Original Research
Patterns of Screening, Infection, and
Treatment of Chlamydia trachomatis and
Neisseria gonorrhea in Pregnancy
Emily R. Goggins, BA, Allison T. Chamberlain, MS, PhD, Tesia G. Kim, MD, MSEd,
Marisa R. Young, MD, PhD, Denise J. Jamieson, MD, MPH, and Lisa B. Haddad, MD, MPH
OBJECTIVE: To describe factors associated with not
Downloaded from http://journals.lww.com/greenjournal by BhDMf5ePHKbH4TTImqenVAHFSsMzGEygfXCM5Loru6FJc8xzokLtbeSE8zKBM4sxNykEDgr8q5k= on 04/11/2020
being tested for Chlamydia trachomatis and Neisseria
gonorrhea infection during pregnancy and for testing
positive and to describe patterns of treatment and tests
of reinfection.
METHODS: We conducted a retrospective cohort study
of women who delivered at an urban teaching hospital
from July 1, 2016 to June 30, 2018. Women with at least
one prenatal care or triage visit were included. The index
delivery was included for women with multiple deliver-
ies. We used logistic regression to analyze factors
associated with not being tested and for testing positive
for these infections in pregnancy. Cox proportional
hazards models were used to examine factors associated
with time to treatment and tests of reinfection. We
From the Department of Gynecology and Obstetrics, Emory University School of
Medicine, and the Department of Epidemiology, Rollins School of Public Health,
Emory University, Atlanta, Georgia; and the Department of Obstetrics and
Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
The Marianne Ruby, MD Award in Obstetrics and Gynecology provided by the
Emory University Department of Gynecology and Obstetrics was used to support
this project.
Presented as a poster at the Infectious Diseases Society for Obstetrics and Gyne-
cology Annual Meeting, August 8–10, 2019, Big Sky, Montana.
The authors thank Jenna Adams, MD, Kamini Doraivelu, MPH, Michele Saums,
MD, Madeline Smith, MD, and Caitlin Szabo, MD at Emory University for
their contribution to the data collection for this study.
Each author has confirmed compliance with the journal’s requirements for
authorship.
Corresponding author: Lisa B. Haddad, MD, MPH, Department of Gynecology
and Obstetrics, Emory University School of Medicine, Atlanta, GA; email:
lisa.haddad@emory.edu.
Financial Disclosure
Allison T. Chamberlain disclosed receiving funds from the American College of
Obstetricians and Gynecologists and as an epidemiology consultant to Fulton
County Board of Health in Atlanta, GA. The other authors did not report any
potential conflicts of interest.
© 2020 by the American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/20
VOL. 135, NO. 4, APRIL 2020
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
reviewed medical records to determine reasons for
delays in treatment longer than 1 week.
RESULTS: Among 3,265 eligible deliveries, 3,177 (97%)
women were tested during pregnancy. Of these, 370
(12%) tested positive (287 chlamydia, 35 gonorrhea, 48
both), and 15% had repeat infections. Prenatal care
adequacy and insurance status were risk factors for not
being tested. Age, race and ethnicity, alcohol use, and
sexually transmitted infection history were associated
with testing positive. Time to treatment ranged from 0 to
221 days, with the majority (55%) of patients experienc-
ing delays of more than 1 week. Common reasons for
delays included lack of clinician recognition and follow-
up of abnormal results (65%) and difficulty contacting the
patient (33%).
CONCLUSION: Traditional risk factors are associated
with increased risk of infection during pregnancy. Pre-
natal care adequacy and insurance status were associated
with the likelihood of being tested. Delays in treatment
and tests of reinfection were common. Point-of-care
testing and expedited partner therapy should be
explored as ways to improve the management of these
infections in pregnancy.
(Obstet Gynecol 2020;135:799–807)
DOI: 10.1097/AOG.0000000000003757
C hlamydia trachomatis and Neisseria gonorrhea are
the most common bacterial sexually transmitted
infections (STIs) in the United States.1–3 In 2017,
there were 748.8 cases of C trachomatis infection per
100,000 women in the South, compared with 682.9 in
the country overall.3 Most infections are asymptom-
atic, and infection can cause maternal and neonatal
complications.4–7 Studies have shown antibiotic treat-
ment to be effective in decreasing adverse health out-
comes.8–10
The Centers for Disease Control and Prevention
recommends screening pregnant women younger
OBSTETRICS & GYNECOLOGY 799
than 25 years and older women with risk factors for C
trachomatis and N gonorrhea infection.11 Risk factors
include multiple sexual partners, inconsistent condom
use, young age, being of non-Hispanic black race–
ethnicity, and previous STI diagnoses.3,12 Nucleic
acid amplification testing is preferred for screening,
given its high sensitivity and specificity.11 Infection
should be treated with antibiotics, followed by a test of
reinfection 3–4 weeks later.13
Delayed treatment among nonpregnant women
carries established risks.14 The primary objective of
this study was to estimate the prevalence of C tracho-
matis and N gonorrhea infection and identify risk factors
for not being tested and for testing positive for these
