Review

Managing sexually transmitted infections

in pregnant women
Nadi K Gupta* & Christine A Bowman
Sexually transmitted infections (STIs) constitute a major public health problem in the UK and may
result in very costly complications. Many STIs pose the risk of a number of adverse pregnancy
outcomes including miscarriage, still birth, preterm delivery, low birth weight and ophthalmia
neonatorum. National guidelines for the management of STIs are produced and regularly revised
by the British Association of Sexual Heath and HIV. This review outlines the latest recommended
treatment options during pregnancy for the commonly encountered STIs.

Sexually transmitted infections (STIs) consti- Bacterial infections

tute a major public health problem, not only
in the UK but worldwide. A 2003 House of
Commons Health Select Committee inquiry
into sexual health described a sexual health cri-
sis in the UK that amounted to a public health
emergency [1] .
The number of newly diagnosed STIs in
England remained high at 418,598 cases
between 2008 and 2010 [101] . Many STIs pose
the risk of a number of adverse pregnancy out-
comes including miscarriage, still birth, pre-
term delivery, low birth weight and ophthalmia
neonatorum. Effective management is impera-
tive as STIs can be detrimental to both the
mother and baby and can result in very costly
complications.
Drugs selected for treatment should not be
contraindicated in pregnant women, should
have a high efficacy and be well tolerated.
The common STIs that are known to have
significant implications in pregnancy are
Chlamydia trachomatis, Neisseria gonorrhoeae,
human papilloma virus (HPV), herpes sim-
plex virus (HSV), Trichomonas vaginalis and
syphilis. This review outlines the treatment
options during pregnancy for the commonly
encountered STIs. NICE has produced guid-
ance for the routine antenatal care of healthy
pregnant women, which includes specific
recommendations for STI screening [102] .
National guidelines for the management of
STIs are produced and regularly revised by
the British Association of Sexual Heath and
HIV (BASHH) [103] . Readers are encouraged
to review both NICE and BASHH guidelines
for more comprehensive information.
It is beyond the remit of this article to dis-
cuss the management of HIV and hepatitis B
during pregnancy.
C. trachomatis
C. trachomatis is an obligate intracellular bac-
terium of which there are several serotypes. It
is the most common bacterial STI in the UK,
with the highest rates in patients under 25 years
of age. Furthermore, results from the National
Chlamydia Screening Programme demonstrated
a high level of asymptomatic infection [101] .
Complications in women include pelvic inflam-
matory disease, ectopic pregnancy and infertil-
ity. Chlamydia, like other acute bacterial and
viral STIs, is associated with increased risk of
both HIV transmission and acquisition [2] .
Untreated cervical chlamydia during preg-
nancy is associated with an increased risk of
preterm delivery and premature rupture of
membranes [3] . Mother-to-child transmission
occurs at the time of vaginal birth and may
result in ophthalmia neonatorum and pneumo-
nitis in the infant and postpartum endometritis
in the mother.
Nucleic acid amplification testing is the gold
standard diagnostic method and offers high sen-
sitivity (90–95%) and specificity. Endocervical Department of Genitourinary
Medicine, Royal Hallamshire Hospital,
or vaginal swabs are the specimens of choice and Sheffield Teaching Hospitals NHS Trust,
are of equivalent sensitivity. Glossop Road, Sheffield, S10 2JF, UK
*Author for correspondence:
Tel.: +44 114 271 1900 ext. 13528
Treatment of chlamydia during nadi.gupta@sth.nhs.uk
pregnancy
Erythromycin is safe for use in pregnancy but
has a significant side-effect profile and is less Keywords
efficacious (<95%) than azithromycin. The
• pregnant women • sexually
WHO recommends the use of azithromycin transmitted infections • treatment
in pregnancy. The British National Formulary guidelines
recommends the use of azithromycin in preg-
nant women only if no alternative is available,
although the data that are available support its
safety. When compared with erythromycin,
meta-analysis showed amoxycillin to have a part of

10.2217/WHE.12.16 © 2012 Future Medicine Ltd Women's Health (2012) 8(3), 313–321 ISSN 1745-5057 313
Review – Gupta & Bowman
similar cure rate and a better side-effect pro-
file [4] . However, penicillin has been shown to
induce chlamydial latency in vitro. Tetracyclines
are contraindicated in pregnancy because of
the risk of bone and dental abnormalities in
the infant.
