Sexually Transmitted Infections in Pregnancy: A Narrative Review of the Global Research Gaps, Challenges, and Opportunities

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Abstract

Curable sexually transmitted infections in pregnant women may cause poor maternal and newborn outcomes worldwide. Syndromic management is practiced in many settings yet fails to identify most infections. Etiologic screening has promise, but further effectiveness and cost-effectiveness studies are needed.

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Background

Sexually transmitted infections (STI), such as chlamydial, gonorrheal, and trichomonal infections, are prevalent in pregnant women in many countries and are widely reported to be associated with increased risk of poor maternal and neonatal outcomes. Syndromic STI management is frequently used in pregnant women in low- and middle-income countries, yet its low specificity and sensitivity lead to both overtreatment and undertreatment. Etiologic screening for chlamydial, gonorrheal, and/or trichomonal infection in all pregnant women combined with targeted treatment might be an effective intervention. However, the evidence base is insufficient to support the development of global recommendations. We aimed to describe key considerations and knowledge gaps regarding chlamydial, gonorrheal, and trichomonal screening during pregnancy to inform future research needed for developing guidelines for low- and middle-income countries.

Methods

We conducted a narrative review based on PubMed and clinical trials registry searches through January 20, 2020, guidelines review, and expert opinion. We summarized our findings using the frameworks adopted by the World Health Organization for guideline development.

Results

Adverse maternal-child health outcomes of potential interest are wide-ranging and variably defined. No completed randomized controlled trials on etiologic screening and targeted treatment were identified. Evidence from observational studies was limited, and trials of presumptive STI treatment have shown mixed results. Subgroups that might benefit from specific recommendations were identified. Evidence on harms was limited. Cost-effectiveness was influenced by STI prevalence and availability of testing infrastructure and high-accuracy/low-cost tests. Preliminary data suggested high patient acceptability.

Discussion

Preliminary data on harms, acceptability, and feasibility and the availability of emerging test technologies suggest that etiologic STI screening deserves further evaluation as a potential tool to improve maternal and neonatal health outcomes worldwide.

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Most cited references 29

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Sexually transmitted infections: challenges ahead.

Magnus Unemo, Catriona S. Bradshaw, Jane Hocking … (2017)

WHO estimated that nearly 1 million people become infected every day with any of four curable sexually transmitted infections (STIs): chlamydia, gonorrhoea, syphilis, and trichomoniasis. Despite their high global incidence, STIs remain a neglected area of research. In this Commission, we have prioritised five areas that represent particular challenges in STI treatment and control. Chlamydia remains the most commonly diagnosed bacterial STI in high-income countries despite widespread testing recommendations, sensitive and specific non-invasive testing techniques, and cheap effective therapy. We discuss the challenges for chlamydia control and evidence to support a shift from the current focus on infection-based screening to improved management of diagnosed cases and of chlamydial morbidity, such as pelvic inflammatory disease. The emergence and spread of antimicrobial resistance in Neisseria gonorrhoeae is globally recognised. We review current and potential future control and treatment strategies, with a focus on novel antimicrobials. Bacterial vaginosis is the most common vaginal disorder in women, but current treatments are associated with frequent recurrence. Recurrence after treatment might relate to evidence that suggests sexual transmission is integral to the pathogenesis of bacterial vaginosis, which has substantial implications for the development of effective management approaches. STIs disproportionately affect low-income and middle-income countries. We review strategies for case management, focusing on point-of-care tests that hold considerable potential for improving STI control. Lastly, STIs in men who have sex with men have increased since the late 1990s. We discuss the contribution of new biomedical HIV prevention strategies and risk compensation. Overall, this Commission aims to enhance the understanding of some of the key challenges facing the field of STIs, and outlines new approaches to improve the clinical management of STIs and public health.

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Committee Opinion No 700: Methods for Estimating the Due Date.

(2017)

Accurate dating of pregnancy is important to improve outcomes and is a research and public health imperative. As soon as data from the last menstrual period, the first accurate ultrasound examination, or both are obtained, the gestational age and the estimated due date (EDD) should be determined, discussed with the patient, and documented clearly in the medical record. Subsequent changes to the EDD should be reserved for rare circumstances, discussed with the patient, and documented clearly in the medical record. A pregnancy without an ultrasound examination that confirms or revises the EDD before 22 0/7 weeks of gestational age should be considered suboptimally dated. When determined from the methods outlined in this document for estimating the due date, gestational age at delivery represents the best obstetric estimate for the purpose of clinical care and should be recorded on the birth certificate. For the purposes of research and surveillance, the best obstetric estimate, rather than estimates based on the last menstrual period alone, should be used as the measure for gestational age.

