All women and men of reproductive age will achieve optimal health and wellness, fostering a healthy life course for them and any children they may have.Background
- Some infections are potentially harmful in pregnancy both to the mother and fetus. These infections include:
- Chlamydia
- Cytomegalovirus
- Gonorrhea
- Hepatitis B
- Hepatitis C
- HIV
- HPV
- HSV
- Influenza
- Listeriosis
- Malaria
- Rubella
- Syphilis
- Tetanus, Diphtheria, Pertussis
- Toxoplasmosis
- Tuberculosis
- Varicella
- For some diseases, insufficient evidence exists to determine the benefits of screening and treatment relative to pregnancy outcomes. Examples include:
- Antibody testing for type-specific HSV in discordant couples;
- Screening for Toxoplasmosis and Cytomegalovirus to determine susceptibility to new infection;
- Screening and treatment for Bacterial Vaginosis (not proven to decrease preterm birth);
- Treatment of periodontal disease prior to or during pregnancy (not proven to decrease the incidence of pregnancy complications or preterm birth).
- The proven impact of some infections on pregnancy outcomes cannot be altered by preconception detection and treatment (examples include group B streptococcus, asymptomatic bacteriuria). For these conditions, the best way to reduce related reproductive risks is to test and treat during pregnancy and in the intrapartum period.
- All women of reproductive age should have their immunization status routinely assessed and updated. Immunity is important to:
- Protect all women from preventable morbidity and mortality including cervical dysplasia and cancers from HPV infections.
- Protect women who become pregnant from the increased severity of some communicable diseases in pregnancy (such in influenza and varicella).
- Decrease the risks of vertical transmission of some infectious diseases to the fetus, neonate and infant.
- Some vaccines contain a live virus and are contraindicated in pregnancy.
- The treatments for some infectious diseases pose teratogenic risks for the fetus which necessitates that treatment be undertaken and completed prior to conception to avoid this preventable risk.
- Choosing a contraceptive method compatible with the disease and treatment is essential to prevent conception during treatment.
- Sexually transmitted infections pose important risks for reproductive health (e.g. infertility) and childbearing which makes them especially important to address before pregnancy is attempted or achieved.
- A complete medical and sexual history should be obtained for all women to identify potential infectious disease exposures; for women who desire or are at risk for pregnancy, environmental risks for infectious diseases (e.g. cytomegalovirus, toxoplasmosis) should also be assessed although this strategy is of uncertain benefit.
- Infectious disease and immunization histories should be reviewed to determine likely immunity and needed immunizations.
- Provide indicated immunizations.
- If the specific practice is unable to administer routine immunizations it is essential the practice has a specific protocol in place to refer women for indicated immunizations as well as follow-up to determine if immunizations were received.
- Effective contraception should be encouraged and provided to women to prevent pregnancy until evaluation and treatment for an infectious disease has either been completed or the disease is under optimal control.
- Using patient’s history and CDC recommendations, test for STIs and treat appropriately.
- Do follow-up testing as recommended by CDC.
- Provide counseling on risk reduction strategies and safe sex practices.
- Vertical transmission of infection or acquisition at birth is an important consideration in the care of women who might become pregnant. Strategies to reduce the likelihood of vertical transmission include:
- Immunization when available for those at risk;
- Screening for specific diseases and treatment based on risk;
- Risk reduction strategies to reduce likelihood of primary infections:
- Prevention of acquisition through encouraging safer sex practices;
- Education about opportunities to alter lifestyle choices to reduce acquisition risk.
- Avoiding infectious diseases before and during early pregnancy provides an important opportunity to increase the chances of a health pregnancy and infant.
- Immunization status should be regularly assessed and updated for all reproductive age women to protect their own health.
- For all women irrespective of pregnancy plans the following are appropriate emphases for care:
- Assess risk for communicable diseases and follow-up with:
- Education on risk reduction strategies
- Indicated testing
- Appropriate treatment (coupled with contraception until treatment complete or the disease is under control (e.g. HIV).