Recommended regimens for chlamydia during
pregnancy can be found in Box 1.
Contact tracing of sexual partners must be
pursued and patients should be advised to avoid
any – including condom protected – sexual inter-
course for at least 7 days after both the patient
and their sexual partner(s) have completed treat-
ment. A repeat swab for test of cure is recom-
mended for all pregnant women 6 weeks after
treatment [102] . It is the authors’ practice to
rescreen in the third trimester.
Gonorrhea
Gonorrhea is caused by the Gram-negative
diplococcus N. gonorrhoeae. It is the second
most common bacterial STI in the UK [101] .
Up to 50% of women may be asymptomatic
and may not present until complications such
as pelvic inflammatory disease are present [5] .
Gonorrhea is associated with serious sequelae
such as infertility, ectopic pregnancy, chronic
pelvic pain and disseminated gonococcal
infection.
Preterm delivery, premature rupture of
membranes, chorioamnionitis and postpartum
infection are more common in pregnant women
with untreated gonorrhea [6] . Gonorrhea is
transmitted to the newborn from the moth-
ers’ genital tract during birth and can cause
ophthalmia neonatorum and systemic neonatal
infection.
Diagnosis is often made using nucleic acid
amplification testing. These are highly sensi-
tive tests (>96%) [7,8] . Endocervical and vagi-
nal swabs are of equivalent sensitivity [9] . False
positives may occur, however. Confirmatory
culture for gonococcus is essential to allow anti­
microbial sensitivity testing, which is of para-
mount importance given increasing antibiotic
resistance.
Box 1. Recommended regimens for
chlamydia during pregnancy.
• Azithromycin 1 g oral single dose
(recommended by WHO)
• Erythromycin 500 mg p.o. for 7 days
• Erythromycin 500 mg p.o. for 14 days
• Amoxycillin 500 mg p.o. for 7 days
p.o.: Per os.
314 www.futuremedicine.com
Treatment of gonorrhea during
pregnancy
There is growing concern regarding the resis-
tance and decreasing sensitivity of the gonococ-
cus to many classes of antibiotics. Patients with
gonorrhea frequently have concomitant infec-
tion with chlamydia. Intramuscular (im.) cef-
triaxone plus cotreatment with azithromycin
is now the first-line recommended treatment.
Azithromycin is recommended as cotreatment
irrespective of the results of chlamydia testing in
order to prevent the emergence of cephalosporin
resistance [10] . There is evidence to suggest syn-
ergy between azithromycin and cephalosporins
[11] . Furthermore, pharyngeal gonorrhea may be
more effectively eradicated with azithromycin
cotreatment [12] .
Oral cefixime plus cotreatment with azithro-
mycin is an alternative to im. ceftriaxone. In
2010, 6.3% of gonococcal isolates demonstrated
decreased susceptibility to cefixime and in 2009,
0.3% to ceftriaxone [101] . A total of 35.7% of
isolates were resistant to ciprofloxacin in 2010
[101] . Moreover, quinolones are contraindicated
in pregnancy.
Recommended regimens for gonorrhea during
pregnancy can be found in Box 2 .
Partner notification must be pursued and
patients are advised to abstain from sexual
intercourse until they and their partners have
been successfully treated. A test of cure is rec-
ommended 1 week after treatment in all cases
in view of concerns regarding emerging resis-
tance. It is the authors’ practice to advise repeat
screening in the third trimester.
Syphilis
Syphilis is caused by the spirochete Treponema
pallidum. The incubation period of primary
syphilis is 9–90 days. The primary ulcer (chan-
cre) usually occurs at the site of inoculation,
which is usually the genital or perianal area. The
lesion is classically solitary and painless but can
be multiple and painful. The primary chancre
spontaneously resolves after a few weeks and
may go unnoticed. Secondary syphilis develops
4–8 weeks later. It has a wide variety of presen-
tations and may mimic many other diseases and
may be easily misdiagnosed as glandular fever
or another similar viral illness. Clinical features
of secondary syphilis include rash, lymphad-
enopathy, mouth ulcers, fever and malaise. The
symptoms and signs resolve without treatment.
