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Maternal and Perinatal Infection: Chlamydia, Gonorrhea, and Syphilis in Pregnancy
Key Points
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All pregnant women younger than 25 years or those at increased risk should be screened for Chlamydia and gonorrhea during pregnancy.
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Women younger than 25 and those at high risk for sexually transmitted infections should be rescreened for Chlamydia during the third trimester.
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Syphilis screening should be performed at the first prenatal visit as well as early in the third trimester. Repeat testing should be performed at the time of delivery in patients at high risk for syphilis.
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If syphilis testing was not done during pregnancy, it should be performed postpartum prior to the patient’s discharge from the hospital.
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NAATs of urine, the endocervix, or the vagina is the preferred screening test for both Chlamydia and gonorrhea.
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Screening for syphilis can be performed using either a treponemal or nontreponemal test.
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Penicillin is the antimicrobial of choice in treating syphilis among pregnant women and for reducing the incidence of congenital syphilis.
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Pregnant women with a penicillin allergy and syphilis infection should undergo penicillin desensitization with subsequent penicillin therapy.
Chlamydia
Epidemiology
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The two most valuable sources of incidence and prevalence data on sexually transmitted pathogens are provided by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO).
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Overall, the WHO 2008 global estimate places the incidence at 105.7 million new cases of Chlamydia infection, 106.1 million new cases of gonorrhea, and 10.6 million new cases of syphilis among people aged 15 to 49 years.
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Genital tract chlamydial infections are generally ascribed to Chlamydia trachomatis and account for the most prevalent reported infectious disease in the United States.
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These infections present unique problems for public health control programs because 50% to 70% of these infections are clinically silent in women.
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Most reported infections occur in the 15- to 24-year-old age group.
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The endorsement of a nationwide broad-based screening program by both the CDC and Institute of Medicine.
Pathogenesis
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Only C. trachomatis and C. pneumoniae claim primates as their endogenous hosts.
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Chlamydiae are obligate intracellular bacteria that grow in eukaryotic epithelial cells, and they have a unique growth cycle, distinct from all other pathogens.
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Because chlamydiae depend on their host cell for the generation of adenosine triphosphate, they require viable cells for survival.
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Major outer membrane protein is a major target for protective host immune responses, such as neutralizing antibodies and possibly protective T-cell responses.
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Chronic immune activation plays a role in propagating clinical disease.
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Aberrations in humoral immunity also appear to modulate clinical disease.
Diagnosis
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Because curative antibiotic therapies for chlamydial infections are available and inexpensive, early diagnosis is an essential component of management and prevention.
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Chlamydial culture has been replaced by nucleic acid amplification tests (NAATs).
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NAATs can be utilized to test for C. trachomatis in endocervical swabs from women, urethral swabs from men, first-catch urine from both men and women, and vaginal swabs from women. The ability of NAATs to detect C. trachomatis without a pelvic examination is a key advantage of NAATs, and this ability facilitates screening men and women in nontraditional screening venues.
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Other antigen-detection methods—such as enzyme immunoassay, direct fluorescence assay, nucleic acid hybridization/probe tests, and nucleic acid genetic transformation tests—are also available but are generally not recommended for routine testing for genital tract specimens.
Treatment
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In pregnancy, the CDC recommends azithromycin in a single 1-g oral dose ( Box 52.1 ).
BOX 52.1Recommended Treatment Regimens ∗∗ The Centers for Disease Control and Prevention recommends treating individuals with a positive Chlamydia -sensitive nucleic acid amplification test. Although tetracycline and doxycycline have the greatest activity against C. trachomatis, these drugs should not be used in pregnancy because of their effects on bone and on dental enamel of the developing fetus (see Chapter 8 ). Owing to gastrointestinal side effects with erythromycin, azithromycin is the drug of choice in pregnancy.
for Chlamydia trachomatis Infections in Pregnancy †
† Sex partners within the preceding 60 days of diagnosis or the most recent sex partner, if that has been longer than 60 days, should be evaluated and treated also.
Modified from Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Morb Mortal Wkly Rep. 2015;64(RR-03):1-137.Recommended Regimen †
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Azithromycin, 1 g orally in a single dose
Alternative Regimens
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Amoxicillin 500 mg orally 3 times a day for 7 days or
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Erythromycin base, 500 mg orally 4 times a day for 7 days or
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Erythromycin base, 250 mg orally 4 times a day for 14 days or
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Erythromycin ethylsuccinate, 800 mg orally 4 times a day for 7 days or
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Erythromycin ethylsuccinate, 400 mg orally 4 times a day for 14 days
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Doxycycline, ofloxacin, and levofloxacin are part of the treatment options in a nonpregnant patient; however, they are contraindicated in pregnancy and should not be used in this population.
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A repeat chlamydial test should be performed 3 to 4 weeks after treatment is completed.
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Women under the age of 25 and patients at high risk for Chlamydia infection should be retested in the third trimester of pregnancy.
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