Pregnant Women
Intrauterine or perinatally transmitted STIs can have debilitating effects on pregnant women, their fetuses, and their partners. All pregnant women and their sex partners should be asked about STIs, counseled about the possibility of perinatal infections, and provided access to recommended screening and treatment, if needed.
Recommendations for screening pregnant women for STIs to detect asymptomatic infections are based on disease severity and sequelae, prevalence among the population, costs, medicolegal considerations (e.g., state laws), and other factors. The following screening recommendations for pregnant women summarize clinical guidelines from federal agencies and medical professional organizations.
Screening Recommendations
HIV Infection
All pregnant women in the United States should be tested for HIV at the first prenatal visit, even if they have been previously tested (138). Testing pregnant women for HIV and prompt linkage to care of women with HIV infection are vital for women’s health and reducing perinatal transmission of HIV through ART and obstetrical interventions. HIV testing should be offered as part of the routine panel of prenatal tests (i.e., opt-out testing). For women who decline HIV testing, providers should address their concerns and, when appropriate, continue to encourage testing. Partners of pregnant patients should be offered HIV testing if their status is unknown (139).
Retesting in the third trimester (preferably before 36 weeks’ gestation) is recommended for women at high risk for acquiring HIV infection. Examples of women at high risk include those who inject drugs, have STIs during pregnancy, have multiple sex partners during pregnancy, have a new sex partner during pregnancy, or have partners with HIV infection; those who are receiving care in health care facilities in settings with HIV incidence ≥1 per 1,000 women per year; those who are incarcerated; those who live in areas with high rates of HIV infection; or those who have signs or symptoms of acute HIV infection (e.g., fever, lymphadenopathy, skin rash, myalgia, arthralgia, headache, oral ulcers, leukopenia, thrombocytopenia, or transaminase elevation) (140).
Rapid HIV testing should be performed for any woman in labor who has not been tested for HIV during pregnancy or whose HIV status is unknown, unless she declines. If a rapid HIV test result is positive, ART should be administered without waiting for the results of confirmatory testing (https://clinicalinfo.hiv.gov/sites/ default/files/inline-files/PerinatalGL.pdf).
Syphilis
During 2012–2019, congenital syphilis rates in the United States increased from 8.4 to 48.5 cases per 100,000 births, a 477.4% increase (141). At least 45 states have a prenatal syphilis testing requirement, with high variability among those requirements (142). In the United States, all pregnant women should be screened for syphilis at the first prenatal visit, even if they have been tested previously (143). Prenatal screening for syphilis has been reported to be suboptimal in the United States (144,145). Testing in the third trimester and at delivery can prevent congenital syphilis cases (146,147). Partners of pregnant women with syphilis should be evaluated, tested, and treated.
When access to prenatal care is not optimal, a stat rapid plasma reagin (RPR) card test and treatment, if that test is reactive, should be administered at the time that a pregnancy is confirmed or when the pregnancy test is performed, if follow-up is uncertain. Pregnant women should be retested for syphilis at 28 weeks’ gestation and at delivery if the mother lives in a community with high syphilis rates or is at risk for syphilis acquisition during pregnancy (e.g., misuses drugs or has an STI during pregnancy, having multiple sex partners, having a new sex partner, or having a sex partner with an STI). Neonates should not be discharged from the hospital unless the syphilis serologic status of the mother has been determined at least once during pregnancy. Any woman who delivers a stillborn infant should be tested for syphilis.
Hepatitis B
All pregnant women should be routinely tested for hepatitis B surface antigen (HBsAg) at the first prenatal visit even if they have been previously vaccinated or tested (148). Women who are HBsAg positive should be provided with, or referred for, counseling and medical management. Women who are HBsAg negative but at risk for HBV infection should be vaccinated. Women who were not screened prenatally, those who engage in behaviors that put them at high risk for infection (e.g., having had more than one sex partner during the previous 6 months, having been evaluated or treated for an STI, having had recent or current injection drug use, or having an HBsAg-positive sex partner), and those with clinical hepatitis should be tested at the time of admission to the hospital for delivery. To avoid misinterpreting a transient positive HBsAg result during the 21 days after vaccination, HBsAg testing should be performed before vaccine administration. All laboratories that conduct HBsAg tests should test initially reactive specimens with a licensed neutralizing confirmatory test. When pregnant women are tested for HBsAg at the time of admission for delivery, shortened testing protocols can be used, and initially reactive results should prompt expedited administration of immunoprophylaxis to neonates (148). Pregnant women who are HBsAg positive should be reported to the local or state health department to ensure that they are entered into a case-management system and that timely and age-appropriate prophylaxis is provided to their infants. Information concerning the pregnant woman’s HBsAg status should be provided to the hospital where delivery is planned and to the health care provider who will care for the newborn. In addition, household and sexual contacts of women who are HBsAg positive should be vaccinated.