- Assess risk for communicable diseases and follow-up with:
- For women planning pregnancy, consider moving the screenings for infectious diseases which are traditionally done during prenatal care to the preconception period. These screenings include:
- Syphilis
- HIV
- Hepatitis B
- Rubella
- Tuberculosis (if indicated)
- Varicella
- Women with an infectious disease that has a chronic component can often achieve a successful pregnancy outcome with guidance and collaboration between primary health care providers and specialty care.
Clinical Guidance
For EVERY woman who does not desire pregnancy in the next year:
- Convey that you hear and respect her decision not to become pregnant in the next year
- Review immune status and provide indicated immunizations especially:
- Influenza (give or counsel to return when current year’s immunization available)
- Hepatitis B
- Rubella (with caution to avoid pregnancy for 3 months after immunization)
- Varicella
- Td
- Assess risk for infectious diseases (see below)
- Screen for infectious diseases based on risk status (see below)
- Counsel on lifestyle choices to minimize risks for various infectious diseases including STIs
RESOURCES
Centers for Disease Control and Prevention (2015). Sexually Transmitted Disease Guidelines available at:
http://www.cdc.gov/std/tg2015/default.htm
The CDC has created an app for quick access to treatment guidelines which can be investigated and downloaded at:
https://itunes.apple.com/us/app/std-tx-guide/id655206856?mt=8
Centers for Disease Control and Prevention (ACIP: Advisory Committee on Immunization Practices) 2013. Adult Immunization Schedule available at http://www.cdc.gov/vaccines/schedules/hcp/adult.html . This site includes many tools appropriate to the primary care practice.
Infectious Disease (in alphabetical order):
[symple_toggle title="Chlamydia" state="closed"]
- Most common bacterial sexually transmitted infection in U.S.
- 70-90% asymptomatic
- Of preconception significance because, if untreated, can lead to infertility, pelvic inflammatory disease, ectopic pregnancies.
- Screen at least annually:
- All sexually active women < age 25;
- All other women at risk for infection should be screened at least annually or more often. Risk factors include:
- history of STIs;
- new or multiple sexual partners;
- inconsistent condom use;
- sex work;
- drug use.
- Screen by endocervical sample, urine sample or self-obtained vaginal swab.
- Treat using CDC guidelines if:
- Positive screen or
- Documented exposure
- Consider expedited partner therapy to reduce risk of re-infection;
- Educate on risk reduction strategies;
- Test for re-infection according to CDC guidelines 3 months following treatment.
RESOURCES
Centers for Disease Control and Prevention (2015). Sexually Transmitted Disease Guidelines available at:http://www.cdc.gov/std/tg2015/default.htm
The CDC has created an app for quick access to treatment guidelines which can be investigated and downloaded at:https://itunes.apple.com/us/app/std-tx-guide/id655206856?mt=8
The CDC has a fact sheet for patients on chlamydia, please click here to access.
[/symple_toggle][symple_toggle title="Cytomegalovirus" state="closed"]- Routine serologic screening not recommended
- Women who have young children/ work with infants and young children/work in the hospital setting should be counseled about risk reduction strategies:
- Gloves/rigorous hand washing after handling diapers or exposure to respiratory secretions.
RESOURCES
The CDC has a website for patients on CMV, please access here.
[/symple_toggle][symple_toggle title="Gonorrhea" state="closed"]- One of the most common infectious diseases in U.S.
- Can be asymptomatic.
- Of preconception significance because, if untreated, can lead to infertility, pelvic inflammatory disease, ectopic pregnancies.
- Screen women at high risk for infection:
- Prior gonorrhea infection or other STDs
- New or multiple sexual partners
- Inconsistent condom use
- Sex work
- Drug use
- Women from demographic groups and communities with high prevalence.
- Screen by either endocervical sample, urine sample or self-obtained vaginal swab.
- Treat using CDC guidelines if:
- positive screen or
- documented exposure
- Consider expedited partner therapy to reduce risk of re-infection.
- Educate on risk reduction strategies.
- Repeat test for re-infection according to CDC guidelines 3 months after treatment with a regimen with ceftriaxone.
- If treated using a regimen that does not include ceftriaxone, a test of cure is needed.