Long-term complications of untreated syphilis
are neurological disease, cardiovascular disease
and gummata (granulomatous skin lesions).
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 Managing sexually transmitted infections in pregnant women –
Box 2. Recommended regimens for gonorrhea during pregnancy.
• Ceftriaxone 500 mg im. injection plus azithromycin 1 g single oral dose
• Cefixime 400 mg single oral dose plus azithromycin 1 g single oral dose (in those who refuse im.
injection)
• Spectinomycin 2 g im. single dose plus azithromycin 1 g single oral dose (in those who are allergic to
penicillin or b-lactam)
im. Intramuscular.
There has been a marked increase in the num-
ber of cases of early syphilis observed since the
late 1990s. There were a total of 2318 cases of
early infectious syphilis diagnosed in England
in 2010, albeit predominantly in men who have
sex with men [101] . However, antepartum syphilis
can have devastating consequences, resulting in
preterm labor, polyhydramnios, hydrops, fetal
death and congenital syphilis. Syphilis may be
transmitted to the baby via the transplacental
route at any stage of pregnancy.
In view of the potential profound adverse
effects of syphilis during pregnancy it is recom-
mended that all pregnant women in the UK
are screened for syphilis at the initial antenatal
appointment. Repeat serological testing may
be indicated in women at high risk of syphilis,
for example, those with sexual partners from
high-risk groups or commercial sex workers.
Diagnosis and staging of disease is based
on history, clinical examination and serology.
Serology involves treponemal-specific tests
and non­treponemal tests. Treponemal-specific
tests include treponemal enzyme immunoas-
say to detect IgG and IgM and T. pallidum
particle agglutination. These tests are specific
for T. pallidum and are reported as positive or
negative.
The nontreponemal tests include the Venereal
Disease Research Laboratory test and rapid
plasma reagin. Nontreponemal test titers usually
correlate with disease activity. False positives can
occur in many conditions including pregnancy.
Treatment of syphilis during pregnancy
The clinical management of syphilis should
be lead by a genitourinary medicine clinician.
All patients diagnosed with syphilis should
have their HIV test repeated. Treatment of
syphilis in pregnancy should be with parenteral
penicillin appropriate for the stage of syphilis.
Pregnant women with early-stage syphilis and
higher Venereal Disease Research Laboratory test
result have a higher risk of having an infant with
congenital syphilis after adequate treatment of
maternal syphilis [13,14] . Treatment in the last tri-
mester is also associated with increased likelihood
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Review
of congenital infection [13–16] . Parenteral peni-
cillin is the drug of choice as there are higher
failure rates with nonpenicillin alternatives.
Nonpenicillin alternatives include ceftriaxone,
erythromycin and azithromycin. Penicillin
desensitization should be considered in those
patients reporting penicillin allergy [17] .
The Jarisch–Herxheimer reaction may occur
just as for nonpregnant women. This may cause
uterine contractions and fetal heart rate decel-
erations, which spontaneously resolve within
24 h. Steroids are not effective in reducing these
effects and are usually only initiated 24 h prior
to antibiotic therapy for cardiovascular syphilis,
neurosyphilis or ophthalmological involvement
in order to prevent complications arising from
acute local inflammation.
Recommended regimens for syphilis during
pregnancy can be found in Box 3.
Box 3. Recommended regimens for syphilis during pregnancy.
Early syphilis
• First-line treatment
– Benzathine penicillin 2.4 MU im. single dose in the first and second trimesters
– Benzathine penicillin 2.4 MU im. two doses 1 week apart if maternal
treatment initiated in the third trimester
– Procaine penicillin G 600,000 units im. daily for 10 days
• Second-line treatment
– Amoxycillin 500 mg p.o. q.d.s. plus probenecid 500 mg p.o. q.d.s. for 14 days
– Ceftriaxone 500 mg im. daily for 10 days
– Azithromycin 500 mg p.o. daily for 10 days
– Erythromycin 500 mg p.o. q.d.s. for 14 days
Late syphilis (for late latent, cardiovascular or gummatous syphilis)
• First-line treatment
– Benzathine penicillin 2.4 MU im. weekly for 2 weeks (three doses)
– Procaine penicillin 600,000 units im. daily for 17 days
• Second-line treatment
– Amoxycillin 2 g p.o. t.d.s. plus probenicid 500 mg p.o. q.d.s. for 28 days
Neurosyphilis
• First-line treatment
– Procaine penicillin 1.8–2.4 MU im. daily plus probenecid 500 mg p.o. q.d.s.
