STDs in Pregnancy: Comprehensive Guide for Nursing Students
Evidence-based nursing notes on screening, diagnosis, treatment, and management
Table of Contents
Introduction
Sexually transmitted diseases (STDs) during pregnancy pose significant risks to both the mother and the developing fetus. These infections can cause serious complications, including preterm birth, low birth weight, stillbirth, and congenital infections. As a nursing student, understanding the pathophysiology, clinical manifestations, diagnostic approaches, and treatment strategies for STDs in pregnancy is crucial for providing quality patient care.
Key Concept
Pregnancy does not provide protection against STDs. In fact, hormonal changes during pregnancy can make women more susceptible to certain infections, and some STDs may become more severe during pregnancy.
There are three main classes of gynecological infections relevant to pregnancy:
- Toxic shock syndrome (TSS): A rare but potentially fatal disorder caused by toxin-producing strains of Staphylococcus aureus.
- Sexually transmitted infections (STIs): Infections spread primarily through sexual contact, though some have additional transmission routes.
- Pelvic inflammatory disease (PID): An infection of the upper reproductive tract, often caused by asymptomatic STIs.
Common STDs in Pregnancy
Chlamydia
Pathophysiology
Chlamydia is caused by the bacterium Chlamydia trachomatis. During pregnancy, the infection can ascend from the cervix to infect the amniotic sac and fetal membranes. The organism can cross the placenta and infect the fetus directly, or more commonly, the newborn can become infected during passage through the birth canal.
Maternal and Fetal Implications
- Increased risk of premature rupture of membranes (PROM)
- Preterm delivery
- Low birth weight
- Postpartum endometritis
- Neonatal conjunctivitis (can lead to blindness if untreated)
- Neonatal pneumonia (develops 4-12 weeks after birth)
Clinical Manifestations
Many pregnant women with chlamydia are asymptomatic (up to 80%). When symptoms occur, they may include:
- Abnormal vaginal discharge
- Burning or painful urination
- Lower abdominal pain
- Irregular vaginal bleeding
- Pain during sexual intercourse
Screening and Diagnosis
The CDC recommends routine screening for all pregnant women at the first prenatal visit, with repeat testing in the third trimester for women under 25 or at increased risk.
- Nucleic acid amplification tests (NAATs) from vaginal swabs or urine specimens
- Culture of endocervical specimens (less sensitive than NAATs)
Treatment
First-line treatment during pregnancy:
- Azithromycin 1g orally in a single dose
Alternative treatment:
- Amoxicillin 500mg orally three times daily for 7 days
Note: Doxycycline is contraindicated during pregnancy.
Memory Aid: “AZ for C”
Remember: Azithromycin is the treatment of choice for Chlamydia in pregnancy.
Gonorrhea
Pathophysiology
Gonorrhea is caused by the bacterium Neisseria gonorrhoeae. The organism can infect the endocervix during pregnancy and may ascend to cause upper genital tract infection. Transmission to the newborn typically occurs during passage through an infected birth canal.
Maternal and Fetal Implications
- Increased risk of preterm labor
- Premature rupture of membranes
- Chorioamnionitis
- Postpartum endometritis
- Neonatal ophthalmia (conjunctivitis that can lead to blindness)
- Neonatal sepsis
Clinical Manifestations
Many women with gonorrhea are asymptomatic. When symptoms occur, they may include:
- Purulent vaginal discharge
- Dysuria
- Cervical friability
- Lower abdominal pain
- Abnormal vaginal bleeding
Screening and Diagnosis
All pregnant women should be screened at the first prenatal visit, with repeat testing in the third trimester for those at increased risk.
- Nucleic acid amplification tests (NAATs) from vaginal, cervical, or urine specimens
- Culture and sensitivity testing (particularly important for monitoring antimicrobial resistance)
Treatment
Due to increasing antibiotic resistance, current CDC recommendations for treatment during pregnancy:
- Ceftriaxone 500 mg intramuscularly as a single dose
Important Note
Due to high rates of coinfection, patients treated for gonorrhea should also be treated for chlamydia unless chlamydia has been ruled out by NAAT testing.
Syphilis
Pathophysiology
Syphilis is caused by the spirochete Treponema pallidum. The organism can cross the placenta at any stage of pregnancy, resulting in congenital syphilis. The risk of vertical transmission is highest during primary and secondary syphilis (60-100%) and decreases with latent stages (40% in early latent, 8% in late latent).
