Clinical Practice Guidelines Antenatal Care — Module II

8.12Resources

Papp JR, Schachter J, Gaydos CA et al; Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC (2014) Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae - 2014. MMWR Recomm Rep 263(RR-02): 1–19.

PHAC (2008) Canadian Guidelines on Sexually Transmitted Infections, 2008 Edition. Ottawa, ON: Public Health Agency of Canada.

Sexually transmitted infections (STIs) in pregnancy. In: Minymaku Kutju Tjukurpa Women’s Business Manual, 4th edition. Congress Alukura, Nganampa Health Council Inc and Centre for Remote Health.

Workowski KA & Berman S (2010) Sexually transmitted diseases treatment guidelines, 2010. Centers for Disease Control and Prevention. MMWR Recomm Rep 59(RR-12): 1–110.

8.13References

AAP (2002) Guidelines for Perinatal Care 5th ed. Elk Grove Village, IL: American Academy of Pediatrics, Washington, DC: American College of Obstetricians and Gynecologists.

ACOG (2003) Primary and preventive care: periodic assessments. American College of Obstetricians and Gynecologists Committee Opinion. Obstet Gynecol 102: 1117–24.

Aledort JE, Hook EW 3rd, Weinstein MC et al (2005) The cost effectiveness of gonorrhea screening in urban emergency departments. Sex Transm Dis 32(7):4 25–36.

Brocklehurst P (2009) Antibiotics for gonorrhoea in pregnancy. Cochrane Database Sys Rev 2002, Issue 2. Art. No.: CD000098. DOI: 10.1002/14651858.CD000098.

CDC (2004) Sexually Transmitted Disease Surveillance Report 2003. Atlanta: Centers for Disease Control and Prevention.

Darling E (2009) Prenatal screening for chlamydia and gonorrhea: an evidence based approach. Can J Midwifery Res Pract 8(2): 6–14.

Fransen L, Nsaze H, Klauss V et al (1986) Ophthalmia neonatorum in Nairobi, Kenya, the role of Neisseria gonorrhoea and Chlamydia trachomatis. J Infect Dis 153: 862–69.

Galega FP, Heymann DL, Nasah BT (1984) Gonococcal ophthalmia neonatorum: the case of prophylaxis in tropical Africa. Bull WHO 61: 95–98.

Goldenberg RL, Culhane JF, Johnson DC (2005) Maternal infection and adverse fetal and neonatal outcomes. Clin Perinatol 32: 523–59.

Hollier LM & Workowski K (2005) Treatment of sexually transmitted infections in pregnancy. Clin Perinatol 32(3): 629–56.

Mehta SD, Bishai D, Howell MR et al (2002) Cost-effectiveness of five strategies for gonorrhea and chlamydia control among female and male emergency department patients. Sex Transm Dis 29(2): 83–91.

Miller JM Jr, Maupin RT, Mestad RE et al (2003) Initial and repeated screening for gonorrhea during pregnancy. Sex Transm Dis 30(9): 728–30.

NCHECR (2009) Annual Surveillance Report. National Centre for HIV Epidemiology and Clinical Research. Sydney: University of New South Wales.

NCHECR (2010) Bloodborne Viral and Sexually Transmitted Infections in Aboriginal and Torres Strait Islander People: Surveillance and Evaluation Report 2010. Sydney: National Centre in HIV Epidemiology and Clinical Research, The University of New South Wales.

Niccolai LM, Ethier KA, Kershaw TS et al (2003) Pregnant adolescents at risk: sexual behaviors and sexually transmitted disease prevalence. Am J Obstet Gynecol 188(1): 63–70.

PHAC (2008) Canadian Guidelines on Sexually Transmitted Infections, 2008 Edition. Ottawa, ON: Public Health Agency of Canada.

RACGP (2009) Guidelines for Preventive Activities in General Practice 7th edition. Melbourne: Royal Australian College of General Practitioners.

Schachter J, Chernesky MA, Willis DE et al (2005) Vaginal swabs are the specimens of choice when screening for Chlamydia trachomatis and Neisseria gonorrhoeae: results from a multicenter evaluation of the APTIMA assays for both infections. Sex Transm Dis 32(12): 725–28.