RESOURCES
Centers for Disease Control and Prevention (2015). Sexually Transmitted Disease Guidelines available at:http://www.cdc.gov/std/tg2015/default.htm
The CDC has created an app for quick access to treatment guidelines which can be investigated and downloaded at:https://itunes.apple.com/us/app/std-tx-guide/id655206856?mt=8
The CDC’s website on gonorrhea can be accessed here.
[/symple_toggle][symple_toggle title="Hepatitis B" state="closed"]- The risk of perinatal infection with acute infection during pregnancy range from 10% (infected in first trimester) to 90% (infected in third trimester.
- These risks are avoidable through preconception vaccination.
- The risk of perinatal transmission is 10-90% for women with chronic Hepatitis B
- Women at high risk and who have not been previously vaccinated should receive the Hepatitis B vaccine before pregnancy.
- Prevaccination antibody screening can be considered but should not be a barrier to vaccination of susceptible persons.
- The vaccine prevents transmission of infection to infants and eliminates the risks to the women of hepatic failure, liver carcinoma, cirrhosis, and death due to HBV infection.
- Chronic Hepatitis B carriers should be instructed on ways to reduce transmission to close contacts and how to prevent vertical transmission to their babies and they should ideally be followed by a specialist to optimize treatment.
- If undergoing treatment, effective contraceptive strategy should be encouraged until treatment complete and disease stable.
- All pregnant women should be tested for Hepatitis B surface antigen (HbsAg) at the first prenatal visit. Hepatitis B vaccine series can be given during pregnancy to complete a series begun prior to pregnancy or for unimmunized pregnant women at high risk for acquiring Hepatitis B.
RESOURCES
Centers for Disease Control and Prevention (2015). Sexually Transmitted Disease Guidelines available at:http://www.cdc.gov/std/tg2015/default.htm
The CDC has created an app for quick access to treatment guidelines which can be investigated and downloaded at:https://itunes.apple.com/us/app/std-tx-guide/id655206856?mt=8
Centers for Disease Control and Prevention (ACIP: Advisory Committee on Immunization Practices) 2013. Adult Immunization Schedule available at http://www.cdc.gov/vaccines/schedules/hcp/adult.html . This site includes many tools appropriate to the primary care practice.
The CDC has a patient fact sheet on Hepatitis B, please click here to access.
[/symple_toggle][symple_toggle title="Hepatitis C" state="closed"]- The following women should be screened before pregnancy:
- Past or current injection drug use
- History of other STIs
- History of blood transfusion or solid organ transplant before 1992
- Receipt of clotting factor concentrates before 1987
- Long-term dialysis
- Signs and symptoms of liver disease.
- Women born between 1945-1965.
- Screening for other women is not recommended.
- If positive for Hepatitis C
- Refer to specialist for appropriate counseling and therapy;
- Educate on link between viral load and neonatal transmission
- Avoid hepatotoxic drugs
- Educate about importance of continued care for her own health to minimize liver disease.
- Counsel for risk reduction strategies.
- If under treatment or has signs of liver disease encourage effective contraceptive methods until treatment complete or disease in best possible control.
RESOURCES
Centers for Disease Control and Prevention (2015). Sexually Transmitted Disease Guidelines available at:http://www.cdc.gov/std/tg2015/default.htm
The CDC has created an app for quick access to treatment guidelines which can be investigated and downloaded at:https://itunes.apple.com/us/app/std-tx-guide/id655206856?mt=8
Centers for Disease Control and Prevention (2010). U.S Medical Eligibility for Contraceptive Use. Available at:http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5904a1.htm?s_cid=rr5904a1_w
The CDC has a fact sheet for patients on Hepatitis C, please click here to access.
[/symple_toggle][symple_toggle title="HIV" state="closed"]- HIV screening recommended for all women ages 15- 64 ( opt-out testing strategy)- encourage to know their HIV status before pregnancy
- Counsel all patients about HIV/STD risk reduction strategies.
- Discuss effective contraception strategies with women and men with HIV who are not seeking conception.
- Women and men who are HIV+ can achieve successful pregnancy outcomes with collaboration between PCP/ provider and ID specialist. Reinforce the importance of a maximally suppressed viral load before pregnancy and discuss safer conception strategies.
