Trichomonas, Gonorrhea, and Chlamydia in Pregnancy
Mentor: Christine A. Carey, MD
Editor: Christopher M. Zahn, MD
Most infections are asymptomatic, but may manifest with urethritis, Bartholin gland infection, or mucopurulent cervicitis. Upper tract infection is uncommon. All pregnant women < 25 years of age, and older if risk factors are present, should be screened for Chlamydia at the first prenatal visit. Women < 25, and those who remain at increased risk, should be re-screened during the third trimester.
Chlamydia may be associated with preterm delivery, premature rupture of membranes, and low birthweight, although the effect on pregnancy outcome is controversial. Chlamydia is not associated with chorioamnionitis or pelvic infection following Cesarean delivery. Neonates are at risk for conjunctivitis and pneumonia.
The recommended diagnostic test is the nucleic acid amplification test (NAAT), performed on a first-catch urine specimen or vaginal or cervical swabs. First-line treatment is azithromycin (1 gram orally x 1); doxycycline is contraindicated in the second and third trimester. A test of cure is recommended 3-4 weeks following treatment. In addition, women should be tested for reinfection 3 months after treatment.
Gonorrhea may be asymptomatic or manifest as cervicitis, urethritis, or periurethral//vestibular gland infections. Acute salpingitis is rare in pregnancy. Recommendations regarding screening (age, risk factors, timing, and re-testing later in pregnancy) and specimen collection are the same as for Chlamydia.
Gonorrhea is associated with septic abortion, chorioamnionitis, preterm birth, premature ruptured membranes, and postpartum infection. Additionally, disseminated gonococcal infections may occur. Neonatal complications include conjunctivitis, pharyngitis, arthritis, and gonococcemia.
The CDC recommended treatment is dual therapy (ceftriaxone 250mg IM and azithromycin, 1 gram both single dose) due to antibiotic resistance. A test of cure is not needed for uncomplicated urogenital gonorrhea treated with the recommended regimen. Women should be tested for reinfection 3 months after treatment.
Most infections are asymptomatic, but may manifest with a malodorous, frothy discharge. Diagnosis may be accomplished by wet-mount microscopy, but NAAT of vaginal, endocervical, or urine specimens is far more sensitive. Molecular tests (antigen detection and DNA probe) are also available. Routine screening of asymptomatic pregnant women is not recommended unless they are HIV-infected; women reporting symptoms should be evaluated.
Trichomonas is associated with premature rupture of membranes, preterm delivery, and low birth weight. However, treatment with metronidazole during pregnancy does not prevent these outcomes. Patients should be counseled regarding the potential risks and benefits of treatment, particularly if asymptomatic. Metronidazole (2-gram single dose) is the recommended regimen. Women should be treated to relieve symptoms and possibly prevent perinatal transmission (manifested by neonatal respiratory or genital infection). Trichomonas infection in pregnancy is associated with an increased risk of HIV acquisition. Trichomonas infection in pregnant women with HIV is a risk factor for vertical transmission of HIV infection. Retesting is only recommended for HIV-positive women.
Sexual partners should be referred for evaluation, testing, and presumptive treatment. Expedited partner treatment is recommended when available and feasible.
Sexually Transmitted Diseases Guidelines, 2015. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/std/tg2015/tg-2015-print.pdf accessed 2/8/18.
Sexually Transmitted Infections. In: Williams Obstetrics, 24th Edition. Eds. F. Gary Cunningham, et al. New York, NY: McGraw-Hill, 2014.
Originally approved November 2015. Revised September 2016; Reaffirmed with minor revisions March 2018.
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