for 17 days
– Benzylpenicillin 18–24 MU daily, given as 3–4 MU intravenously every 4 h for
17 days
• Second-line treatment
– Amoxycillin 2 g p.o. t.d.s. plus probenecid 500 mg p.o. q.d.s. for 28 days
– Ceftriaxone 2 g im. daily for 10–14 days.
im. Intramuscular; MU: Million units; p.o.: Per os; q.d.s.: Four-times daily; t.d.s.: Three-times daily.
Women's Health (2012) 8(3) 315
Review – Gupta & Bowman
Partner notification is essential. Management
should involve close liaison between genitouri-
nary medicine, obstetrics and pediatrics. Both
the mother and baby require close monitoring
and follow-up.
Viral infections
Genital herpes
Both HSV types 1 and 2 can cause genital her-
pes. Genital herpes is the most common ulcer-
ative STI in the UK. The presence of genital
ulcers also increases the likelihood of HIV
transmission [18] .
Disease episodes may be first-episode or
recurrent, and symptomatic or asymptomatic.
First-episode genital herpes is subdivided into
primary (newly acquired infection) and non­
primary infection (first clinical episode of a pre-
viously acquired herpes infection). It can be dif-
ficult to distinguish primary infection from the
first clinically apparent episode of a previously
acquired infection. Primary genital herpes can
be very painful and distressing. Most clinicians
make a clinical diagnosis and prescribe empirical
treatment after taking swabs for HSV. Full STI
and HIV screening is important, but swabs are
usually deferred until the lesions have healed.
The diagnosis is confirmed by obtaining
a swab from the base of an ulcer. HSV DNA
detection by PCR is more sensitive than culture
[19] . PCR can distinguish HSV-1 from HSV-2.
Serology can be difficult to interpret and may not
become positive for 6–8 weeks after a primary
episode. Routine serology has poor specificity.
Type-specific serology is expensive and type-
1-seropositivity fails to differentiate between
oropharyngeal and genital herpes infections.
The main risks of genital herpes during preg-
nancy are first or second trimester miscarriage
and neonatal herpes. The highest risk of neonatal
herpes is in women who acquire HSV during the
third trimester. A prospective study of 58,000
women in the USA found 202 cases where HSV
was isolated at the time of labor [20] . There were
ten cases of neonatal herpes. Transmission is
usually from direct contact with the virus dur-
ing delivery; in utero transmission can occur but
is rare. Untreated neonatal herpes is associated
with a high mortality and can cause disability
even with appropriate timely treatment.
Treatment of HSV in pregnancy
General advice includes saline bathing and
analgesia. Management of genital herpes in
pregnancy is determined by the gestation of the
pregnancy at the time of herpes acquisition and
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can be categorized into management of first epi-
sodes and recurrent episodes. However, this can
be difficult to distinguish clinically. Obtaining
paired serum samples for type-specific serology
several weeks apart may be useful to demonstrate
seroconversion (i.e., recent infection).
First-episode genital herpes in first or second
trimester
If first-episode genital herpes occurs in the first
or second trimester, there is an association with
miscarriage but there is no conclusive evidence
that it causes birth defects. A 3–5 day course of
aciclovir should be used to reduce the severity
and duration of the episode. Although aciclovir
is not licensed for use in pregnancy, it appears
to be relatively safe [21] .
Prophylactic suppressive aciclovir from
36 weeks gestation may be considered in order
to reduce the likelihood of a HSV outbreak
at labor, ultimately reducing the likelihood of
Cesarean section [22] .
In the absence of lesions or prodromal
symptoms at labor, vaginal delivery should be
anticipated.
First-episode genital herpes in third trimester
The risk of neonatal herpes is greatest when the
mother acquires herpes in the third trimester. The
mother acquires herpes but is unable to develop
IgG antibodies before delivery and so the baby
is born without the protection of passive immu-
nity. In this situation, there is a 30–50% risk
of neonatal herpes [22,23] . Therefore, all women
with first-episode genital herpes at the time of
delivery or within 6 weeks of the expected date
of delivery should be offered Cesarean section
[102] . However, there are no published random-
ized controlled trials evaluating the effective-
ness of Cesarean section for the prevention of
neonatal herpes.