- Medication is available to prevent HIV transmission to partners who are at high-risk for HIV acquisition (i.e. in an HIV serodiscordant relationship). Counsel patients about the availability of pre-exposure prophylaxis (PrEP).
RESOURCES
Centers for Disease Control and Prevention (2015). Sexually Transmitted Disease Guidelines available at:http://www.cdc.gov/std/tg2015/default.htm
The CDC has created an app for quick access to treatment guidelines which can be investigated and downloaded at:https://itunes.apple.com/us/app/std-tx-guide/id655206856?mt=8
Centers for Disease Control and Prevention (2012). Update to CDC’s U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: Revised Recommendations for the Use of Hormonal Contraception Among Women at High Risk for HIV Infection or Infected with HIV: available at:http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6124a4.htm?s_cid=mm6124a4_e%0D%0A.
Centers for Disease Control and Prevention. Prevention with Persons with HIV. Reproductive and Pregnancy Care.
Clinician Consultation Center. The Clinician Consultation Center provides rapid expert consultation and advice on management of HIV/AIDS, perinatal HIV, and post-exposure prophylaxis for blood borne pathogen exposures.
Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. (2014, March 28). Recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States.
US Public Health Service. (2014). PreExposure Prophylaxis for the Prevention of HIV Infection in the United States – 2014: A Clinical Practice Guide.
[/symple_toggle][symple_toggle title="HPV" state="closed"]- Vaccine recommended for girls ages 9-26 (and boys);
- Screen and treat for cervical cytology as recommended by ASCCP;
- Studies suggest that punch biopsies and cryosurgery do not affect cervical integrity; more study is needed to determine definitively if LEEP poses a risk for incompetent cervix in future pregnancies.
RESOURCES
Centers for Disease Control and Prevention (2015). Sexually Transmitted Disease Guidelines available at:http://www.cdc.gov/std/tg2015/default.htm
The CDC has created an app for quick access to treatment guidelines which can be investigated and downloaded at:https://itunes.apple.com/us/app/std-tx-guide/id655206856?mt=8
Centers for Disease Control and Prevention (ACIP: Advisory Committee on Immunization Practices) 2013. Adult Immunization Schedule available at http://www.cdc.gov/vaccines/schedules/hcp/adult.html . This site includes many tools appropriate to the primary care practice.
The CDC has a patient fact sheet about HPV, please click here to access.
[/symple_toggle][symple_toggle title="HSV" state="closed"]- Women with history of genital herpes should be counseled about the risks of vertical transmission to the fetus and newborn
- Educate all women/ partners on the risk/symptoms/transmission/natural course/management strategies for genital herpes
- Universal serologic screening not recommended but type-specific serologic testing of asymptomatic partners of individuals with genital herpes has been recommended (discordant couples)
- Effective contraceptive strategy/planned pregnancy.
RESOURCES
Centers for Disease Control and Prevention (2015). Sexually Transmitted Disease Guidelines available at:http://www.cdc.gov/std/tg2015/default.htm
The CDC has created an app for quick access to treatment guidelines which can be investigated and downloaded at:https://itunes.apple.com/us/app/std-tx-guide/id655206856?mt=8
The CDC has a patient fact sheet on herpes, please click here to access.
[/symple_toggle][symple_toggle title="Influenza" state="closed"]- Vaccination recommended for everyone 6 months of age and older.
- Important for women who will be pregnant during the influenza season – increased morbidity in pregnant and postpartum women.
RESOURCES
Centers for Disease Control and Prevention (ACIP: Advisory Committee on Immunization Practices), 2013. Adult Immunization Schedule available at http://www.cdc.gov/vaccines/schedules/hcp/adult.html. This site includes many tools appropriate to the primary care practice.
The CDC has a fact sheet for patients about influenza, please click here to access.
[/symple_toggle][symple_toggle title="Listeriosis" state="closed"]- Pregnant women exposed at any stage of pregnancy can have serious pregnancy complications
- Preconception counseling on risk reduction strategies during pregnancy – avoid raw (unpasteurized ) milk, soft cheeses made from unpasteurized milk, pate, meat spreads, and refrigerated smoked seafood (unless canned/shelf stable). Ready-to-eat foods including hotdogs and deli meat should be reheated until steaming hot
RESOURCES
The CDC has a website for patients about listeria, please click here to access.
