Management of Sexually Transmitted Infections in Pregnancy
Pregnant women should receive comprehensive STI screening including syphilis, hepatitis B, HIV, gonorrhea, and chlamydia testing, with appropriate treatment based on CDC guidelines to prevent maternal complications and fetal transmission. 1
Recommended Screening Tests for Pregnant Women
All pregnant women should undergo the following screening tests:
Syphilis serology: At first prenatal visit, third trimester (for high-risk women), and at delivery 2
- Any woman who delivers a stillborn infant after 20 weeks gestation should be tested for syphilis
Hepatitis B surface antigen (HBsAg): At first prenatal visit 2, 1
HIV testing: At first prenatal visit, with appropriate counseling and informed consent 2, 1
Gonorrhea testing: At first prenatal visit, with repeat testing in third trimester for women at increased risk 2, 1
Chlamydia testing: At first prenatal visit, with repeat testing in third trimester for:
Treatment Guidelines for Common STIs in Pregnancy
Syphilis
- Treatment: Benzathine penicillin G is the only recommended treatment
- Early syphilis: 2.4 million units IM once
- Late syphilis: Three weekly doses of 2.4 million units IM 3
- Penicillin-allergic patients should be referred to specialists for desensitization 2
Gonorrhea
- Treatment:
- Fluoroquinolones are contraindicated during pregnancy 3
- Test of cure recommended due to risk of treatment failure and perinatal complications 3
Chlamydia
- Treatment:
- Test of cure recommended 3-4 weeks after treatment 4
Trichomoniasis
- Treatment: Metronidazole 500 mg orally twice daily for 7 days 3
- Earlier concerns about teratogenesis have not been confirmed by recent data
- Single-dose treatment (2g) should be avoided in first trimester 6
Bacterial Vaginosis
- Treatment: Only for symptomatic women or those with risk factors for preterm delivery 5
- Metronidazole 500 mg orally twice daily for 7 days 3
Genital Herpes
- Management:
- Routine serologic screening not recommended 5
- For women with active lesions or history of recurrent herpes:
- Suppressive therapy with acyclovir or valacyclovir from 36 weeks' gestation 5
- Cesarean delivery recommended only for women with active genital lesions at time of delivery 2
- Genital warts are not an indication for cesarean section 2
Special Considerations
Partner Management
- All sex partners should be notified, examined, and treated for the STI identified in the pregnant patient 2
- Partners and patients should abstain from sexual intercourse until therapy is completed 2
Follow-Up Testing
- Test of cure is recommended for most STIs in pregnancy due to:
Referral to Specialists
Pregnant women with the following conditions may need specialist referral:
- Primary genital herpes
- Hepatitis B virus infection
- Primary cytomegalovirus infection
- Group B streptococcal infection
- Syphilis with penicillin allergy 2
Common Pitfalls in STI Management During Pregnancy
- Inadequate screening: Failure to screen for all recommended STIs at appropriate intervals
- Missed follow-up: Not confirming treatment success through test of cure
- Incomplete partner treatment: Failing to ensure partners are treated, leading to reinfection
- Inappropriate medication selection: Using contraindicated medications during pregnancy
- Delayed treatment: Postponing treatment can increase risk of complications and transmission
By following these comprehensive screening and treatment guidelines, providers can significantly reduce the risk of adverse pregnancy outcomes and perinatal transmission of STIs.