A narrative review identified gaps in knowledge and considerations for informing sexually transmitted infection (STI) screening guidelines and treatment to improve the health of pregnant women and children.
To inform a high-level National Institutes of Health (NIH) meeting, Juliana Grant, MD, MPH, founder of the consulting company Public Health Nerds, LLC, in Seattle, Washington, and colleagues conducted a narrative review that was published in the journal Sexually Transmitted Diseases. The authors’ goal was to find knowledge gaps and key considerations for pregnant women with STIs to inform future research needed for the creation of guidelines for screening and treatment in low- and middle-income countries. The authors said that prior to the review, current evidence was insufficient to develop global guidelines.
Grant and colleagues said that in many countries, STIs such as trichomoniasis, chlamydia, and gonorrhea are common in pregnant women, and are linked to poor neonatal and maternal outcomes such as preterm labor and birth, low birthweight, pregnancy loss, and neonatal/perinatal mortality. However, no global standard STI screening and treatment guidelines exist. “Syndromic STI management is frequently used in pregnant women in low- and middle-income countries, yet its low specificity and sensitivity lead to both overtreatment and undertreatment,” the authors said.
Study authors searched PubMed literature and clinical trial registry searches through January 20, 2020. They also reviewed the World Health Organization (WHO) and other agency guidelines and collected expert opinions. Results were limited to full-text English, and the authors noted that literature searches were not done systematically because this was not a systematic review; articles and studies were not evaluated with standard criteria.
Grant and colleagues reported that adverse maternal-child outcomes ranged widely and had variable definitions. They did not find any randomized, controlled trials of etiologic screenings or targeted treatment. They only found limited evidence from observational studies. In addition, they reported mixed results from trials of presumptive STI treatment. The authors identified subgroups of pregnant women that could benefit from specific recommendations. They also noted that harm evidence was limited, and that STI prevalence and testing infrastructure availability and high/low accuracy of tests influenced cost-effectiveness. They also said that high patient acceptability was suggested by preliminary data.
“Preliminary data on harms, acceptability, and feasibility and the availability of emerging test technologies suggest that etiologic STI screening deserves further evaluation as a potential tool to improve maternal and neonatal health outcomes worldwide,” the authors wrote.
One important subgroup of women who could benefit from guidelines were pregnant women with HIV, who have higher rates of STIs, the authors said. Another high priority subgroup included pregnant women living in regions with endemic malaria and/or places that intermittently use preventative treatment for malaria.
Study senior author Jeffrey D Klausner, MD, MPH, professor of preventive medicine at the Division of Disease Prevention, Policy and Global Health in the Department of Preventive Medicine at the University of Southern California Keck School of Medicine in Los Angeles, California discussed the review in an interview with Contemporary OB/GYN®. He said the most important takeaway for providers was the importance of full STI screening for pregnant women, including consideration of emergent infections. He said this was especially the case due to STIs such as Mycoplasma genitalium, which is not routinely screened for, and for which there is little research on how it impacts pregnancy.
“STIs in pregnancy are under-recognized and under-researched, even in the United States,” he explained. While the US has routine screening for pregnant women for HIV, gonorrhea, chlamydia, syphilis, and hepatitis B, Klausner said there needs to be wider screening for STIs worldwide. “There are only 13 countries that routinely screen pregnant women for gonorrhea, and 14 for chlamydia,” he said. “These easily treatable infections are known to cause adverse pregnancy outcomes like prematurity, low birth weight, stillbirth, newborn sepsis, and blindness.” He said the gap is in implementation of testing, and the goal of the review was to figure out how to raise awareness and increase STI screening. Klausner noted that congenital syphilis is at a 20-year high in the US, highlighting the urgency of screening and treatment implementation for pregnant women. He said the pandemic is further impacting screening with women avoiding in person healthcare visits, resulting in an increase of STIs due to delays in testing and treatment. He advocated for at-home STI testing for pregnant women, but added that the costs are often not covered by insurance, which causes this option to be underutilized.
To assist patients, Klausner said “practicing providers need to regularly monitor their own practice and make sure pregnant patients are fully screened for the 5 recommended STIs (syphilis, gonorrhea, chlamydia, hepatitis B, and HIV). Results should be handled in a timely manner, and both women and their partners should be treated and retested. Providers need quality assurance programs in their practices,” to ensure optimal positive pregnancy outcomes.
Grant JS, Chico RM, Lee AC, et al. Sexually transmitted infections in pregnancy: a narrative review of the global research gaps, challenges, and opportunities. Sex Transm Dis. 2020;47(12):779-789. doi:10.1097/OLQ.0000000000001258.