infections in pregnancy in an urban teaching hospital.
Our secondary objective was to explore patterns of
treatment and tests of reinfection.
METHODS
We conducted a retrospective cohort study of women
who delivered at Grady Memorial Hospital under the
supervision of Emory University clinicians. Grady
Memorial Hospital is an urban teaching hospital that
serves a diverse range of patients, including many
who are indigent, uninsured, or underinsured.15 We
included all women who delivered one or more fe-
tuses after 20 weeks of gestation, regardless of viabil-
ity, from July 1, 2016 to June 30, 2018. Women with
at least one prenatal care or triage visit were consid-
ered eligible. For women with multiple pregnancy
episodes in the study period, only the index delivery
was included.
The electronic health record of all patients
identified was reviewed for demographic and clinical
characteristics. Study data were collected and man-
aged using Research Electronic Data Capture.16 Re-
searchers included medical and public health graduate
students. All researchers were trained in abstraction
and used a codebook to ensure consistency. The
Emory University Institutional Review Board and
the Grady Research Oversight Committee approved
this study.
The primary outcomes of our study were 1) not
being tested for C trachomatis and N gonorrhea infection
and 2) testing positive for C trachomatis or N gonorrhea
infection during pregnancy. Because women who
receive care at Grady Memorial Hospital live in
a high-prevalence area, all women, regardless of age,
are considered at risk and are routinely screened in
pregnancy. Testing is done through a single-probe
nucleic acid amplification testing from a urine sample
or cervical swab which offers high sensitivity and
specificity as well as testing for both infections at once.
800 Goggins et al Chlamydia trachomatis and N gonorrhea in Pregnancy
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
A positive C trachomatis or N gonorrhea infection was
defined as a positive result on nucleic acid amplifica-
tion testing processed at Grady Memorial Hospital.
Self-reported testing results from an outside hospital
were classified as unknown. Women without a docu-
mented nucleic acid amplification testing were consid-
ered to not have had testing.
Our secondary outcomes were time to treatment
and test of reinfection. Time to treatment was defined
as the time from a positive nucleic acid amplification
test result to the initiation of treatment before deliv-
ery. Date of treatment was defined as the date the
prescription was written or medication administered.
Time to test of reinfection was defined as the time
from treatment initiation to subsequent nucleic acid
amplification testing performed 21 or more days later.
Tests conducted before 21 days after treatment were
excluded owing to the potential for false-positive
results due to nonviable organisms.17 Testing and
treatment occurring after delivery were excluded.
Exposures of interest included age at delivery,
race or ethnicity, preferred language, parity, history of
chronic medical conditions, primary insurance type at
admission for delivery, and diagnosis of symptomatic
bacterial vaginosis during the current pregnancy.
Because the majority of women in our population
are non-Hispanic black, race–ethnicity was dichoto-
mized into non-Hispanic black and other. Prenatal
care adequacy was defined using the Kotelchuck
index.18 History of STIs before the current pregnancy
included self-reported history of C trachomatis, N gon-
orrhea, trichomoniasis, syphilis, human immunodefi-
ciency virus (HIV), hepatitis B, or herpes simplex
virus. Diagnosis of an STI other than C trachomatis
and N gonorrhea in the current pregnancy included
these same STIs. Substance use during pregnancy
and history of intimate partner violence were deter-
mined by documentation in a clinic or triage note.
We used logistic regression to analyze factors
associated with not being tested and for testing
positive for C trachomatis or N gonorrhea infection in
pregnancy. Variables that were significant in bivariate
analyses at alpha less than 0.1 were entered into an
adjusted model and retained regardless of significance
in the adjusted model. The unknown or missing cate-
gory was retained for variables missing more than 5%
of data for any outcome category. The adjusted mod-
els were examined for multicollinearity using a vari-
ance inflation factor cutoff of 10. Chi-square, Fisher
exact, and Kruskal-Wallis H tests were used to com-
pare proportions and times to treatment and test of
reinfection by STI diagnosis. To account for women
with multiple infections, we used a shared frailty Cox
OBSTETRICS & GYNECOLOGY
proportional hazards model to investigate factors
associated with time to treatment and tests of reinfec-
tion. The model was created by stepwise selection
with the same variables examined in the bivariate
logistic regression models. All analyses were con-
ducted using SAS 9.4. Statistical tests were considered
significant if the P-value was less than .05. We re-
viewed medical records to determine reasons for de-
lays in treatment longer than 7 days and grouped
these reasons into common themes.