Chlamydia
All pregnant women aged <25 years as well as older women at increased risk for chlamydia (e.g., those aged ≥25 years who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has an STI) should be routinely screened for Chlamydia trachomatis at the first prenatal visit (149). Pregnant women who remain at increased risk for chlamydial infection also should be retested during the third trimester to prevent maternal postnatal complications and chlamydial infection in the neonate. Pregnant women identified as having chlamydia should be treated immediately and have a test of cure to document chlamydial eradication by a nucleic acid amplification test (NAAT) 4 weeks after treatment. All persons diagnosed with a chlamydial infection should be rescreened 3 months after treatment.
Gonorrhea
All pregnant women aged <25 years as well as women aged ≥25 years at increased risk for gonorrhea (e.g., those with other STIs during pregnancy or those with a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has an STI or is exchanging sex for money or drugs) should be screened for Neisseria gonorrhoeae at the first prenatal visit (149). Pregnant women who remain at high risk for gonococcal infection also should be retested during the third trimester to prevent maternal postnatal complications and gonococcal infection in the neonate. Clinicians should consider the communities they serve and might choose to consult local public health authorities for guidance on identifying groups that are more vulnerable to gonorrhea acquisition on the basis of local disease prevalence. Gonococcal infection, in particular, is concentrated among specific geographic locations and communities (https://www.cdc.gov/std/statistics/2019/default. htm). Pregnant women identified as having gonorrhea should be treated immediately. All persons diagnosed with gonorrhea should be rescreened 3 months after treatment.
Hepatitis C Virus
The rate of hepatitis C virus (HCV) infection has increased among pregnant women in recent years (150–153). HCV screening should be performed for all pregnant women during each pregnancy, except in settings where the HCV infection (HCV positivity) rate is <0.1% (154–156). The most important risk factor for HCV infection is past or current injecting drug use (157). Additional risk factors include having had a blood transfusion or organ transplantation before July 1992, having received clotting factor concentrates produced before 1987, having received an unregulated tattoo, having been on long-term hemodialysis, having other percutaneous exposures, or having HIV infection. All women with HCV infection should receive counseling, supportive care, and linkage to care (https://www.hcvguidelines.org). No vaccine is available for preventing HCV transmission.
Cervical Cancer
Pregnant women should undergo cervical cancer screening and at the same frequency as nonpregnant women; however, management differs slightly during pregnancy (158). Colposcopy is recommended for the same indications during pregnancy as for nonpregnant women. However, biopsies may be deferred, and endocervical sampling should not be performed. Treatment should not be performed during pregnancy unless cancer is detected.
Bacterial Vaginosis, Trichomoniasis, and Genital Herpes
Evidence does not support routine screening for BV among asymptomatic pregnant women at high risk for preterm delivery (159). Symptomatic women should be evaluated and treated (see Bacterial Vaginosis). Evidence does not support routine screening for Trichomonas vaginalis among asymptomatic pregnant women. Women who report symptoms should be evaluated and treated (see Trichomoniasis). In addition, evidence does not support routine HSV-2 serologic screening among asymptomatic pregnant women. However, type-specific serologic tests might be useful for identifying pregnant women at risk for HSV-2 infection and for guiding counseling regarding the risk for acquiring genital herpes during pregnancy. Routine serial cultures for HSV are not indicated for women in the third trimester who have a history of recurrent genital herpes.
For more detailed discussions of STI screening and treatment among pregnant women, refer to the following references: Screening for HIV Infection: U.S. Preventive Services Task Force Recommendation Statement (138); Recommendations for the Use of Antiretroviral Drugs in Pregnant Women with HIV Infection and Interventions to Reduce Perinatal HIV Transmission in the United States (https://clinicalinfo.hiv.gov/sites/default/ files/inline-files/PerinatalGL.pdf ); Guidelines for Perinatal Care (160); Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices (12); Screening for Chlamydia and Gonorrhea: U.S. Preventive Services Task Force Recommendation Statement (149); Screening for Bacterial Vaginosis in Pregnant Persons to Prevent Preterm Delivery: U.S. Preventive Services Task Force Recommendation Statement (159); Screening for Syphilis Infection in Pregnant Women: U.S. Preventive Services Task Force Recommendation Statement (161); Serologic Screening for Genital Herpes Infection: U.S. Preventive Services Task Force Recommendation Statement (162); Screening for HIV Infection in Pregnant Women: A Systematic Review for the U.S. Preventive Services Task Force (163); Screening for Hepatitis B in Pregnant Women: Updated Evidence Report and Systematic Review for the U.S. Preventive Services Task Force (164); and CDC Recommendations for Hepatitis C Screening Among Adults — United States, 2020 (156).