Improving services for prevention and treatment of STI/RTI
Chapter 7. STI/RTI assessment in pregnancy, childbirth and the postpartum period

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Key points

• Women should be encouraged to attend antenatal clinic early in pregnancy to allow timely detection and prevention of any problems, including STI/RTI.
• Women should be screened for syphilis at the first antenatal visit. Screening for syphilis should be done on-site, and results and treatment made available to the woman before she leaves the clinic.
• Screening for other STIs/RTIs, including cervical infections, bacterial vaginosis and HIV, should be offered if available.
• Women should be asked at each antenatal visit about STI symptoms in themselves and their partner. Screening and/or treatment of partners should be offered, for at least symptomatic STIs, syphilis and HIV.
• STI prevention should be promoted during pregnancy as a way of protecting both mother and child, and of safeguarding future fertility.
• Access to counselling and testing for HIV, interventions to prevent mother-to-child-transmission, and care of the mother should be available on-site or by referral.
• Prophylaxis for ophthalmia neonatorum should be given routinely to all newborn babies.

 

STI/RTI prevention and management are as important during pregnancy as at any other time. A woman�s sexual activity may increase or decrease, and exposure to infection may change. A number of STIs�including syphilis, gonorrhoea, chlamydia, trichomoniasis, genital herpes and HIV�can cause complications during pregnancy and contribute to poor pregnancy outcomes. Among endogenous infections, bacterial vaginosis is associated with preterm labour. Yeast infection is more common during pregnancy and, although it is not associated with any adverse pregnancy outcomes, the symptoms may be unpleasant and women should receive appropriate treatment. Upper genital tract infection may be a complication of spontaneous or induced abortion, or preterm rupture of membranes, or may occur following delivery�and may be life-threatening.

Some of the most important STI/RTI-related problems in pregnancy�including postabortion and postpartum infections, and congenital syphilis�are not technically difficult or expensive to manage or prevent altogether. Yet maternal and perinatal morbidity and mortality due to these problems remain high. Simple improvements in service delivery using available technology�such as same-day, on-site syphilis screening in antenatal clinics�can lead to dramatic improvements in pregnancy outcome. Treatment of symptomatic bacterial vaginosis can reduce the risk of preterm labour, and prevention and effective management of postpartum and postabortion infections can reduce maternal morbidity and mortality.

Women of reproductive age should be educated about the importance of early antenatal care and STI/RTI screening. Couples should be counselled during pregnancy on symptoms of preterm labour, safer sex practices and avoidance of other partners during the pregnancy.

Antenatal clinic visits provide opportunities for preventing and detecting STIs/RTIs, and women should be encouraged to attend early in pregnancy. WHO recommends four antenatal care visits for women with uncomplicated pregnancy. Figure 7.1 illustrates the WHO antenatal care model, which provides a checklist for basic antenatal care services as well as tools for identifying women who need additional care.

 

Figure 7.1. The WHO antenatal care (ANC) model

Source: WHO antenatal randomized trial: manual for the implementation of the new model. Geneva, World Health Organization, 2002.

 

Step 1: Initial assessment visit during pregnancy

A woman may first come to the antenatal clinic any time between the first trimester and the onset of labour. She may or may not return to the clinic before delivery. It is therefore important to make the most of the first visit, and some consideration of STIs/RTIs should be included in the assessment.

 

 

The following is recommended as a minimal STI/RTI assessment at the initialantenatal visit:

• Ask the woman about symptoms of STI/RTI and whether her partner has urethral discharge or other symptoms. If the woman or her partner has symptoms, they should be managed using the flowcharts in Chapter 8.
• Serological syphilis testing using RPR or equivalent non-treponemal syphilis antibody test should be carried out as early as possible in pregnancy (Chapter 3). Testing should be done on-site where possible, and the woman should receive her results and treatment before leaving the clinic. Treatment of her partner should also be encouraged, and active assistance given if requested.
• Pregnant women with a history of spontaneous abortion or preterm delivery should be screened for bacterial vaginosis and trichomoniasis. Those who test positive should be treated (after the first trimester of pregnancy) with metronidazole, 500 mg three times a day for seven days, to reduce risk of adverse pregnancy outcome.
• Counselling and testing for HIV should be available on-site or through referral. Women who test positive should be referred to appropriate support services and advised on how to reduce the risk of mother-to-child transmission (MTCT) (Box 7.1).
• Prevention of STIs (including HIV) should be discussed with the woman and her partner in the context of ensuring a healthy pregnancy and protecting future fertility.
• Plans for delivery and the postpartum period should be discussed early in pregnancy. Infection with a viral STI such as HIV or HSV-2 may influence the birth plan. STI/RTI prevention needs should be discussed when considering options for postpartum family planning.