Stages of Syphilis
- Primary: Characterized by a painless chancre at the site of infection
- Secondary: Systemic spread with mucocutaneous lesions and lymphadenopathy
- Latent: Asymptomatic period (early latent: <1 year; late latent: >1 year)
- Tertiary: Affects multiple organ systems including cardiovascular and neurological
Maternal and Fetal Implications
- Miscarriage or stillbirth (40% of untreated cases)
- Preterm birth
- Congenital syphilis with multi-organ involvement
- Early manifestations in the infant: hepatosplenomegaly, lymphadenopathy, mucocutaneous lesions, osteochondritis, pseudoparalysis, anemia, thrombocytopenia
- Late manifestations: Hutchinson’s teeth, saddle nose, saber shins, neurological impairment
Clinical Manifestations in Pregnancy
Manifestations depend on the stage of syphilis:
- Primary: Painless, firm chancre that heals within 3-6 weeks
- Secondary: Maculopapular rash (often on palms and soles), mucosal lesions, lymphadenopathy, fever
- Latent: Asymptomatic
- Tertiary: Gummatous lesions, cardiovascular and neurological complications
Screening and Diagnosis
Universal screening is recommended at the first prenatal visit, with additional screening at 28 weeks and delivery for women at high risk.
- Initial screening with non-treponemal tests: RPR (Rapid Plasma Reagin) or VDRL (Venereal Disease Research Laboratory)
- Confirmation with treponemal tests: FTA-ABS (Fluorescent Treponemal Antibody Absorption) or TP-PA (T. pallidum Particle Agglutination)
- Reverse screening algorithm: Automated treponemal test followed by non-treponemal test if positive
Treatment
Penicillin is the only proven effective treatment for preventing maternal transmission to the fetus and treating fetal infection:
- Early syphilis (primary, secondary, early latent): Benzathine penicillin G 2.4 million units IM in a single dose
- Late latent or unknown duration: Benzathine penicillin G 2.4 million units IM once weekly for 3 weeks
Memory Aid: “Penicillin Prevents Problems”
For syphilis in pregnancy, only penicillin can effectively treat the fetus. Desensitization is required for penicillin-allergic patients, as alternative antibiotics do not adequately cross the placenta.
Jarisch-Herxheimer Reaction
An acute febrile reaction with headache, myalgia, and worsening of cutaneous lesions that may occur within 24 hours after treatment. It may induce preterm labor or cause fetal distress. Monitor patients closely after initial treatment.
Herpes Simplex Virus (HSV)
Pathophysiology
HSV infection in pregnancy is primarily caused by HSV-2, though HSV-1 can also cause genital infection. Transmission to the newborn usually occurs during passage through the birth canal when the mother has active lesions or asymptomatic viral shedding. Rarely, transplacental transmission can occur, leading to congenital HSV infection.
Classifications
- Primary infection: First-time infection during pregnancy
- Recurrent infection: Reactivation of latent virus
- Non-primary first episode: First clinical episode in a person with preexisting antibodies to the other HSV type
Maternal and Fetal Implications
- Primary infection during pregnancy may be associated with spontaneous abortion or preterm birth
- Risk of neonatal HSV is highest with primary infection near term (30-50%)
- Risk with recurrent infection is much lower (1-3%)
- Neonatal HSV can present as:
- Skin, eye, and mouth disease (45%)
- CNS disease (30%)
- Disseminated disease (25%) – highest mortality rate
Clinical Manifestations
Primary infection may cause:
- Multiple painful genital vesicles and ulcers
- Regional lymphadenopathy
- Systemic symptoms (fever, headache, myalgia)
- Urinary retention or dysuria
Recurrent infection typically causes:
- Localized lesions with prodromal symptoms (tingling, burning)
- Milder symptoms than primary infection
- Shorter duration of lesions and viral shedding
Diagnosis
- PCR testing of lesion swabs (most sensitive)
- Viral culture from active lesions
- Type-specific serologic testing to determine previous exposure
Management
- Antiviral therapy for clinical outbreaks:
- Acyclovir 400 mg orally three times daily for 7-10 days
- Valacyclovir 1 g orally twice daily for 7-10 days
- Suppressive therapy from 36 weeks gestation:
- Acyclovir 400 mg orally three times daily
- Valacyclovir 500 mg orally twice daily
- Delivery considerations:
- Cesarean delivery recommended for women with active genital lesions or prodromal symptoms at the time of delivery
- Vaginal delivery may be considered in the absence of active lesions, even with history of HSV
Memory Aid: “36-C-3”
Start suppressive therapy at 36 weeks, consider Cesarean if active lesions, primary infection carries 30-50% transmission risk.