RESULTS
There were 3,723 deliveries during the study period
(July 1, 2016–June 30, 2018). After excluding 375
deliveries for women who did not have at least one
prenatal care or triage visit and 83 subsequent deliv-
eries for women who delivered more than once dur-
ing the study period, 3,265 eligible deliveries
remained (Fig. 1).
The median age at delivery was 28 years, and the
majority of women were non-Hispanic black (Table 1).
The majority of patients experienced less-than-
adequate prenatal care. Nearly a third of women
had been diagnosed with an STI before the current
pregnancy, and a minority of women were diagnosed
with an STI other than C trachomatis or N gonorrhea in
the current pregnancy. However, testing for some of
these infections, particularly herpes simplex virus and
trichomoniasis, was conducted on only a subset of
patients.
Among all eligible deliveries, 88 (3%) women
were not tested for C trachomatis and N gonorrhea infec-
tion. In bivariate analyses, Spanish language, drug
use, Medicaid insurance status, and diagnosis of an
STI other than C trachomatis and N gonorrhea in this
pregnancy were associated with an increase in testing.
Unknown history of intimate partner violence and
transfer of care or less-than-adequate prenatal care
were associated with an increased odds of not being
tested (Table 1). Prenatal care adequacy remained sig-
nificant in the full model with an increased odds of not
being tested for those who transferred care or had less-
than-adequate prenatal care (adjusted odds ratio 2.83,
P,.01) (Table 2). Those with Medicaid insurance and
those who were diagnosed with a STI other than C
trachomatis or N gonorrhea during the current preg-
nancy were at decreased risk.
Of the 3,177 women who were tested, 370 (12%)
tested positive. Thirty-five (1%) women were diag-
nosed with N gonorrhea infection, 287 (9%) with C
trachomatis infection, and 48 (2%) with both. These
370 women who tested positive contributed 440
unique diagnoses: 348 C trachomatis infections, 47 N
Fig. 1. Inclusion of study participants and distribution of
primary outcome.
Goggins. Chlamydia trachomatis and N gonorrhea in Pregnancy.
Obstet Gynecol 2020.
gonorrhea infections, and 45 co-infections. Fifteen per-
cent of women who tested positive had multiple in-
fections in pregnancy: 43 had two infections, 12 had
three, and one had four.
In bivariate analyses, younger age; being of non-
Hispanic black race–ethnicity; alcohol or drug use;
history of intimate partner violence; receiving less-
than-adequate prenatal care; diagnosis of symptom-
atic bacterial vaginosis during the current pregnancy;
being diagnosed with another STI during the current
pregnancy; and STI history were each associated with
testing positive (Table 3). Having a primary language
other than English was associated with a decreased
risk of infection. In multivariate analysis, being youn-
ger than 25 years of age, non-Hispanic black race–
ethnicity, alcohol use, being diagnosed with another
STI during the current pregnancy, and history of any
STI before the current pregnancy remained associated
with testing positive (Table 3). Having a primary
language other than Spanish or English was associated
with a decreased risk.
Of the 440 unique patients with C trachomatis and
N gonorrhea infection identified, 95% received antibiotic
treatment before delivery. The proportion treated dif-
fered by STI diagnosis (C trachomatis 96%, N gonorrhea
87%, co-infection 91%, P5.02). Time to treatment
ranged from 0 to 221 days, with the majority (55%)
of patients experiencing a delay of more than 1 week
(Fig. 2). Treatment occurred during hospital admission