Smith DW, Tapsall JW, Lum G (2005) Guidelines for the use and interpretation of nucleic acid detection tests for Neisseria gonorrhoeae in Australia: A position paper on behalf of the Public Health Laboratory Network. Comm DIs Intel 29(4): 358–65.

Sullivan EA, Koro S, Tabrizi S et al (2004) Prevalence of sexually transmitted diseases and human immunodeficiency virus among women attending prenatal services in Apia, Samoa. Int J STD AIDS 15(2): 116–19.

USPSTF (2005) Screening for gonorrhea: recommendation statement. United States Preventive Services Task Force. Am Fam Physician 72(9): 1783–86.

9

9.1Trichomoniasis

Identifying the cause of vaginitis symptoms enables a woman to make an informed decision about treatment during pregnancy.

Background

Trichomoniasis is a sexually transmitted vaginitis caused by the single-celled protozoan parasite Trichomonas vaginalis. Around 70% of people with trichomoniasis do not experience symptoms (Workowski & Berman 2010). When symptoms are present in women, they include a smelly, yellow-green vaginal discharge with vulval irritation (Workowski & Berman 2010). Trichomoniasis is associated with infertility, pelvic inflammatory disease and enhanced HIV transmission (Sobel 2005; Sutton et al 2007; Johnston & Mabey 2008; Fichorova 2009).

Prevalence of trichomoniasis in pregnancy

Trichomoniasis is the most common curable sexually transmitted infection globally, with a prevalence among women of 8.1% (WHO 2011). Prevalence varies with age as well as geographical region.

Population-level data: There are no accurate data available regarding the national prevalence of trichomoniasis in Australia and the infection is not notifiable.

Geographical location: The reported prevalence of trichomoniasis in different regions of Australia is extremely variable, ranging from virtually zero in the largest cities (Marrone et al 2008; Lusk et al 2010; Uddin et al 2011) to 25% in remote northern Aboriginal communities (Guy et al 2011). A study of prevalence in rural and remote New South Wales found that prevalence increased with remoteness in both Aboriginal and non-Indigenous women (Ryder et al 2012).

Aboriginal and Torres Strait Islander women: Small studies of discrete populations have found a prevalence among pregnant women of 15.5–17.6% (Josif et al 2012) in remote areas and 7.2% in an urban area (Panaretto et al 2006).

Country of origin: Prevalence has been estimated as 3–3.7% among women in the United States (French et al 2006; Sutton et al 2007; Mann et al 2009), 0.3–6% among South American women (Lobo et al 2003; Gondo et al 2010), 5.5–8.5% among Asian women (Sami & Baloch 2005; Azargoon & Darvishzadeh 2006; Madhivanan et al 2009), 10–14% among African American women (Caliendo et al 2005; Miller et al 2005; French et al 2006) and 5.4–17.6% among African women (Adu-Sarkodie 2004; Stringer et al 2010).

Risk factors: Risk factors include multiple sexual partners, previous sexually transmitted infections, non-use of barrier contraceptives, work in the sex industry, intravenous drug use, smoking, low socioeconomic status and incarceration (Brown 2004; Say & Jacyntho 2005; Johnston & Mabey 2008; Workowski & Berman 2010).

Risks associated with trichomoniasis in pregnancy

Pregnancy risks: Trichomoniasis in pregnancy may be associated with increased risk of preterm birth and low birth weight (Buchmayer et al 2003; Mann et al 2009; Gülmezoglu & Azhar 2011).

Risks to the baby: Maternal trichomoniasis has been associated with genital and respiratory infections of the newborn (Carter & Whithaus 2008; Trintis et al 2010).

Screening for trichomoniasis

Summary of the evidence

In the United States (Workowski & Berman 2010), testing for trichomoniasis during pregnancy is only recommended for women with symptoms. Recommendations on screening during pregnancy have not previously been developed in the United Kingdom or Australia.

Specimen collection

Small low-level studies in non-pregnant populations have concluded that:

self-collected vaginal swabs correlate with specimens collected by health professionals (Smith et al 2005; Kashyap et al 2008; Huppert et al 2010) and are easy to perform (Kashyap et al 2008); and

self-collection by tampon sampling is acceptable to women (van de Wijgert et al 2006), is easily incorporated into practice and may be suitable in remote settings as samples do not require refrigeration (Garland & Tabrizi 2004).