HIV
Pathophysiology
HIV (Human Immunodeficiency Virus) can be transmitted from mother to child during pregnancy (transplacental), during labor and delivery (through maternal blood and secretions), or through breastfeeding. Without intervention, the risk of mother-to-child transmission (MTCT) is 15-45%.
Maternal and Fetal Implications
- Pregnancy generally does not worsen HIV progression in women who are clinically stable
- HIV may increase risk of adverse pregnancy outcomes including preterm birth, low birth weight, and stillbirth
- Children infected with HIV may develop AIDS, opportunistic infections, neurodevelopmental delay, and failure to thrive
Screening and Diagnosis
Universal screening is recommended for all pregnant women:
- Initial HIV testing at the first prenatal visit
- Repeat testing in the third trimester (preferably before 36 weeks) for women at high risk or in high-prevalence areas
- Rapid HIV testing during labor for women with unknown HIV status
- Testing algorithms include a combination of antibody/antigen tests and confirmatory tests
Management
- Antiretroviral therapy (ART):
- All pregnant women with HIV should receive ART regardless of CD4 count or viral load
- Treatment should be initiated as early as possible
- Combination ART with at least three drugs is recommended
- Continue ART postpartum regardless of initial indications for therapy
- Intrapartum management:
- Intravenous zidovudine during labor for women with viral load >1000 copies/mL
- Consideration of scheduled cesarean delivery at 38 weeks for women with viral load >1000 copies/mL
- Postpartum management:
- Antiretroviral prophylaxis for the infant
- Avoidance of breastfeeding in settings where safe alternatives are available
- Early infant diagnosis and follow-up
Key Point
With comprehensive interventions (antepartum/intrapartum antiretroviral drugs, infant prophylaxis, and avoidance of breastfeeding), the risk of perinatal transmission can be reduced to less than 1%.
Human Papillomavirus (HPV)
Pathophysiology
HPV infection is the most common viral STI. There are over 100 types of HPV, with some high-risk types associated with cervical cancer. During pregnancy, hormonal changes can lead to proliferation of existing HPV lesions.
Maternal and Fetal Implications
- Genital warts may grow rapidly during pregnancy due to hormonal changes and immune modulation
- Large lesions may cause dystocia or bleeding during delivery
- Rare occurrence of laryngeal papillomatosis in infants exposed during vaginal delivery
- Vertical transmission rate is very low (<2%)
Clinical Manifestations
- Genital warts (condylomata acuminata)
- Most infections are asymptomatic
- Cervical dysplasia detected on Pap smear
Diagnosis
- Visual inspection for genital warts
- Cervical cytology (Pap smear)
- HPV DNA testing as part of cervical cancer screening
Management during Pregnancy
- Observation: Often the preferred approach as many lesions regress spontaneously postpartum
- Treatment options for symptomatic warts:
- Trichloroacetic acid (TCA) 80-90% applied to warts
- Cryotherapy
- Surgical excision for large lesions
- Contraindicated treatments during pregnancy:
- Podophyllin
- Podofilox
- Imiquimod
- Sinecatechins
- Cesarean delivery is not routinely indicated solely for HPV infection or genital warts unless the birth canal is obstructed or vaginal delivery would result in excessive bleeding
Maternal and Fetal Outcomes
STDs during pregnancy can lead to various adverse outcomes for both the mother and the developing fetus or newborn. The implications vary based on the specific pathogen, timing of infection, severity, and whether appropriate treatment was received.