 

Step 2: Follow-up antenatal visit

 

When women return for follow-up antenatal visits, attention should be paid to STI/RTI prevention and detection since risk of infection may persist. As at the first visit, women should be asked about symptoms in themselves or their partners. Any symptomatic STIs/RTIs should be managed using the flowcharts in Chapter 8 and Chapter 9.

 

• Syphilis testing should be repeated in late pregnancy, if possible, to identify women infected during pregnancy (Chapter  3). All women should be tested at least once during each pregnancy, and all women with reactive serology should receive treatment (see Annex 3 for information on interpreting syphilis test results in women treated previously).
• For women who are HIV positive, management during the antenatal period will depend on the specific protocol followed. Health care providers should review the birth plan and discuss options for infant feeding and postpartum contraception.
• Prevention of STIs/RTIs should be stressed. The woman and her partner should understand that, regardless of previous treatment, an STI acquired in late pregnancy is capable of causing pregnancy complications and congenital infection. Condoms should be offered. Where partner treatment is indicated, it may be more readily accepted if offered as a precaution to ensure a safe delivery and healthy newborn.

 

Box 7.1. HIV and pregnancy

Mother-to-child transmission (MTCT) of HIV is the major cause of HIV infection in children throughout the world. Over half a million children are infected this way each year. Without intervention, up to 40% of children born to HIV-infected women will be infected. Infection can be transmitted from mother to child during pregnancy, during labour and delivery, and through breastfeeding. Prevention of MTCT should begin as early as possible in pregnancy by offering counselling and testing of the parents for HIV infection. Routine antenatal care is similar for women who are HIV positive and for those who are uninfected. Detection and treatment of STIs/RTIs are important, since several STIs/RTIs increase the amount of HIV in genital secretions, which increases the risk of transmitting infection to the child during delivery. Careful attention should be paid to symptoms or physical examination findings suggestive of opportunistic infections or STI/RTI. Invasive procedures such as amniocentesis should be avoided. Apart from antiviral treatment, there is no need for HIV-infected women to be treated differently than other women during labour and delivery or to be isolated. Universal precautions to reduce the risk of transmission of HIV and other infections should be used by staff for all patients, not only for those who are known to be HIV-infected (see Annex 2). HIV-positive women require special attention in the postpartum period. They may benefit from further care, counselling and support, and may need assistance if they choose substitute infant feeding. They should be referred to care and support services.

 

Step 3: Labour and delivery

 

STI/RTI concerns during labour and delivery are few but potentially important. The objectives are to identify infection that may not have been detected during the antenatal period, and to intervene where possible to prevent and manage STIs/RTIs in the newborn (Box 7.3).

 

• Look for signs of infection. Most STIs/RTIs are not emergencies and treatment can be delayed until after delivery. Vesicles or ulcers suggestive of a first episode of genital herpes (primary HSV-2 infection) near delivery may be an indication for caesarean section since vaginal delivery carries a risk for the newborn of disseminated herpes, and a high risk of neonatal death. Where caesarean section is not possible or would be unsafe, transport to a referral hospital should be considered if delivery is not imminent. Caesarean delivery is not beneficial if more than six hours have passed since rupture of the membranes.
• Genital warts, even when extensive, are not an indication for caesarean delivery.
• Preterm rupture of membranes and rupture of membranes before the onset of labour require careful management to reduce risk of infection (see Chapter 9).
• Manage HIV-infected women (including administration of antiretroviral treatment) according to local protocols.

Universal precautions should be followed for all deliveries (Box 7.2).