Recurrent genital herpes
Pregnant women who acquired HSV prior to
pregnancy will already have IgG antibodies to
HSV and will pass these antibodies to the fetus.
Neonatal herpes is uncommon in this situation.
If there are HSV lesions at the time of vaginal
birth, the risk of neonatal herpes is reported to
be 2–5% [24] . There is a small risk of asymptom-
atic shedding and the risk of neonatal herpes in
these cases is reported to be 0.02–0.05% [24,25] .
Suppressive aciclovir should be considered from
36 weeks until delivery in order to prevent clini-
cal recurrences and therefore reduce the need for
Cesarean section [26] . Cesarean section should be
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 Managing sexually transmitted infections in pregnant women –
considered if there are genital lesions at the onset
of labor. Vaginal delivery should be anticipated if
there are no lesions present at delivery. The risk
of neonatal herpes following vaginal delivery is
small and one must balance this against the risk
of Cesarean section to the mother [24] .
Recommended regimens for HSV can be
found in Box 4 (see text as above).
HPV
Genital warts are caused by infection with HPV
and are the most prevalent viral STI diagnosed
in the UK. Infection may not be clinically
apparent.
There are over 100 documented HPV geno­
types of which approximately 40 are tropic
for anogenital skin. Most anogenital warts are
benign; however, there are certain genotypes
that are associated with an increased risk of
anogenital neoplasia, specifically, genotypes 16
and 18 are associated with the greatest risk.
External warts are generally due to types 6 and
11, which are not considered to be oncogenic.
However, warts can also be caused by other
oncogenic strains [27,28] . The most important
risk of HPV infection to women is the risk of
anogenital cancer. The recent introduction of
HPV vaccination programs has led to a sig-
nificant decrease in high-grade smear abnor-
malities [29] . Quadrivalent HPV vaccination
has also resulted in decreased incidence of
genital warts [30] .
Genital warts may increase in size and num-
ber during pregnancy. The diagnosis is usu-
ally made clinically upon visual inspection.
Maternal infection is associated with juvenile
laryngeal papillomatosis in the infant. This
is a rare condition that can cause hoarseness
and respiratory distress in children. Cesarean
section is not indicated in mothers with geni-
tal warts as vertical transmission of HPV is
rare [31] .
Treatment of HPV during pregnancy
The same as in nonpregnant patients, treat-
ment is usually for cosmetic rather than medi-
cal purposes in the majority of cases. Treatment
is only really necessary in the unlikely event
that the warts cause obstruction of the birth
canal and impede vaginal delivery. All treat-
ments have significant failure and relapse rates
[32] and no single treatment is considered to be
better than another. Cryotherapy with liquid
nitrogen causes cytolysis at the dermo–epider-
mal junction and is safe for use in pregnancy.
A freeze/thaw technique should be employed,
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Review
Box 4. Recommended regimens for
herpes simplex virus.
Episodic treatment
• Aciclovir 400 mg t.d.s. p.o. for 3–5 days
Suppressive treatment (from 36 weeks)
• Aciclovir 400 mg b.i.d. p.o. until delivery
b.i.d.: Twice-daily; p.o.: Per os; t.d.s.: Three-times daily.
whereby liquid nitrogen is applied for approxi-
mately 10 s until a halo of freeze develops a few
millimetres around the wart. This is repeated
three or more times for each lesion during the
treatment session. Cryotherapy can be adminis-
tered every 1–2 weeks. Lesions may regress after
delivery without any treatment. Podophyllin,
podophyllotoxin and imiquimod should be
avoided in pregnancy. Contact tracing is not
required.
Protozoal infections
T. vaginalis
T. vaginalis is a flagellated protozoan. Women
may experience offensive discharge, dysuria
and vulval irritation but may also be asymp-
tomatic. Infection in pregnancy is associated
with premature delivery and low birth weight
[33,34] . Neonatal infection is uncommon but
should be considered in infants with vaginal
discharge or unexplained respiratory disease.
Nasal secretions, tracheal secretions, urine and
vaginal swabs from the neonate should be closely
examined for trichomonads [35] .