[/symple_toggle][symple_toggle title="Malaria" state="closed"]- Women planning a pregnancy should be advised to avoid travel to malaria-endemic areas.
- If travel cannot be deferred – advise effective contraceptive strategy/defer pregnancy until travel is complete.
- Antimalarial chemoprophylaxis should be provided to those women planning a pregnancy and traveling to malaria-endemic areas.
RESOURCES
The CDC has a website for patients about malaria, please click here to access.
[/symple_toggle][symple_toggle title="Rubella" state="closed"]- All women of reproductive age should be screened for rubella immunity (serology)
- Immunization (MMR vaccine) should be offered to those nonpregnant women who have not been vaccinated or who are not immune
- Vaccine provides protection against measles, mumps and rubella
- Counseled not to become pregnant for 3 months after receiving the vaccine.
- Effective contraceptive strategy/ plan pregnancy
- Screen for rubella immunity in pregnancy
RESOURCES
Centers for Disease Control and Prevention (ACIP: Advisory Committee on Immunization Practices) 2013. Adult Immunization Schedule available at http://www.cdc.gov/vaccines/schedules/hcp/adult.html . This site includes many tools appropriate to the primary care practice.
The CDC has a website for patients about rubella, please click here to access.
[/symple_toggle][symple_toggle title="Syphilis" state="closed"]- Routine screening for women at high risk (history of STIs, new or multiple sex partners) for infection and treat (CDC guidelines)
- Education on risk reduction strategies
- Re-test as per CDC guidelines to assess treatment success
- Effective contraceptive strategy until treatment is complete
- Screening is also recommended at first prenatal visit and again in the third trimester based on risk
RESOURCES
Centers for Disease Control and Prevention (2015). Sexually Transmitted Disease Guidelines available at:http://www.cdc.gov/std/tg2015/default.htm
The CDC has created an app for quick access to treatment guidelines which can be investigated and downloaded at:https://itunes.apple.com/us/app/std-tx-guide/id655206856?mt=8
Centers for Disease Control and Prevention (2010). U.S Medical Eligibility for Contraceptive Use. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5904a1.htm?s_cid=rr5904a1_w.
The CDC has a fact sheet for patients on syphilis, please click here to access.
[/symple_toggle][symple_toggle title="Tetanus, Diptheria, Pertussis" state="closed"]- Women of reproductive age should be up to date for tetanus toxoid (passive immunity probably is protective against neonatal tetanus)
- Tetanus, Diphtheria, Pertussis (Tdap) vaccine now indicated for women during every pregnancy (passive protection for infants vs. pertussis)
RESOURCES
Centers for Disease Control and Prevention (ACIP: Advisory Committee on Immunization Practices), 2013. Adult Immunization Schedule available at http://www.cdc.gov/vaccines/schedules/hcp/adult.html . This site includes many tools appropriate to the primary care practice.
The CDC has websites on Tetanus, Diphtheria, and Pertussis for more information and clinical recommendations.
[/symple_toggle][symple_toggle title="Toxoplasmosis" state="closed"]- No clear evidence that preconception counseling/testing will reduce infection or improve treatment of women who are infected
- If preconception testing is performed – women who test positive can be reassured that they are not at risk of contracting toxoplasmosis during pregnancy. Women who are negative – counseled on ways to prevent infection
- Most common means of toxoplasmosis acquisition via environmental exposure – contaminated cat litter boxes or soil and/ or ingestion of undercooked meat from infected animals
- Counsel on risk reduction strategies
- Universal screening in pregnancy not recommended/ controversial
- Women who convert during pregnancy may be offered treatment
RESOURCES
The CDC has a website for patients about toxoplasmosis, please click here to access.
