Clinical Practice Guidelines Antenatal Care — Module II

8.9Resources

CGE (2007) Fact sheet 34: Thalassaemias and sickle cell disease. Sydney: NSW Health Centre for Genetics Education.

8.10References

Bryan S, Dormandy E, Roberts T et al (2011) Screening for sickle cell and thalassaemia in primary care: a cost-effectiveness study. Br J Gen Pract 61(591): e620–27.

CGE (2007) Fact Sheet 34: Thalassaemias and Sickle Cell Disease. Sydney: NSW Health Centre for Genetics Education.

Dormandy E, Bryan S, Gulliford MC et al (2010a) Antenatal screening for haemoglobinopathies in primary care: a cohort study and cluster randomised trial to inform a simulation model. The Screening for Haemoglobinopathies in First Trimester (SHIFT) trial. Health Technol Assess 4(20).

Dormandy E, Gulliford M, Bryan S et al (2010b) Effectiveness of earlier antenatal screening for sickle cell disease and thalassaemia in primary care: cluster randomised trial. BMJ 341(oct05 2): c5132.

Dyson SM, Culley L, Gill C et al (2006) Ethnicity questions and antenatal screening for sickle cell/thalassaemia [EQUANS] in England: a randomised controlled trial of two questionnaires. Ethn Health 11(2): 169–89.

Gaff C, Newstead J, Saleh M (2007) Haemoglobinopathies. In: Genetics in Family Medicine: The Australian Handbook for General Practitioners. Ed. Commonwealth of Australia: Biotechnology Australia.

Koren A, Zalman L, Palmor H et al (2009) Sickle cell anemia in northern Israel: screening and prevention. Isr Med Assoc J 11(4): 229–34.

Langlois S, Ford JC, Chitayat D et al (2008) Carrier screening for thalassemia and hemoglobinopathies in Canada. J Obstet Gynaecol Can 30(10): 950–71.

Leung KY, Lee CP, Tang MH et al (2004) Cost-effectiveness of prenatal screening for thalassaemia in Hong Kong. Prenat Diagn 24(11): 899–907.

Leung KY, Cheong KB, Lee CP et al (2010) Ultrasonographic prediction of homozygous alpha0-thalassemia using placental thickness, fetal cardiothoracic ratio and middle cerebral artery Doppler: alone or in combination? Ultrasound Obstet Gynecol 35(2): 149–54.

Modell B & Darlison M (2008) Global epidemiology of haemoglobin disorders and derived service indicators. Bull World Health Organ 2008(6): 480–87.

RANZCOG (2009) Pre-pregnancy Counselling and Routine Antenatal Assessment in the Absence of Pregnancy Complications (C-Obs-3). Melbourne: Royal Australia and New Zealand College of Obstetricians and Gynaecologists.

Sirichotiyakul S, Maneerat J, Sa-nguansermsri T et al (2005) Sensitivity and specificity of mean corpuscular volume testing for screening for alpha-thalassemia-1 and beta-thalassemia traits. J Obstet Gynaecol Res 31(3): 198–201.

8.11Gonorrhoea

Background

Diagnoses of gonorrhoea in Australia

Data on diagnoses of gonorrhoea are incomplete and may provide a distorted view of population rates in Australia. Differences in rates of diagnosis between areas and populations may reflect a range of factors, including variations in approaches to offering testing, the uptake of testing, access to services, and recording of Indigenous status. Rates reported vary by community and will be higher if local screening programs are in place or research is being carried out.

Rates of diagnosis: In 2011, rates of diagnoses of gonorrhoea per 100,000 population were 52 in the general population overall; 22 among non-Indigenous Australians and 673 among Aboriginal and Torres Strait Islanders living in states and territories other than ACT and NSW (Kirby Inst 2012). The rate of diagnosis was lowest in inner regional areas and increased with remoteness among both non-Indigenous Australians and Aboriginal and Torres Strait Islanders (Kirby Inst 2012).

Country of origin: In 2008, the World Health Organization estimated the incidence of gonorrhoea per 1,000 women aged 15–49 years to be 50 in Africa, 35 in the Western Pacific, 19 in the Americas, 16 in South-East Asia and 8 in Europe (WHO 2012).

Age distribution: Among women, approximately 75% of diagnoses of gonorrhoea in 2011 were in the 15–29 year age group (Kirby Inst 2012).

Incidence in pregnancy: The incidence of gonorrhoea in pregnant women who are not at high risk for infection is generally low. However, it varies by population; approximately 1% among pregnant women in the United States (Goldenberg et al 2005) (range 0.2–4%) (CDC 2004), 3.3% in a developing country setting (Sullivan et al 2004) and 3.4% among adolescent women in a low-income area in the United States (Niccolai et al 2003).

Risk factors: Increased risk of gonorrhoea has been associated with previous gonorrhoea infection or other sexually transmitted infection, new or multiple sex partners and inconsistent condom use, commercial sex work and drug use and living in communities with a high prevalence of gonorrhoea (USPSTF 2005).

Risks associated with gonorrhoea in pregnancy

Untreated gonorrhoea during pregnancy is associated with adverse obstetric outcomes including ectopic pregnancy, septic spontaneous miscarriage, chorioamnionitis, premature rupture of membranes, preterm labour and postpartum infection (Hollier & Workowski 2005; USPSTF 2005).