Common Maternal Outcomes
- Premature rupture of membranes (PROM)
- Preterm labor and delivery
- Chorioamnionitis
- Postpartum endometritis
- Pelvic inflammatory disease (PID)
- Increased risk of ectopic pregnancy
- Increased likelihood of cesarean delivery
- Long-term sequelae including infertility and increased risk of cervical cancer (with HPV)
Common Fetal and Neonatal Outcomes
- Spontaneous abortion and stillbirth
- Preterm birth and low birth weight
- Congenital infections
- Neonatal sepsis
- Pneumonia
- Conjunctivitis
- Neurological damage
- Congenital anomalies
- Long-term developmental delays
- Neonatal death
| STD | Key Maternal Outcomes | Key Fetal/Neonatal Outcomes |
|---|---|---|
| Chlamydia | PROM, endometritis | Conjunctivitis, pneumonia |
| Gonorrhea | PROM, chorioamnionitis | Ophthalmia neonatorum, sepsis |
| Syphilis | Various depending on stage | Congenital syphilis, multiorgan damage |
| HSV | Genital lesions, pain | Skin/eye/mouth disease, CNS disease, disseminated disease |
| HIV | Generally not worsened by pregnancy | Perinatal HIV infection, AIDS |
| HPV | Genital warts, dysplasia | Rarely, laryngeal papillomatosis |
Key Concept
Early detection and appropriate treatment of STDs during pregnancy significantly reduces the risk of adverse outcomes for both mother and child. Timing of intervention is critical, as some infections may have already affected the fetus before diagnosis.
Screening Protocols
Systematic screening for STDs during pregnancy is essential for early detection and intervention. Current recommendations from the CDC and professional organizations include:
Universal Screening (All Pregnant Women)
- First Prenatal Visit:
- HIV testing
- Syphilis serology
- Hepatitis B surface antigen (HBsAg)
- Chlamydia testing for all women under 25 and older women at increased risk
- Gonorrhea testing for women at increased risk
Risk-Based or Regional Screening
- Third Trimester (28-32 weeks):
- Repeat HIV testing for women at high risk or in high-prevalence areas
- Repeat syphilis testing for women at high risk or in high-prevalence areas
- Repeat chlamydia testing for women under 25 or at continued risk
- Repeat gonorrhea testing for women at continued risk
- Hepatitis C antibody testing for women with risk factors
Additional Considerations
- At Delivery:
- Rapid HIV testing for women with undocumented HIV status
- Repeat syphilis testing in high-prevalence areas or if not previously tested
- HSV Screening:
- Not routinely recommended for asymptomatic pregnant women
- Type-specific serologic testing may be considered for women with history of genital symptoms or whose partner has genital herpes
- HPV Screening:
- Not specifically altered during pregnancy
- Follow routine cervical cancer screening guidelines
Memory Aid: “CHIPS HI 3rd”
Chlamydia, Hepatitis B, Immunodeficiency virus (HIV), Particularly syphilis, Syphilis at first visit; High-risk repeat at 3rd trimester.
Important Consideration
Screening recommendations may vary by geographic location, patient population, and risk factors. Always refer to the most current guidelines and local protocols when implementing screening strategies.
Diagnostic Approaches
Accurate diagnosis of STDs during pregnancy is essential for appropriate management. Various diagnostic methods are used depending on the suspected infection, clinical presentation, and available resources.
Laboratory Testing
| STD | Preferred Diagnostic Methods | Specimen Types |
|---|---|---|
| Chlamydia | NAAT (Nucleic Acid Amplification Test) | Vaginal swab, endocervical swab, urine |
| Gonorrhea | NAAT, culture for antimicrobial susceptibility | Vaginal swab, endocervical swab, urine |
| Syphilis | Two-step process: nontreponemal test (RPR, VDRL) followed by treponemal test (TP-PA, FTA-ABS) | Serum |
| HSV | PCR of lesion, viral culture, type-specific serologic testing | Lesion swab, serum |
| HIV | 4th generation antigen/antibody test with confirmation | Serum |
| HPV | HPV DNA testing (as part of cervical cancer screening) | Cervical swab |
Clinical Diagnosis
Some STDs may be diagnosed based on characteristic clinical findings, particularly when laboratory testing is not immediately available:
- Genital herpes: Grouped vesicular lesions
- Syphilis: Painless chancre (primary) or generalized rash involving palms and soles (secondary)
- HPV: Visible genital warts (condylomata acuminata)
However, laboratory confirmation is strongly recommended whenever possible, especially during pregnancy.