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Is Open Access

The GRADE Evidence to Decision (EtD) framework for health system and public health decisions

Jenny Moberg, Andrew D Oxman, Sarah Rosenbaum … (2018)

Objective To describe a framework for people making and using evidence-informed health system and public health recommendations and decisions. Background We developed the GRADE Evidence to Decision (EtD) framework for health system and public health decisions as part of the DECIDE project, in which we simultaneously developed frameworks for these and other types of healthcare decisions, including clinical recommendations, coverage decisions and decisions about diagnostic tests. Developing the framework Building on GRADE EtD tables, we used an iterative approach, including brainstorming, consultation of the literature and with stakeholders, and an international survey of policy-makers. We applied the framework to diverse examples, conducted workshops and user testing with health system and public health guideline developers and policy-makers, and observed and tested its use in real-life guideline panels. Findings All the GRADE EtD frameworks share the same basic structure, including sections for formulating the question, making an assessment and drawing conclusions. Criteria listed in the assessment section of the health system and public health framework cover the important factors for making these types of decisions; in addition to the effects and economic impact of an option, the priority of the problem, the impact of the option on equity, and its acceptability and feasibility are important considerations that can inform both whether and how to implement an option. Because health system and public health interventions are often complex, detailed implementation considerations should be made when making a decision. The certainty of the evidence is often low or very low, but decision-makers must still act. Monitoring and evaluation are therefore often important considerations for these types of decisions. We illustrate the different components of the EtD framework for health system and public health decisions by presenting their application in a framework adapted from a real-life guideline. Discussion This framework provides a structured and transparent approach to support policy-making informed by the best available research evidence, while making the basis for decisions accessible to those whom they will affect. The health system and public health EtD framework can also be used to facilitate dissemination of recommendations and enable decision-makers to adopt, and adapt, recommendations or decisions. Electronic supplementary material The online version of this article (10.1186/s12961-018-0320-2) contains supplementary material, which is available to authorized users.

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Author and article information

Contributors

Juliana S. Grant

R. Matthew Chico

Anne CC. Lee

Nicola Low

Andrew Medina-Marino

Rose L. Molina

Chelsea Morroni

Doreen Ramogola-Masire

Chrysovalantis Stafylis

Weiming Tang

Andrew J. Vallely

Adriane Wynn

Nava Yeganeh

Jeffrey D. Klausner

Journal

Journal ID (nlm-ta): Sex Transm Dis

Journal ID (iso-abbrev): Sex Transm Dis

Journal ID (publisher-id): OLQ

Title: Sexually Transmitted Diseases

Publisher: Lippincott Williams & Wilkins

ISSN (Print): 0148-5717

ISSN (Electronic): 1537-4521

Publication date (Print): December 2020

Publication date (Electronic): 10 August 2020

Volume: 47

Issue: 12

Pages: 779-789

Affiliations

From the [∗ ]Public Health Nerds, LLC, Seattle, WA

[† ]Department of Disease Control, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Topical Medicine, London, United Kingdom

[‡ ]Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

[§ ]Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland

[¶ ]Research Unit, Foundation for Professional Development, East London, South Africa; The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa

[∥ ]Obstetrics, Gynecology, and Reproductive Biology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA

[∗∗ ]Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom; Botswana Harvard AIDS Institute, Gaborone, Botswana; Botswana UPenn Partnership, Gaborone, Botswana; Women’s Health Research University, School of Public Health and Family Medicine, University of Cape Town, South Africa

[†† ]Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Botswana, Gabarone, Botswana

[‡‡ ]Department of Obstetrics and Gynecology, Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA

[§§ ]Division of Infectious Diseases, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA

[∥∥ ]University of North Carolina Project-China

[¶¶ ]Dermatology Hospital of Southern Medical University, Guangzhou, China

[∗∗∗ ]Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea

[††† ]Kirby Institute, University of New South Wales, Sydney, Australia

[§§§ ]Division of Infectious Diseases and Global Public Health, University of California, San Diego, San Diego

[‡‡‡ ]Pediatric Infectious Disease, David Geffen School of Medicine

[¶¶¶ ]Division of Infectious Diseases and Department of Epidemiology, University of California, Los Angeles David Geffen School of Medicine and Fielding School of Public Health, Los Angeles, CA

Author notes

[*]Correspondence: Jeffrey D. Klausner, MD, MPH, Division of Infectious Disease and Department of Epidemiology, UCLA David Geffen School of Medicine and Fielding School of Public Health, 10920 Wilshire Blvd, Los Angeles, CA 90025. E-mail: JDKlausner@ 123456mednet.ucla.edu .

Article

Publisher ID: OLQ50947 Accession ID: 00001

DOI: 10.1097/OLQ.0000000000001258

PMC ID: 7668326

PubMed ID: 32773611

SO-VID: 714c397e-7793-4477-afa9-870411924103

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

History

Date received : 08 March 2020

Date accepted : 21 July 2020

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Sexually Transmitted Infections in Pregnancy: A Narrative Review of the Global Research Gaps, Challenges, and Opportunities

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Abstract

Background

Methods

Results

Discussion

Related collections

HLA-G and immune tolerance in pregnancy

Most cited references 29

Sexually transmitted infections: challenges ahead.

Committee Opinion No 700: Methods for Estimating the Due Date.

The GRADE Evidence to Decision (EtD) framework for health system and public health decisions

Author and article information

Contributors

Journal

Affiliations

Author notes

Article

History

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Custom metadata

Comments

Comment on this article

Similar content 123

Cited by 13

Most referenced authors 310