[/symple_toggle][symple_toggle title="Tuberculosis" state="closed"]- All women at high risk should be screened and treated appropriately before pregnancy (population screening recommendations)
- Some medications used to treat tuberculosis not recommended in pregnancy
- May screen with tuberculin skin test or serum interferon-gamma release assay ( IGRA)
- Education on risk reduction strategies/ close contacts screened
- Effective contraception strategy until treatment is complete. Screening for TB in pregnancy based on population risk factors
RESOURCES
For more information from the CDC about TB please click here.
The CDC has created an app for quick access to treatment guidelines for latent TB which can be investigated and downloaded, click here for more information.
The CDC has multiple fact sheets for providers, please click here for access.
[/symple_toggle][symple_toggle title="Varicella" state="closed"]- Screening for varicella immunity (history of previous vaccination/ previous varicella infection verified by health care provider/or laboratory evidence of immunity) should be ideally performed before pregnancy
- All nonpregnant women of childbearing age without evidence of varicella immunity should be vaccinated against varicella (avoid pregnancy for one month)
- Effective contraceptive strategy
- Varicella vaccine contraindicated during pregnancy (live vaccine)
- Screen for varicella immunity during pregnancy if unknown status
RESOURCES
Centers for Disease Control and Prevention (ACIP: Advisory Committee on Immunization Practices), 2013. Adult Immunization Schedule available at http://www.cdc.gov/vaccines/schedules/hcp/adult.html . This site includes many tools appropriate to the primary care practice.
The CDC’s website for clinical information on varicella is available here.
[/symple_toggle]Clinical Tools
Centers for Disease Control and Prevention. Preconception Clinical Care for Women: Immunizations (2013).
http://www.cdc.gov/preconception/careforwomen/immunization.html.
Centers for Disease Control and Prevention. Preconception Clinical Care for Women: Infectious Diseases (2013).
http://www.cdc.gov/preconception/careforwomen/disease.html
Centers for Disease Control and Prevention. Pregnancy and Immunizations (Before, During and After) (2013)
http://www.cdc.gov/vaccines/pubs/downloads/f_preg_chart.pdf
Centers for Disease Control and Prevention. Risks of STDs during pregnancy (2013). http://www.cdc.gov/std/pregnancy/STD-Preg-factsheet-August-2013.pdf
Centers for Disease Control and Prevention. Sexually Transmitted Disease Guidelines (2015). available at: http://www.cdc.gov/std/tg2015/
CDC 2015 STD Treatment Guidelines app for iPhone:
https://itunes.apple.com/us/app/std-tx-guide/id655206856?mt=8
Centers for Disease Control and Prevention (ACIP: Advisory Committee on Immunization Practices) 2013. Adult Immunization Schedule.
http://www.cdc.gov/vaccines/schedules/hcp/adult.html. This site includes many tools appropriate to the primary care practice.
Centers for Disease Control and Prevention (2010). U.S Medical Eligibility for Contraceptive Use. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5904a1.htm?s_cid=rr5904a1_w.
Patient Resources
Printable patient handouts available from the CDC:
Patient Websites from the CDC:
Additional Resources:
March of Dimes: Rubella and Pregnancy (2012)
Immunization Action Coalition: Vaccine Information Handouts (2013)
Immunization Action Coalition: Vaccine Schedules (2013)
In addition, the CDC has an A to Z list of resources which may be very useful for patients. offers access to many CDC resources.
References
American College of Obstetricians and Gynecologists (2007). Guidelines for Women’s Health Care: A Resource Manual (3rd ed). Washington, DC: ACOG.
American Academy of Pediatrics and American College of Obstetricians and Gynecologists (2013). Guidelines for Perinatal Care (7th ed.). Evansville, Ill: AAP/ACOG.
Centers for Disease Control and Prevention. (2015). Sexually Transmitted Diseases Treatment Guidelines.
http://www.cdc.gov/std/tg2015/
Centers for Disease Control and Prevention (2010). U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 (Adapted from the World Health Organization Medical Eligibility Criteria for Contraceptive Use, 4th edition). Morbidity and Mortality Weekly Report, 59(RR04): 1-6. Available at: http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm.
Coonrod, D.V., Jack, B.W., Stubblefield, P.G. et. al. (2008) The clinical content of preconception care: infectious diseases in preconception care. American Journal of Obstetrics and Gynecology, 199 (6B),S290-295.