VOL. 135, NO. 4, APRIL 2020 Goggins et al Chlamydia trachomatis and N gonorrhea in Pregnancy 801

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Table 1. Demographic and Clinical Characteristics by Maternal Chlamydia trachomatis and Neisseria
gonorrhea Infection Status

Total Study Chlamydia- or Chlamydia- and

Population Not Gonorrhea-Positive Gonorrhea-Negative
Characteristic (N53,265) Tested (n588) (n5370) (n52,807)

Age at delivery (y) 27.7 (23.1–32.4) 30.4 (24.4–34.4) 23.0 (20.0–27.0) 28.3 (23.6–32.9)
Younger than 25 1,129 (35) 24 (27) 227 (61) 878 (31)
25 or older 2,136 (65) 64 (73) 143 (39) 1,929 (69)
Race–ethnicity
Non-Hispanic black 2,191 (67) 64 (73) 313 (85) 1,814 (65)
Other 1,048 (32) 22 (25) 53 (14) 973 (35)
Unknown or missing 26 (1) 2 (2) 4 (1) 20 (1)
Preferred language
English 2,359 (72) 67 (76) 330 (89) 1,962 (70)
Spanish 645 (20) 9 (10) 37 (10) 599 (21)
Other 259 (8) 12 (14) 3 (1) 244 (9)
Unknown or missing 2 (0) 0 (0) 0 (0) 2 (0)
Parity
0 768 (24) 14 (16) 124 (34) 630 (22)
1 264 (8) 7 (8) 36 (10) 221 (8)
2 777 (24) 15 (17) 97 (25) 669 (24)
3 or more 1,456 (45) 52 (59) 117 (32) 1,287 (46)
Chronic medical condition
Cardiovascular disease 27 (1) 0 (0) 4 (1) 23 (1)
Diabetes mellitus 48 (1) 1 (1) 4 (1) 43 (2)
Asthma 234 (7) 3 (3) 41 (11) 190 (7)
HIV 69 (2) 3 (3) 8 (2) 58 (2)
Substance use
Tobacco 341 (10) 14 (16) 47 (13) 280 (10)
Alcohol 87 (3) 4 (5) 22 (6) 61 (2)
Illicit drugs 416 (13) 5 (6) 81 (22) 330 (12)
History of intimate
partner violence
No 2,878 (88) 73 (83) 314 (85) 2,491 (89)
Yes 310 (9) 8 (9) 51 (14) 251 (9)
Unknown or missing 77 (2) 7 (8) 5 (1) 65 (2)
Prenatal care adequacy
Transfer of care 377 (12) 32 (36) 31 (8) 314 (11)
Inadequate–intermediate 1,949 (57) 47 (53) 248 (67) 1,654 (59)
Adequate–adequate plus 929 (28) 8 (9) 91 (25) 830 (30)
Unknown or missing 10 (0) 1 (1) 0 (0) 9 (0)
Primary insurance type
Medicaid 2,898 (89) 66 (75) 339 (92) 2,493 (89)
Other 241 (7) 14 (16) 24 (6) 203 (7)
Unknown or missing 126 (4) 8 (9) 7 (2) 111 (4)
Symptomatic bacterial
vaginosis diagnosed
this pregnancy
No 2,976 (91) 84 (95) 320 (86) 2,572 (92)
Yes 289 (9) 4 (5) 50 (14) 235 (8)
STI other than chlamydia
or gonorrhea diagnosed
this pregnancy
No 2,832 (87) 83 (94) 265 (72) 2,484 (88)
Yes 424 (13) 3 (3) 105 (28) 316 (11)
Unknown or missing 9 (0) 2 (2) 0 (0) 7 (0)
History of any STI
before pregnancy
No 2,187 (67) 65 (74) 199 (54) 1,923 (69)
Yes 1,016 (31) 22 (25) 162 (44) 832 (30)
Unknown or missing 62 (2) 1 (1) 9 (2) 52 (2)
HIV, human immunodeficiency virus; STI, sexually transmitted infection.
Data are median (interquartile range) or n (%).