The diagnosis is confirmed by direct micros-
copy of a wet-mount preparation of vaginal
secretions from the posterior fornix. This
method of diagnosis is routinely employed in
genitourinary medicine clinics. Microscopy has
a sensitivity of approximately 70% [36] . Culture
of vaginal secretions using specific media is more
sensitive but rarely available now. Highly sensi-
tive PCR techniques have been developed but
are not yet in routine use.
Treatment of T. vaginalis during
pregnancy
Metronidazole is the drug of choice and is highly
efficacious. Metronidazole appears to be safe for
use during the first trimester of pregnancy [37] .
The British National Formulary advises avoiding
high-dose metronidazole in pregnancy. Patients
should be advised to abstain from alcohol while
taking metronidazole and for 48 h afterwards
because of possible disulfiram-like reaction.
Recommended regime for T. vaginalis can be
found in Box 5.
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Review – Gupta & Bowman
Box 5. Recommended regime for
Trichomonas vaginalis.
• Metronidazole 400–500 mg b.i.d. p.o. for
5–7 days
b.i.d.: Twice-daily; p.o.: Per os.
Patients should be advised to abstain from
intercourse until they and their partner have been
successfully treated. It is the authors’ practice to
perform a test of cure 1 week later in all cases.
Other
Bacterial vaginosis
Bacterial vaginosis is not regarded as an STI but
its prevalence is higher in sexually active women.
Bacterial vaginosis is a condition resulting from
replacement of the usual H 2O2 lactobacilli
in the vagina with anaerobic bacteria such as
Mobiluncus sp. and Gardnerella vaginalis. It is a
common cause of vaginal discharge in women
of childbearing age but 50% of patients may be
asymptomatic. A prevalence rate of 12% was
found in pregnant women attending an antena-
tal clinic in the UK [38] . The patho­physiology,
particularly in the context of pregnancy, is poorly
understood [39] . Bacterial vaginosis is associated
with increased risk of preterm delivery, post-
partum endometritis and pelvic inflammatory
disease [40] .
The diagnosis can be confirmed using either
clinical (Amsel’s) criteria or Gram stain (Nugent
or Hay-Ison) criteria. Amsel’s criteria require at
least three out of four of the following to be
present: thin, white homogeneous discharge,
clue cells on microscopy of wet mount, pH of
vaginal fluid >4.5 or release of fishy odor upon
adding alkali (10% potassium hydroxide) [41] .
This so-called amine or ‘whiff’ test is not often
performed in genitourinary medicine clinics
now for health and safety reasons.
The Nugent score is determined by estimat-
ing the relative concentration of bacterial mor-
photypes that occur in bacterial vaginosis [42] .
UK guidelines recommend using the Hay-Ison
criteria:
• Grade 1/normal: Lactobacillus morphotypes
predominate;
Box 6. Recommended regime for
bacterial vaginosis in pregnancy.
• Metronidazole 400–500 mg b.i.d. p.o. for
5–7 days
b.i.d.: Twice-daily; p.o.: Per os.
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• Grade 2/intermediate: mixed flora with some
lactobacilli present, but Gardnerella or
Mobiluncus morphotypes also present;
• Grade 3/bacterial vaginosis: predominantly
Gardnerella and/or Mobiluncus with few or
absent lactobacilli [43] .
Treatment of bacterial vaginosis in
pregnancy
Symptomatic women should be treated.
However, the same as in nonpregnant women,
asymptomatic pregnant women may opt for
treatment if offered.
There are conflicting data regarding the value
of screening and treating bacterial vaginosis in
pregnancy. Evidence from systematic reviews
does not support the routine screening and treat-
ment of pregnant women with bacterial vagino-
sis [44] . However, other data suggest that screen-
ing and treating women at high risk for preterm
delivery based on their history may significantly
reduce the risk for preterm delivery [45–47] .
Metronidazole is the drug of choice and
has an estimated cure rate of at least 70% [48] .
Alcohol should be avoided during treatment
and for 48 h after to prevent a disulfiram-like
reaction.
Recommended regime for bacterial vaginosis
in pregnancy can be found in Box 6.
Routine screening and treatment of male sex-
ual partners is not required as studies have not
shown any effect on likelihood of relapse [49] .