N. gonorrhoeae can be transmitted from the mother's genital tract to the newborn at the time of birth and occasionally, when there is prolonged rupture of the membranes, it can be transmitted to the baby before birth (Brocklehurst 2009). The usual manifestation of neonatal infection is conjunctivitis (ophthalmia neonatorum), which begins in the first days of life and, if left untreated, may lead to blindness (Brocklehurst 2009). The risk of transmission from an infected mother is between 30% and 47% (Galega et al 1984; Fransen et al 1986).

Screening for gonorrhoea

While screening all women for gonorrhoea during pregnancy is recommended in Canada (PHAC 2008), a number of bodies in the United States recommend screening only women at high risk (AAP 2002; ACOG 2003; AAFP 2004; USPSTF 2005). The Royal Australian College of General Practitioners (RACGP) also supports screening only women considered to be at risk (RACGP 2009). The prevalence of gonorrhoea is regionally variable and, in some areas, high prevalence may occur with that of other sexually transmitted infections, such as chlamydia. It is important for health professionals to be aware of the rates of sexually transmitted infection in their community and develop local protocols accordingly.

Summary of the evidence

Diagnostic accuracy of tests

In Australia, culture methods for detection of N. gonorrhoeae have been increasingly replaced by nucleic acid detection tests (NAATs), especially in remote areas (Smith et al 2005). These tests can be performed on self-collected vaginal swabs, urine and endocervical specimens. The sensitivity and specificity of vaginal swabs are similar whether collected by the woman (96.1%; 99.3%) or health professional (96.2%; 99.3%), identifying as many infections as endocervical swabs and more than first-catch urine samples (Schachter et al 2005). These tests are evolving and guidelines for laboratories on their use and interpretation have been developed to reduce the high risk of false positives associated with some tests (Smith et al 2005). Where possible, positive results should be confirmed with culture for antibiotic sensitivity testing and to exclude false positives, particularly in low-risk individuals.

In a retrospective study, repeat testing of women at high risk at 34 weeks identified additional women with infection (n=751) (Miller et al 2003). In the United States (USPSTF 2005) and Canada (PHAC 2008), testing is recommended in the first trimester, with testing in subsequent trimesters (Canada) or in the third trimester (United States) for women at continued risk or with a new risk factor.

Harms and benefits of screening

There is some evidence that testing and subsequent treatment of pregnant women at high risk of gonorrhoea may prevent complications associated with gonococcal infection during pregnancy (USPSTF 2005; Darling 2009). Potential harms of screening include false-positive test results, anxiety and unnecessary antibiotic use (USPSTF 2005). There is insufficient evidence to quantify the magnitude of these harms but it is likely that they are outweighed by the benefits of screening women at increased risk (USPSTF 2005).

No evidence on the cost-effectiveness of screening for gonorrhoea in pregnancy was identified.

Effect of treatments on risks associated with gonorrhoea

The aim of treating gonorrhoea during pregnancy is to eradicate the infection and prevent neonatal infection, postpartum sepsis for the mother and transmission to sexual partners (Brocklehurst 2009). In a systematic review (n=346)(Brocklehurst 2009), all tested antibiotic regimens (penicillins, spectinomycin or ceftriaxone) demonstrated a high level of effectiveness as judged by 'microbiological cure', with eradication rates of between 89% and 97%. However, the effects of treatment on substantive outcomes such as ophthalmia neonatorum have not been reported and may vary between different antibiotics.

Consensus-based recommendation xv

Do not routinely offer gonorrhoea testing to all women as part of antenatal care.

Offer gonorrhoea testing to pregnant women who have known risk factors or who live in or come from areas where prevalence is high.

Discussing gonorrhoea

Discussion to inform a woman’s decision-making about gonorrhoea screening should take place before testing takes place and include:

it is possible to have gonorrhoea without experiencing symptoms;

risk factors for sexually transmitted infection;

the possibility of false positive results;

gonorrhoea causes problems with the pregnancy including spontaneous miscarriage, preterm birth and infection of the newborn;

treatment of gonorrhoea may prevent pregnancy complications associated with infection;

testing and treatment of partners is advisable if infection is identified and the couple should abstain from sex until treatment is complete and symptoms have resolved;

testing for other sexually transmitted infections may be needed;

a second test may be given a week later if symptoms remain; and

repeat testing for gonorrhoea may be needed for women at ongoing risk of infection.

Practice summary: gonorrhoea

When: A woman has risk factors for gonorrhoea infection, lives in an area of high prevalence or has come from a country with high prevalence.

Who: Midwife; GP; obstetrician; Aboriginal and Torres Strait Islander Health Practitioner; Aboriginal and Torres Strait Islander Health Worker; multicultural health worker; sexual health worker.

Discuss the reasons for gonorrhoea screening: Explain that it is important to find out whether a woman has gonorrhoea because of the effects that infection can have on the pregnancy and the baby.

Take a holistic approach: If a woman is found to have gonorrhoea infection, other considerations include counselling, contact tracing, partner testing, testing for other sexually transmitted infections and follow-up.

Document and follow-up: If a woman is tested for gonorrhoea, tell her the results and note them in her antenatal record. Have a follow-up system in place so that infected women receive timely treatment or referral. Consider repeat testing for women who may be at ongoing risk of infection.

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