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Table 2. Unadjusted and Adjusted* Odds of Not Being Tested for Chlamydia trachomatis and Neisseria
gonorrhea Infection in Pregnancy

Characteristic Unadjusted OR (95% CI) P Adjusted* OR (95% CI) P

Age at delivery (y)

Younger than 25 0.70 (0.44–1.13) .15
25 or older Ref
Race–ethnicity
Non-Hispanic black 1.40 (0.86–2.29) .18
Other Ref
Preferred language
English Ref Ref
Spanish 0.48 (0.24–0.98) .04 0.49 (0.24–1.01) .05
Other 1.66 (0.89–3.12) .11 1.15 (0.58–2.26) .69
Any tobacco use this pregnancy
No Ref
Yes 1.60 (0.90–2.87) .11
Any alcohol use this pregnancy
No Ref
Yes 1.73 (0.62–4.82) .30
Any illicit drug use this pregnancy
No Ref Ref
Yes 0.40 (0.16–0.98) .05 0.45 (0.18–1.16) .10
History of intimate partner violence
No Ref Ref
Yes 1.02 (0.49–2.13) .96 1.30 (0.61–2.79) .50
Unknown or missing 3.84 (1.71–8.65) ,.01 7.20 (3.01–17.20) ,.01
Prenatal care adequacy
Transfer of care 10.68 (4.87–23.40) ,.01 9.21 (4.14–20.45) ,.01
Inadequate–intermediate 2.85 (1.34–6.05) ,.01 2.83 (1.32–6.07) ,.01
Adequate–adequate plus Ref Ref
Primary insurance type
Medicaid 0.38 (0.21–0.68) ,.01 0.48 (0.26–0.90) ,.01
Other Ref Ref
Unknown or missing 1.10 (0.45–2.70) .84 0.70 (0.27–1.83) .46
Symptomatic bacterial vaginosis diagnosed
this pregnancy
No Ref
Yes 0.48 (0.18–1.33) .16
STI other than chlamydia or gonorrhea
diagnosed this pregnancy
No Ref Ref
Yes 0.24 (0.07–0.75) .01 0.17 (0.04–0.71) .02
History of any STI before pregnancy
No Ref
Yes 0.72 (0.44–1.18) .19
OR, odds ratio; Ref, referent group; STI, sexually transmitted infection.
* Adjusted for variables listed.

for delivery in 25 of the treated patients (6%). Time to
treatment did not differ by STI diagnosis (median days
to treatment: C trachomatis 8, N gonorrhea 12, co-
infection 15, P5.11). Among the 228 patients who
experienced delays of greater than 1 week, the most
common reasons included health care provider recog-
nition and follow-up of the abnormal result (n5147,
65%) and difficulty contacting the patient (n576,
33%). Less common reasons included delay in the
patient presenting to clinic for treatment (n519, 8%)
and the patient not collecting or not taking the medi-
cation (n518, 8%). These reasons were not mutually
exclusive.
A test of reinfection was completed in 76% of all
treated patients with C trachomatis and N gonorrhea infec-
tion. Among those retested, the test of reinfection was
delayed by more than 1 month beyond the recommen-
ded 21–28-day period in 24% of patients (Fig. 3). Time
to test of reinfection (median days to retesting: C tra-
chomatis 37, N gonorrhea 43, co-infection 43, P5.83) and

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Table 3. Unadjusted and Adjusted* Odds of Maternal Chlamydia trachomatis or Neisseria gonorrhea
Infection in Pregnancy†

Characteristic Unadjusted OR (95% CI) P Adjusted* OR (95% CI) P

Age at delivery (y)

