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11/1/2015

Trichomonas, Gonorrhea, and Chlamydia in Pregnancy

Chlamydia trachomatis

Most infections are asymptomatic, but may manifest with urethritis, Bartholin gland infection, or mucopurulent cervicitis. Upper tract infection is uncommon. All pregnant patients < 25 years of age, and older if risk factors are present, should be screened for chlamydia at the first prenatal visit. Patients < 25, and those who remain at increased risk, should be re-screened during the third trimester.

Chlamydia may be associated with preterm delivery, premature rupture of membranes, and low birthweight, although the effect on pregnancy outcome is controversial. Chlamydia is not associated with chorioamnionitis or pelvic infection following cesarean delivery. Neonates are at risk for conjunctivitis and pneumonia.

The recommended diagnostic test is the nucleic acid amplification test (NAAT), performed on a first-catch urine specimen or vaginal or cervical swabs. First-line treatment is azithromycin (1 gram orally x 1); doxycycline is contraindicated in the second and third trimester. A test-of-cure is recommended three to four weeks following treatment which is a difference from non-pregnant patients. In addition, patients should be retested for re-infection within threemonths of treatment.

 

Neisseria gonorrhea

Gonorrhea may be asymptomatic or manifest as cervicitis, urethritis, or periurethral/vestibular gland infections. Acute salpingitis is rare in pregnancy. Recommendations regarding screening (age, risk factors, timing, and re-testing later in pregnancy) and specimen collection are the same as chlamydia.

Gonorrhea is associated with septic abortion, chorioamnionitis, preterm birth, premature rupture of membranes, and postpartum infection. Additionally, disseminated gonococcal infection may occur. Neonatal complications include conjunctivitis, pharyngitis, arthritis, and gonococcemia (disseminated gonococcal infection).

The CDC’s recommended treatment is single agent therapy with ceftriazone based on weight.   A test-of-cure is not needed for uncomplicated urogenital/rectal gonorrhea treated with the recommended regimen. Patients should  be retested for re-infection within three months of treatment.

 

Trichomonas vaginalis

Most infections are asymptomatic, but may manifest with a malodorous, frothy discharge. Diagnosis may be accomplished by wet-mount microscopy, but NAAT of vaginal, endocervical, or urine specimens is far more sensitive. Molecular tests (antigen detection and DNA probe) are also available. Routine screening of asymptomatic pregnant patients is not recommended unless they are HIV-infected; patients reporting symptoms should be evaluated.

Trichomoniasisis associated with premature rupture of membranes, preterm delivery, and low birth weight. However, treatment with metronidazole during pregnancy does not prevent these outcomes. Patients should be counseled regarding the potential risks and benefits of treatment, particularly if asymptomatic. Metronidazole (2-gram single dose) is the recommended regimen. Patientsshould be treated to relieve symptoms and possibly prevent perinatal transmission (manifested by neonatal respiratory or genital infection). Trichomoniasis infection is a risk factor for vertical transmission of HIV, so HIV-infected patients should be screened and re-tested after treatment. 

 

Partner Treatment

Sexual partners should be referred for evaluation, testing, and presumptive treatment. Expedited partner treatment is recommended when available and feasible.

 

Further Reading:

Sexually Transmitted Diseases (STDs) Detailed Fact SheetCenters for Disease Control and Prevention. Available at: https://www.cdc.gov/std/pregnancy/stdfact-pregnancy-detailed.htm accessed 4/27/2021.

St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K, Torrone E, Weinstock H, Kersh EN, Thorpe P. Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep. 2020 Dec 18;69(50):1911-1916. doi: 10.15585/mmwr.mm6950a6. PMID: 33332296; PMCID: PMC7745960.

Originally approved November 2015. Revised March 2018; Reaffirmed September 2019; Revised May 2021

 

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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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