Interpretation of Results
- False positives and negatives: Certain tests may have limitations in sensitivity or specificity, requiring careful interpretation
- Window periods: Recent infections may not be detected if testing is performed before antibodies develop
- Previous treatment: History of treated infections may affect interpretation of serologic tests, particularly for syphilis and HSV
Diagnostic Challenges
Some STDs can be particularly challenging to diagnose during pregnancy due to:
- Physiologic changes that may alter clinical presentation
- Increased vaginal discharge as a normal finding in pregnancy
- Mixed infections with multiple pathogens
- Previous partially treated infections
When in doubt, consultation with infectious disease specialists or maternal-fetal medicine experts is recommended.
Treatment Guidelines
Treatment of STDs during pregnancy requires careful consideration of both maternal and fetal safety. The primary goals are to treat the infection effectively, prevent maternal complications, and prevent transmission to the fetus/newborn.
General Principles
- Prompt treatment is essential to reduce the risk of complications
- Medication selection must consider pregnancy safety categories
- Partner treatment is crucial to prevent reinfection
- Follow-up testing is often recommended to ensure cure
- Some infections require special considerations for management during labor and delivery
Treatment Recommendations by Infection
| STD | First-Line Treatment | Alternative Treatment | Follow-up |
|---|---|---|---|
| Chlamydia | Azithromycin 1g orally in a single dose | Amoxicillin 500mg orally three times daily for 7 days | Test-of-cure 3-4 weeks after treatment |
| Gonorrhea | Ceftriaxone 500mg IM in a single dose | Consult infectious disease specialist if cephalosporin-allergic | Test-of-cure if symptoms persist |
| Syphilis | Benzathine penicillin G:
– Early: 2.4 million units IM once – Late/Unknown: 2.4 million units IM weekly for 3 weeks |
Penicillin desensitization if allergic (no alternative regimens proven effective) | Monthly quantitative nontreponemal tests |
| Genital Herpes | First episode: Acyclovir 400mg orally three times daily for 7-10 days
Suppression from 36 weeks: Acyclovir 400mg orally three times daily |
Valacyclovir 1g orally twice daily for 7-10 days
Valacyclovir 500mg orally twice daily from 36 weeks |
Clinical assessment at delivery |
| HIV | Combination antiretroviral therapy (cART) based on current guidelines | Regimens tailored based on resistance testing, comorbidities | Regular viral load monitoring |
| HPV (warts) | Trichloroacetic acid (TCA) 80-90% or cryotherapy | Surgical excision if large or obstructing | As needed based on symptoms |
Important Treatment Considerations
- Doxycycline, fluoroquinolones, and tetracyclines are generally contraindicated during pregnancy
- For syphilis, penicillin is the only proven effective therapy for preventing maternal-fetal transmission
- Monitor for Jarisch-Herxheimer reaction after syphilis treatment
- Some topical treatments for HPV (podophyllin, podofilox, imiquimod) are contraindicated during pregnancy
- Treatment guidelines are regularly updated; always refer to the most current CDC guidelines
Partner Treatment
Treatment of sexual partners is essential to prevent reinfection:
- Partners should be referred for evaluation and treatment
- Expedited partner therapy (EPT) may be considered where legally permissible
- Abstinence from sexual activity is recommended until both partners complete treatment
- Condom use should be encouraged even after treatment
Special Considerations for Labor and Delivery
- Active genital herpes lesions: Consider cesarean delivery
- HIV: Intravenous zidovudine during labor for women with viral load >1000 copies/mL; consider cesarean delivery
- Untreated chlamydia or gonorrhea: Administer appropriate antibiotics before delivery if possible
- Syphilis: Treatment at least 30 days before delivery is needed to prevent congenital syphilis
Nursing Management
Nurses play a critical role in the comprehensive management of STDs during pregnancy. Their responsibilities span from prevention and screening to treatment, education, and psychosocial support.
Assessment and Screening
- Obtain thorough sexual and medical history using a non-judgmental approach
- Assess for risk factors: multiple partners, previous STDs, substance use, etc.