Conclusion
Many STIs pose the risk of a number of adverse
pregnancy outcomes including miscarriage, still
birth, preterm delivery, low birth weight and
ophthalmia neonatorum. It should be empha-
sized that optimal management of any diagnosed
STIs in pregnancy should include screening for
other STIs and HIV, partner notification and fol-
low-up where appropriate. Close liaison between
genitourinary medicine, obstetrics and pediatrics
is imperative. Patients should be given a detailed
explanation of their condition with particular
emphasis on the long-term health implications
for themselves, their partners and the infant.
Early diagnosis and treatment of STIs not
only alleviates symptoms and reduces compli-
cations, but also reduces the period of infectivity
and onward transmission.
Future perspective
More emphasis needs to be placed on primary
prevention of STIs with healthcare workers
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 Managing sexually transmitted infections in pregnant women – Review

playing a key role in improving awareness and
promoting sexual health.
Increasing resistance to antibiotics, includ-
ing third-generation cephalosporins, will make
treatment for gonorrhea more challenging.
Current data regarding the value of screening
for bacterial vaginosis in pregnancy is conflict-
ing. More research is needed to identify if cer-
tain groups of pregnant women may benefit from
screening and treatment of bacterial vaginosis.
Currently, only HIV, syphilis and hepati-
tis B are routinely screened for in UK antenatal
clinics. Further work is needed to evaluate the
outcomes of screening for other STIs known to
have adverse effects in pregnancy.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial
involvement with any organization or entity with a finan-
cial interest in or financial conflict with the subject matter
or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or
options, expert testimony, grants or patents received or
pending, or royalties.
No writing assistance was utilized in the production of
this manuscript.

Executive summary
Background
• Sexually transmitted infections (STIs) constitute a major public health concern in the UK.
• STIs during pregnancy may be detrimental to both the mother and baby.
• Close liaison between genitourinary medicine, obstetrics and pediatrics is imperative.
• Effective management of an STI includes full screening for other STIs, a test of cure and partner notification where appropriate.
Bacterial infections
• Chlamydia trachomatis
– Chlamydia is the most common bacterial STI in the UK with the highest rates among under 25-year-olds.
– Asymptomatic carriage is common.
– Although azithromycin is not licensed for use in pregnancy, there are data to support its safety for use in pregnancy. It is also
recommended by the WHO as first-line treatment for chlamydia during pregnancy.
• Gonorrhea
– There are growing concerns regarding decreasing susceptibility of gonorrhea to third-generation cephalosporins.
– Intramuscular ceftriaxone with azithromycin cotreatment (regardless of chlamydia result) is now first-line treatment.
• Syphilis
– Pregnant women with early-stage syphilis and higher Venereal Disease Research Laboratory result are at higher risk of having an
infant with congenital syphilis.
– Treatment in the last trimester is also associated with increased likelihood of congenital infection.
– Parenteral penicillin is the treatment of choice for all stages of syphilis.
Viral infections
• Herpes simplex virus
– Risk of neonatal herpes is greatest when the mother acquires herpes simplex infection in the third trimester of pregnancy.
– Neonatal herpes is uncommon in women with known recurrent genital herpes.
– Data from the Aciclovir Pregnancy Registry support its safety for use in pregnant women.
• Human papilloma virus
– Warts may increase in size and number during pregnancy.
– Genital warts are usually treated for cosmetic reasons.
– It is unusual for warts to enlarge to the degree that would obstruct vaginal delivery.
– Cryotherapy with liquid nitrogen is safe for use in pregnancy.
– Recent introduction of a quadrivalent human papilloma virus vaccine has led to a falling incidence of high-grade cervical smear
abnormalities and genital warts.
Protozoal infection
• Trichomonas vaginalis
– Infection during pregnancy is associated with prematurity and low birth weight.
– Metronidazole is the drug of choice.
Other
• Bacterial vaginosis
– Bacterial vaginosis is not regarded as an STI, however, it carries an increased risk of preterm delivery, postpartum endometritis and
pelvic inflammatory disease.
– Metronidazole is the drug of choice.
– There are conflicting data regarding the value of screening and treating bacterial vaginosis in pregnancy. Current UK guidelines do
not support the routine screening of pregnant women.

future science group Women's Health (2012) 8(3) 319

Review – Gupta & Bowman
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