Younger than 25 3.49 (2.79–4.36) ,.01 2.97 (2.33–3.77) ,.01
25 or older Ref Ref
Race–ethnicity
Non-Hispanic black 3.17 (2.34–4.28) ,.01 1.92 (1.12–3.30) .02
Other Ref
Preferred language
English Ref Ref
Spanish 0.37 (0.26–0.52) ,.01 1.10 (0.59–2.07) .76
Other 0.07 (0.02–0.23) ,.01 0.17 (0.05–0.55) ,.01
Any tobacco use this pregnancy
No Ref
Yes 1.30 (0.93–1.80) .12
Any alcohol use this pregnancy
No Ref Ref
Yes 2.82 (1.71–4.64) ,.01 2.35 (1.35–4.11) ,.01
Any illicit drug use this pregnancy
No Ref Ref
Yes 2.07 (1.57–2.71) ,.01 1.12 (0.82–1.53) .47
History of intimate partner violence
No Ref Ref
Yes 1.61 (1.17–2.23) ,.01 1.04 (0.73–1.48) .84
Unknown or missing 0.61 (0.24–1.53) .29 0.75 (0.23–2.49) .64
Prenatal care adequacy
Transfer of care 0.90 (0.59–1.38) .63 0.94 (0.60–1.48) .79
Inadequate–intermediate 1.37 (1.06–1.76) .02 1.13 (0.86–1.49) .38
Adequate–adequate plus Ref Ref
Primary insurance type
Medicaid 1.15 (0.74–1.78) .53
Other Ref
Unknown or missing 0.53 (0.22–1.28) .16
Symptomatic bacterial vaginosis diagnosed
this pregnancy
No Ref Ref
Yes 1.71 (1.23–2.37) ,.01 1.06 (0.74–1.52) .75
STI other than chlamydia or gonorrhea
diagnosed this pregnancy
No Ref Ref
Yes 3.12 (2.42–4.02) ,.01 2.14 (1.62–2.83) ,.01
History of any STI before pregnancy
No Ref Ref
Yes 1.88 (1.51–2.35) ,.01 1.29 (1.00–1.66) .05
OR, odds ratio; Ref, referent group; STI, sexually transmitted infection.
* Adjusted for variables listed.
†
Analyses restricted to 3,257 women who were tested during pregnancy.

the proportion retested (C trachomatis 73%, N gonorrhea DISCUSSION

85%, co-infection 85%, P5.06) did not differ signifi-
cantly by STI diagnosis. The only demographic or
clinical variable that was associated with time to treat-
ment and tests of reinfection in bivariate analysis was
increasing gestational age (in weeks) at diagnosis. In
a Cox model with only gestational age, treatment haz-
ard ratio was 1.03 (95% CI 1.02–1.04) and test of rein-
fection hazard ratio was 1.04 (95% CI 1.02–1.05).
A higher proportion of our study population was
screened for C trachomatis and N gonorrhea infection in
pregnancy (97%) compared with previous reports of
screening rates of approximately 60% for both STIs
based on U.S. laboratory data.19 Women with Med-
icaid insurance were more likely to be tested.
Although factors associated with STI screening have
not been specifically studied in pregnancy, our

804 Goggins et al Chlamydia trachomatis and N gonorrhea in Pregnancy OBSTETRICS & GYNECOLOGY

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Unauthorized reproduction of this article is prohibited.
Fig. 2. Distribution of time to treat-
ment in weeks.
Goggins. Chlamydia trachomatis and N
gonorrhea in Pregnancy. Obstet Gynecol
2020.

findings support previous research in nonpregnant documentation of previous screening. Additionally,

patients, which has shown increased odds of accepting
C trachomatis testing by those with public insurance.20
Patient language has also been associated with STI
risk assessment, but language was not significant in
our adjusted model.21
Less-than-adequate prenatal care and transfer of
care were associated with not being tested for C tra-
chomatis and N gonorrhea infection. This finding may be
due in part to health care providers assuming that
patients who transferred care were screened at the
previous institution or patients reporting or providing
women with inadequate prenatal care may be more
likely to have other immediately pressing issues to
address in a clinic visit of limited duration. Although
it is unsurprising that prenatal care adequacy is asso-
ciated with lack of testing, this finding reveals an
opportunity to remind clinicians or implement stan-
dard checklists to ensure screening is offered.
Our measured prevalence of 11% for C trachoma-
tis and 3% for N gonorrhea infection is higher than the
national median of 8% and 1%, respectively.6 Several
demographic and clinical characteristics were

Fig. 3. Distribution of time to test of

reinfection in weeks.
Goggins. Chlamydia trachomatis and N
gonorrhea in Pregnancy. Obstet Gynecol
2020.