- Identify physical signs and symptoms that may indicate STDs
- Assist with specimen collection for diagnostic testing
- Monitor for signs of complications during pregnancy
Nursing Interventions
- Medication Administration:
- Administer prescribed medications accurately
- Monitor for adverse effects and therapeutic response
- Educate patients about medication regimens
- Pain and Symptom Management:
- Provide comfort measures for genital lesions or discomfort
- Recommend sitz baths for perineal comfort
- Suggest loose-fitting cotton underwear to reduce irritation
- Infection Control:
- Implement standard precautions
- Educate about preventing transmission to partners
- Encourage partner notification and treatment
Patient Education
- Disease Process:
- Explain the nature of the infection and its implications
- Discuss potential risks to pregnancy and the fetus
- Address misconceptions about STDs
- Treatment Adherence:
- Emphasize the importance of completing the full course of treatment
- Discuss potential side effects and when to report concerns
- Explain the importance of follow-up testing
- Prevention:
- Counsel on safer sex practices
- Advise on abstinence during treatment
- Discuss condom use for preventing reinfection
- Labor and Delivery Considerations:
- Explain specific precautions needed during delivery
- Prepare patients for potential interventions (e.g., cesarean delivery for active herpes)
- Discuss intrapartum medications if indicated
Psychosocial Support
- Address concerns about stigma and emotional reactions to diagnosis
- Provide support for disclosing the diagnosis to partners
- Connect patients with counseling services or support groups if needed
- Help navigate relationship challenges that may arise
- Address anxiety about potential effects on the baby
Documentation and Reporting
- Document assessments, interventions, and patient education
- Report notifiable diseases to public health authorities as required
- Document treatment adherence and response
- Ensure communication of STD status to labor and delivery staff
Memory Aid: “STDS CARE”
- Screening and assessment
- Treatment administration
- Documentation
- Support (psychosocial)
- Counseling and education
- Advocacy for patient needs
- Reporting to authorities
- Evaluation of outcomes
Prevention Strategies
Prevention of STDs during pregnancy involves both primary prevention (preventing initial infection) and secondary prevention (preventing complications of existing infections). Comprehensive prevention strategies include:
Primary Prevention
- Patient Education:
- Safer sex practices, including consistent and correct condom use
- Limiting the number of sexual partners
- Communication with partners about sexual health
- Avoiding high-risk sexual behaviors
- Preconception Counseling:
- STD screening before pregnancy
- Treatment of existing infections before conception
- Vaccination (HPV, hepatitis B) before pregnancy when applicable
- Partner Management:
- Encouraging partner testing and treatment
- Education about mutual monogamy
- Addressing substance use that may contribute to high-risk behaviors
Secondary Prevention
- Early Screening:
- Universal and targeted screening based on risk factors
- Repeat screening during pregnancy for high-risk women
- Prompt testing when symptoms develop
- Effective Treatment:
- Timely and appropriate antimicrobial therapy
- Adherence to treatment regimens
- Treatment of partners to prevent reinfection
- Management during Labor and Delivery:
- Appropriate interventions based on STD status
- Prophylactic measures for the newborn when indicated
- Mode of delivery considerations for specific infections
Health System Strategies
- Integration of STD screening into routine prenatal care
- Provider education on current screening and treatment guidelines
- Expedited partner therapy programs where legally permissible
- Confidential services that reduce stigma barriers
- Access to affordable testing and treatment
- Surveillance and public health reporting systems
Nursing Education Priorities
When educating pregnant women about STD prevention, focus on:
- Using simple, non-technical language
- Emphasizing the benefits of prevention for both mother and baby
- Providing written materials to reinforce verbal education
- Creating a non-judgmental environment that encourages questions
- Addressing cultural or religious factors that may influence preventive behaviors
- Involving partners in education when possible and appropriate
Best Practices
The following best practices represent current evidence-based approaches to managing STDs in pregnancy:
1. Universal Screening with Targeted Approach
Implement universal screening for HIV, syphilis, and hepatitis B for all pregnant women at the first prenatal visit, with additional risk-based screening for chlamydia, gonorrhea, and other STDs. Target repeat screening in the third trimester for high-risk populations.
2. Integrated Care Model
Utilize an integrated care approach that combines STD services with routine prenatal care, ensuring seamless access to testing, treatment, and follow-up. This model improves patient compliance and outcomes.
3. Partner Management Strategies
Implement comprehensive partner notification and treatment strategies to prevent reinfection. This may include expedited partner therapy where appropriate, referrals for partner testing, or involvement of public health authorities for contact tracing.
4. Patient-Centered Education
Provide culturally sensitive, linguistically appropriate education about STD prevention, symptoms, testing, and treatment. Utilize multiple educational formats (verbal, written, visual) to enhance understanding and retention of information.
5. Technology-Enhanced Approaches
Leverage technology for reminders about follow-up appointments, medication adherence, and test result notification. Electronic health records can facilitate communication between prenatal care providers and specialty services.
