks for late latent/tertiary syphilis, and penicillin-allergic patients should undergo desensitization as alternatives are inadequate during pregnancy 1.
- Gonorrhea treatment consists of ceftriaxone 500mg IM as a single dose, while chlamydia requires azithromycin 1g orally once or amoxicillin 500mg three times daily for 7 days, and partners must be treated simultaneously to prevent reinfection, and follow-up testing is essential to confirm cure 1. Regular prenatal screening, particularly in the first and third trimesters for high-risk women, allows for early detection and management of these infections, significantly reducing the risk of adverse pregnancy outcomes and vertical transmission 1.
From the FDA Drug Label
Azithromycin, at the recommended dose, should not be relied upon to treat syphilis. All patients with sexually-transmitted urethritis or cervicitis should have a serologic test for syphilis and appropriate cultures for gonorrhea performed at the time of diagnosis. Appropriate antimicrobial therapy and follow-up tests for these diseases should be initiated if infection is confirmed
The STIs that impact vaginal delivery are:
- Syphilis: Azithromycin at the recommended dose should not be relied upon to treat syphilis.
- Gonorrhea: Patients with gonorrhea should have appropriate cultures performed at the time of diagnosis.
- Chlamydia: Azithromycin is effective in treating Chlamydia.
- Herpes Simplex Virus (HSV): There is no direct information in the provided drug labels regarding the impact of HSV on vaginal delivery.
- HIV: There is no direct information in the provided drug labels regarding the impact of HIV on vaginal delivery.
Management strategies for women with certain STIs during pregnancy include:
- Serologic testing for syphilis
- Appropriate cultures for gonorrhea
- Antimicrobial therapy for Chlamydia and other susceptible bacteria
- Follow-up tests to confirm infection and adjust antimicrobial therapy accordingly 2
From the Research
STI Considerations for Vaginal Delivery
The following STIs can impact vaginal delivery:
- Human Immunodeficiency Virus (HIV)
- Herpes Simplex Virus (HSV)
- Syphilis
- Gonorrhea
- Chlamydia
Risks Associated with STIs during Pregnancy
Women with certain STIs during pregnancy are at risk for complications, including:
- Increased risk of transmission to the neonate 3
- Increased risk of maternal and neonatal complications during childbirth 4
- Potential long-term health consequences for the woman and her fetus 5
Management Strategies for STIs during Pregnancy
Management strategies for women with STIs during pregnancy include:
- Screening for STIs, such as gonorrhea, chlamydia, and syphilis 3, 6
- Treatment with effective antimicrobial therapies, such as ceftriaxone, doxycycline, and penicillin 3, 7
- Promotion of effective barrier contraception to prevent STI transmission 3
- Monitoring of both the woman and her fetus for potential complications 5
Specific Considerations for Each STI
- HIV: effective treatment and management can reduce the risk of transmission to the neonate 5
- HSV: antiviral medications, such as acyclovir, valacyclovir, and famciclovir, can provide clinical benefit in the treatment of genital herpes 7
- Syphilis: parenteral penicillin continues to be the drug of choice for treatment of all stages of syphilis 7
- Gonorrhea and Chlamydia: effective treatment with antimicrobial therapies, such as ceftriaxone and doxycycline, can reduce the risk of complications 3, 7