Closing the STI screening and follow-up gap in pregnancy, with Damian Alagia, III, MD

Asymptomatic presentation, clinician assumptions about patient risk, and fragmented access to prenatal care are all potential reasons that could lead to sexually transmitted infections (STIs) going undetected and untreated during pregnancy, according to Damian Alagia, III, MD, MS, MBA, FACS, Chief, Hospital and Health Systems, and Senior Medical Director, Advanced Diagnostics / Women's Health, Quest Diagnostics. The discussion continues Alagia's case for universal, non-judgmental testing.

Assumptions that drive missed diagnoses

Alagia emphasized that risk-based assumptions fail because most infections produce no symptoms.

“Most of these sexually transmitted infections are asymptomatic. They are silent. [Patients] did not go looking for an STI. They just maybe got one from their partner, and so they may be in a committed relationship, but the partner may not be in a committed relationship,” he said.

“ACOG is now moving to testing 3 times again in a nonjudgmental way during pregnancy, at the first trimester, 28 weeks when they are coming in for their glucose, and then when they deliver. That is just standard protocol,” Alagia said.

Follow-up as the second failure point

Detection alone is insufficient, Alagia noted, citing a study he coauthored with researchers from Quest Diagnostics and the University of Alabama, published in Journal of Lower Genital Tract Disease and previously reported by Contemporary OB/GYN. The analysis identified 4,077,212 pregnancies across the United States from January 2010 through July 2022.²

“We found that only a third of the patients who tested positive for STI during pregnancy had follow-up. So these babies were possibly delivered with chlamydia, gonorrhea, or syphilis,” he said, adding that untreated congenital syphilis can carry severe, long-term consequences, and that undiagnosed chlamydia and gonorrhea can result in severe pulmonary infection or blindness.

Per the published findings previously reported by Contemporary OB/GYN, 35.1% of patients who tested positive for chlamydia and 36.9% of those who tested positive for gonorrhea did not receive a follow-up negative test before delivery, suggesting they may not have been treated or cured, or were treated and later reinfected.²

Structural barriers to prenatal access

Alagia described tiers of care that leave many patients without a consistent point of contact.

“There is urgent care where they come into the emergency room for some other issue, and it could be an eye infection. It could be a pulmonary infection. You say, well, we missed an opportunity to test for syphilis or to do chlamydia and gonorrhea testing. [But urgent care is] not set up to do that, and you are really limited in the emergency room for time, and you do not have the resources, and they are not connected to care,” he said.

He attributed the gap to systemic design rather than individual clinical decisions.

“It is the failure of the system, and we do not have the systems in place, nor have we ever had the systems in place to provide consistent care and access to these patients when they do get pregnant,” Alagia said.

References:

1. Should I get tested for syphilis during pregnancy? American College of Obstetricians and Gynecologists. Accessed July 23, 2026. https://www.acog.org/womens-health/experts-and-stories/ask-acog/should-i-get-tested-for-syphilis-during-pregnancy
2. Ebert M. Study finds lack of testing for gonorrhea, chlamydia during pregnancy. Contemporary OB/GYN. August 15, 2024. Accessed July 23, 2026. https://www.contemporaryobgyn.net/view/study-finds-lack-of-testing-for-gonorrhea-chlamydia-during-pregnancy