 

Box 7.2. Universal precautions during childbirth

The following precautions are advised for every childbirth regardless of the HIV or STI/RTI status of the woman. Use gloves, carefully wash hands between procedures, and high-level disinfect or sterilize all instruments/equipment used in the process of delivery. Follow standard practice for the delivery, avoiding unnecessary vaginal examinations, minimizing trauma, and actively managing the second stage of labour. Episiotomy should only be done for obstetric indications and not as a routine procedure. If assisted delivery is required, this should involve as little trauma as possible. Cut the umbilical cord under cover of a lightly wrapped gauze swab to prevent blood spurting. Do not apply suction to the newborn�s airway with a nasogastric tube unless there are signs of meconium. Mouth-operated suction should be avoided. Regardless of the HIV status of the mother, wear gloves when handling any newborn baby until maternal blood and secretions have been washed off. Immediately after birth, remove the mother�s blood as well as meconium with soap and water. All babies should be kept warm after delivery.

 

Box 7.3. Prevention and management of STIs/RTIs in the newborn

1. Neonatal eye prophylaxis All newborn babies, regardless of maternal signs or symptoms of infection, should receive prophylaxis against ophthalmia neonatorum due to gonorrhoea or chlamydial infection. The eye ointments and drops that may be used are listed below.

Prevention of ophthalmia neonatorum Instil one drop of the following in each eye within one hour of birth tetracycline ophthalmic ointment (1%) in a single application OR provide iodine drops 2.5% in a single application OR silver nitrate (1%) freshly prepared aqueous solution in a single application

2. Congenital syphilis Syphilis test results should be reviewed at this time, and the newborn evaluated for signs of congenital syphilis. Women who have not previously been tested for syphilis should be tested. Results should be obtained as soon as possible so that early treatment can be given to newborns of mothers who test positive. Newborn babies should be managed as described in Table 7.1, regardless of whether the mother received treatment for syphilis during pregnancy. The mother and her partner should also be treated if this has not already been done.

 

Table 7.1. Treatment of neonatal syphilis (first month of life)

	Mother�s RPR/VDRL status
	Reactive	Unknown	Non-reactive
Infant with signs of congenital syphilisa	Treatment 1 or 2	Test mother	Repeat test
		Start treatment 1 or 2 while awaiting results (if delay expected) If reactive, continue treatment If negative, investigate for other causes and modify treatment accordingly
Infant without signs of congenital syphilisa	Treatment 3 Single injection	Test mother	No treatment
Treatment 1	Aqueous crystalline benzylpenicillin 100 000�150 000 units/kg of body weight per day, administered as 50 000 units/kg of body weight, intramuscularly or intravenously, every 12 hours during the first 7 days of life and every 8 hours thereafter for a total of 10 days
Treatment 2	Procaine benzylpenicillin 50 000 units/kg of body weight, intramuscularly, in a single daily dose for 10 days
Treatment 3	Benzathine benzylpenicillin 50 000 units/kg of body weight, intramuscularly, in a single dose

^a. Signs of congenital syphilis: vesicular eruptions on palms or soles, hepatosplenomegaly, pseudoparalysis, oedema/ascites, fever (in first week of life), prolonged or conjugated hyperbilirubinaemia, petechiae, bleeding, syphilitic facies. Infants are often asymptomatic at birth.

 

Step 4: Postpartum care

 

It is as important to be aware of signs of infection following delivery as during pregnancy. Postpartum uterine infection is a common and potentially life-threatening condition, and early detection and effective treatment are important measures to prevent complications. All women are vulnerable to infection following delivery, and retained blood and placental tissue increase the risk. Other risk factors for infection include prolonged labour, prolonged rupture of membranes and manipulation during labour and delivery. Management of postpartum infection is covered in Chapter 9.

Women should be examined within 12 hours following delivery. When they are discharged from the health care facility, women should be advised to return to the clinic if they notice symptoms, such as fever, lower abdominal pain, foul-smelling discharge or abnormal bleeding. They should be given information on care of the perineum and breasts, and instructed on the safe disposal of lochia and blood-stained pads or other potentially infectious materials. Health care providers should be alert to signs of infection including fever, lower abdominal pain or tenderness and foul-smelling discharge.

• HIV-positive women may need continued care and support, including access to treatment and support in carrying out a substitute feeding plan.
• If contraception was not discussed before delivery, it should be brought up early in the postpartum period. Planning for a suitable method should include consideration of need for STI/RTI protection (see Chapter 6). Dual protection should also be discussed with women who choose a long-term contraceptive method, such as an IUD, following delivery.