Diagnostic test accuracy

Testing for trichomoniasis in Australia is mostly carried out using PCR, which is rapidly replacing culture testing as it has higher sensitivity and results are available more quickly.

PCR testing of vaginal swabs has high sensitivity (96–100%) and specificity (97–100%) (Lobo et al 2003; Caliendo et al 2005; Smith et al 2005; Pillay et al 2007). Small studies have found that PCR testing of tampon samples has high sensitivity (94–100%) (Knox et al 2002; Sturm et al 2004). PCR testing of urine samples has lower sensitivity and specificity (76.7% and 97%) (Pillay et al 2007).

Culture testing of vaginal swabs has a sensitivity of 63.0–98.2% and specificity of 99.4–100% (Lobo et al 2003; Adu-Sarkodie 2004; Caliendo et al 2005; Smith et al 2005). It requires an incubator and culture medium and may take up to 7 days for a result.

While trichomoniasis is occasionally diagnosed by Pap smear, its use is not adequate as the sole method of diagnosis because of its low sensitivity (60.7–72.1%) and the delay in obtaining results (Lara-Torre & Pinkerton 2003; Lobo et al 2003; Smith et al 2005).

Benefits and harms of screening

While accurate diagnostic tests are available, the benefits of screening are limited by uncertainties about the effect of treatments during pregnancy. Advantages of identifying and treating trichomoniasis include relief of symptoms, reduced risk of further transmission and possible prevention of genital and respiratory infections in the newborn (Workowski & Berman 2010). Potential harms of screening include false positive diagnosis (Johnson et al 2007) and adverse effects associated with treatment (see below).

Recommendation 23 Grade B

Offer testing to women who have symptoms of trichomoniasis, but not to asymptomatic women.

Availability of safe and effective treatments for trichomoniasis

Metronidazole and tinidazole are used to treat trichomoniasis (Owen & Clenney 2004; Fung & Doan 2005; Wendel & Workowski 2007; Workowski & Berman 2010). The Therapeutic Goods Administration classifies metronidazole as pregnancy category B2 and tinidazole as B3.

Based on the limited evidence available, treatment with metronidazole provides parasitological cure in around 90% of women and would likely be more effective if partners were also treated (Workowski & Berman 2010; Gülmezoglu & Azhar 2011). However, it does not reduce risk of preterm birth or low birth weight in asymptomatic women (Gülmezoglu & Azhar 2011) and may increase the risk of preterm birth (Carey & Klebanoff 2003; Hay & Czeizel 2007).

Studies into the effect of treatment in women with symptomatic trichomoniasis are also limited and findings are inconsistent. Some suggest an increased incidence of preterm birth (Riggs & Klebanoff 2004; Okun et al 2005) and others found no association with preterm birth (Mann et al 2009). Findings may be affected by method of assessing gestational age (Stringer et al 2010) and timing of diagnosis.

Due to the lack of clarity on the risk of preterm birth, treatment of asymptomatic pregnant women is not recommended but may be a consideration after 37 weeks gestation. Treatment for women with symptoms requires consideration of the risks and benefits for the individual woman.

Repeat screening

Due to the high rates of reinfection among women diagnosed with trichomoniasis, rescreening 3 months following treatment may be a consideration, although this approach has not been evaluated (Workowski & Berman 2010).

Discussing trichomoniasis

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

trichomoniasis is a sexually transmitted infection and most people do not experience symptoms;

trichomoniasis is associated with increased risk of preterm birth and low birth weight and may cause some types of infection in the newborn;

treatment of trichomoniasis relieves symptoms, reduces the risk of transmission and may prevent related infections in the newborn but may not reduce the risk of preterm birth;

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; and

testing for other sexually transmitted infections may be needed.

Practice summary: trichomoniasis

When: A woman has signs or symptoms of vaginitis.

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 testing for trichomoniasis: Explain that testing is necessary to identify the cause of the symptoms.

Take a holistic approach: If a woman is found to have trichomoniasis, other considerations include counselling, contact tracing, partner testing and treatment and testing for other sexually transmitted infections.

Document and follow-up: If a woman is tested for trichomoniasis, tell her the results and note them in her antenatal record. Have a system in place so that women’s decisions about treatment are documented and women who test positive for trichomoniasis during pregnancy are given ongoing follow-up and information.

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