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associated with testing positive including age, race–
ethnicity, primary language, alcohol use, and history
of STIs. Though younger age was a risk factor for
infection, 39% of those who tested positive were 25
years of age or older. Limiting screening to risk al-
gorithms may miss many infections, especially in
similar high-risk populations.
Many women experienced delays in treatment
and tests of reinfection, though these delays were not
associated with demographic or clinical characteristics
with the exception of gestational age at diagnosis. This
association may reflect that testing later in pregnancy
more often occurs in triage rather than during
scheduled prenatal care visits at our institution, and
the lack of continuity makes timely follow-up of
abnormal results more difficult. Moreover, during
the study period, results from triage visits were not
sent directly to health care providers’ inboxes as clinic
test results were. Though the majority of patients were
treated, fewer patients with N gonorrhea infection were
treated compared with C trachomatis alone, possibly
due to the need to present in person for intramuscular
ceftriaxone.
Information from this study is being used at our
hospital for health care provider education and to
help streamline processes for identification and treat-
ment of abnormal lab results. Results from triage tests
are now sent to the ordering provider’s inbox. Point-
of-care testing may be an opportunity to expedite
treatment by eliminating the major barriers to timely
treatment identified in this study. There are several
commercially available point-of-care testing modali-
ties available for C trachomatis and N gonorrhea infec-
tion, and their use has been shown to decrease time to
treatment in low-resource settings.22 These tests are
highly specific, but sensitivity varies widely, ranging
from 13% to greater than 90%.23–27 Emerging tech-
nology is focused on offering point-of-care tests with
high sensitivity and specificity and validating their use
and cost-effectiveness in the clinical setting.26,27 More-
over, fewer than a third of treated patients in our study
received a test of reinfection during the recommended
timeframe, and 15% of women diagnosed with C tra-
chomatis or N gonorrhea infection had more than one
infection during their pregnancies. Retesting after
treatment and partner treatment are critical, and expe-
dited partner therapy should be considered in appro-
priate settings.28
This study has some important limitations. First,
we focused on a high-risk, medically underserved
population, and, although our findings may not be
generalizable to all pregnant women, they are relevant
to understanding what factors associated with STI
806 Goggins et al Chlamydia trachomatis and N gonorrhea in Pregnancy
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
screening and positivity may be modifiable among
women at greatest risk for STIs. Moreover, prenatal
care is delivered at our hospital by trainees and
rotating residents and our findings may not be
generalizable outside of similar academic practices.
Additionally, we excluded tests of reinfection before
21 days after treatment. However, a subset of women
had a negative test of reinfection during this time
period, and this may affect our evaluation of time to
test of reinfection. Finally, reasons for delays in
treatment were abstracted from the medical record
and may not be fully understood. Strengths of our
study include the large sample size and detailed
information on patient demographics, clinical history,
and STI diagnoses and treatment obtained from
medical record review. Although the sample size
was overall high, subsets of the analysis dealt with
small numbers, raising the issue of decreased power
for nonsignificant associations and possible over-
fitting. To address this, we reran the adjusted models
excluding variables with low counts and found that all
adjusted point estimates changed by less than 10%.
This study highlights the need for continued STI
risk assessment and follow-up of positive results,
especially in high-risk populations. It adds to the
existing STI literature by describing patterns of
positivity, treatment, and retesting in a pregnant
population and identifying potential avenues for
improved clinical management. Strong promotion of
prenatal care and proactive outreach is important to
improve prenatal care adequacy as well as STI
detection and treatment. Given the effect of treatment
on reducing risks for adverse pregnancy outcomes,
routine screening in areas with high STI prevalence is
imperative.
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PEER REVIEW HISTORY
Received November 15, 2019. Received in revised form December
27, 2019. Accepted January 9, 2020. Peer reviews and author cor-
respondence are available at http://links.lww.com/AOG/B785.
Chlamydia trachomatis and N gonorrhea in Pregnancy 807