Current Challenges
Despite best practices, several challenges persist in STD management during pregnancy:
- Late entry into prenatal care, limiting early screening opportunities
- Antimicrobial resistance, particularly for gonorrhea
- Stigma associated with STD diagnosis
- Partner notification and treatment barriers
- Healthcare access disparities among vulnerable populations
Recent Updates in Care
STD management guidelines are regularly updated based on emerging evidence and changing patterns of disease and resistance. The following represent recent updates and emerging trends in the management of STDs during pregnancy:
1. Updated CDC Treatment Guidelines
- Gonorrhea: Increased dose of ceftriaxone (from 250mg to 500mg) due to emerging antimicrobial resistance
- Chlamydia: Emphasis on test-of-cure for pregnant women
- Syphilis: Enhanced screening recommendations, with some regions now recommending three screenings during pregnancy (first visit, 28 weeks, delivery)
2. Congenital Syphilis Prevention
With rising rates of congenital syphilis in many regions, there has been increased emphasis on:
- Enhanced surveillance systems
- Case review of all congenital syphilis cases to identify system failures
- Expanded screening recommendations
- Community outreach to high-risk populations
3. Improved Diagnostic Technologies
- More sensitive and specific molecular diagnostic tests
- Point-of-care testing for rapid results during the same visit
- Expanded use of NAAT testing for extragenital sites
- Increased availability of dual testing for chlamydia and gonorrhea
Best Practice Recommendations
- Enhanced screening for syphilis – Consider testing three times during pregnancy in high-prevalence areas
- Improved partner notification strategies – Utilizing technology-based approaches for anonymous notification
- Integration of behavioral interventions – Incorporating motivational interviewing and harm reduction approaches into STD prevention counseling
Summary Key Points
- STDs during pregnancy can cause significant maternal and fetal complications, including preterm birth, congenital infections, and long-term disabilities.
- Common STDs affecting pregnancy include chlamydia, gonorrhea, syphilis, herpes, HIV, and HPV, each with specific risks and management approaches.
- Universal screening at the first prenatal visit is recommended for HIV, syphilis, and hepatitis B, with targeted screening for other STDs based on risk factors.
- Treatment during pregnancy requires careful consideration of medication safety for both mother and fetus, with some medications specifically contraindicated.
- Nursing management encompasses screening, treatment administration, patient education, psychosocial support, and coordination of care.
- Comprehensive prevention strategies include both primary prevention (safer sex practices) and secondary prevention (early detection and treatment).
- Partner notification and treatment are essential components of effective STD management to prevent reinfection.
- Recent updates include enhanced screening protocols and treatment modifications due to antimicrobial resistance concerns.
References
- Centers for Disease Control and Prevention. (2021). Sexually transmitted infections treatment guidelines, 2021. Morbidity and Mortality Weekly Report, 70(4), 1-187.
- American College of Obstetricians and Gynecologists. (2020). Management of genital herpes in pregnancy: ACOG Practice Bulletin No. 220. Obstetrics & Gynecology, 135(5), e193-e202.
- World Health Organization. (2016). WHO guidelines for the treatment of Treponema pallidum (syphilis). Geneva: World Health Organization.
- Galan, H. L., Kilpatrick, S. J., and Barss, V. A. (2020). Bacterial infections in pregnancy. UpToDate.
- Centers for Disease Control and Prevention. (2020). Congenital syphilis – United States, 2014-2018. Morbidity and Mortality Weekly Report, 69(22), 661-665.
- Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. (2022). Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States.
- Baldeh, A., & Isara, A. (2019). Knowledge of sexually transmitted infections and risk perception among pregnant women in Ojo, Lagos State, Nigeria. Western Journal of Nursing Research, 41(2), 257-274.
- Fasugba, O., Mitchell, B. G., McInnes, E., Koerner, J., Cheng, A. C., Cheng, H., & Middleton, S. (2020). Increased fluid intake for the prevention of urinary tract infection in adults and children in all settings: a systematic review. Journal of Hospital Infection, 104(1), 68-77.
- Widman, L., Nesi, J., Kamke, K., Choukas-Bradley, S., & Stewart, J. L. (2018). Technology-based interventions to reduce sexually transmitted infections and unintended pregnancy among youth. Journal of Adolescent Health, 62(6), 651-660.