Third Trimester Pregnancy Screening for Syphilis and HIV

ird Trimester Pregnancy

Screening for Syphilis and HIV

Sexually active pregnant women are as susceptible to

a sexually transmitted disease (STD) as non-pregnant

women, but the health risks associated with infection

are higher. Many STDs, including HIV, do not show

symptoms— making screening and testing of pregnant

women imperative to prevent these serious health

complications. The earlier treatment is received, the

better the health outcomes. The results of untreated

STDs acquired before or during pregnancy can have

serious, even oddslot life-threatening, outcomes for

the development of the fetus.

The Centers for Disease Control and Prevention (CDC)

recommends prenatal testing for syphilis and HIV during

a woman’s rst prenatal visit and repeat testing for “high-

risk” mothers during the third trimester (preferably 28-32

weeks). Increased testing for HIV during pregnancy has

helped in drastically reducing vertical, or mother-to-child,

transmission of HIV. Many states require testing pregnant

women for HIV during their rst and third trimester, leading

to a public health victory in preventing perinatal cases of HIV.

Of concern now are the rising rates of syphilis in the U.S., and

bone deformities, become blind or deaf, have brain

problems that cause developmental delays or seizures,

or die.

According to the United States Preventive Services

Task Force (USPSTF), all pregnant women in the U.S.

should be tested for syphilis.

The CDC recommends

that all women should be screened for syphilis at their

rst prenatal visit and those who are at high risk for

syphilis, are previously untested, or live in areas of high

syphilis morbidity should be screened again early in the

third trimester and at delivery.

Where the amount of

prenatal care delivered is not optimal (i.e. there is no

rst trimester care), screening should be performed at

the time that pregnancy is conrmed.

Human Immunodeciency Virus

(HIV)

HIV can be transmitted through bodily uid and can

pass from mother to child during pregnancy, labor and

delivery, or breastfeeding. Transmission from mother

to child is preventable through antiretroviral treatment

and avoiding breastfeeding. If acquired, HIV destroys

blood cells that are crucial to helping the body ght

disease and can lead to acquired immune deciency

syndrome (AIDS).

When pregnant women know their HIV status and

are on treatment, they can greatly reduce the risk of

transmitting HIV to the fetus. If a woman is receiving

treatment for HIV throughout her pregnancy, the risk of

transmitting HIV to her baby can be 1 percent or less.

However, like syphilis, HIV can often be asymptomatic

for a period of time, which makes testing women during

pregnancy essential to prevent transmission.

consequently increasing rates of congenital syphilis. The

majority of states only mandate testing pregnant women

for syphilis during their rst trimester, but increasing rates

of congenital syphilis are leading public health ofcials

and legislators to consider adding a requirement for third

trimester syphilis testing. Harmonizing syphilis and HIV

testing in the third trimester for pregnant women could

have a signicant impact on reducing congenital syphilis in

the United States.

Syphilis

Syphilis is a bacterial STD, which if found during pregnancy

can be treated in the mother, and a congenital infection in

the fetus can be treated or prevented. If left untreated,

women who acquire a syphilis infection before or during

pregnancy are at risk for transmitting the infection to their

baby. Congenital syphilis is a disease that occurs when

a mother with syphilis passes the infection to the fetus

during pregnancy. In babies, syphilis is linked to premature

birth, stillbirth, and in some cases, death shortly after birth.

Untreated infants that survive may develop problems in

multiple organs including the brain, eyes, ears, teeth, and

bones.

Due to the fact that many STDs, including syphilis, are

without symptoms in adults, it is critical that women who

are pregnant be tested and treated for syphilis. Depending

on the length of the syphilis infection, there are varying

impacts on the health of the fetus. The longer a syphilis

infection goes untreated in pregnant women, the higher

the risk of stillbirth or death for a baby shortly after birth.

Untreated syphilis in pregnant women results in stillbirth or

infant death in up to 40 percent of cases.

A live baby born

with syphilis may not have signs or symptoms of disease, but

if not treated immediately, the baby may develop serious

problems within weeks. Untreated babies may develop

The U.S. Preventative Services Task Force recommends

that clinicians screen all pregnant women for HIV.

The

CDC’s Revised Recommendations for HIV Testing of

Adults, Adolescents, and Pregnant Women in Health

Care Settings state, “HIV screening should be included

in the routine panel of prenatal screening tests for

all pregnant women….Repeat screening in the third

trimester is recommended in certain jurisdictions

with elevated rates of HIV infection among pregnant

women.”

According to the American College of

Obstetricians and Gynecologists’ (ACOG) Committee on

Obstetric Practice Recommendations, repeat testing in

the third trimester for HIV, or rapid HIV testing at labor

and delivery or both are recommended as strategies to

further reduce the rate of perinatal HIV transmission.

ACOG recommends repeat conventional or rapid HIV

testing in the third trimester for women in areas with

high HIV prevalence, women known to be at high risk

for acquiring HIV infection, and women who declined

testing earlier in the pregnancy.

Current State Policy Trends

To assure the health of pregnant women and children,

there have been major efforts to reduce transmission

of STD and HIV infections during pregnancy. There

has been a 90 percent reduction of mother-to-child

transmission (MTCT) of HIV in the United States,

and in the past, similar elimination success with the

transmission of syphilis from pregnant women to their

fetuses. However, over the past several years, there

has been a signicant increase in incidences of MTCT

syphilis, or congenital syphilis.

According to data

from the CDC, between 2012 and 2014 the national

congenital syphilis rate increased an alarming 38

percent from 8.4 cases per 100,000 live births in 2012

to 11.6 cases per 100,000 in 2014, or from 334 actual

cases nationally to 458.

A majority of states have policies requiring providers to

offer testing for syphilis and HIV in the rst trimester

or at the rst prenatal visit. Many state laws require

HIV testing in the third trimester (at least 30 days

before delivery) to assure that HIV is not transmitted

to the fetus later in the pregnancy or at delivery. Due

to the increasing rates of congenital syphilis, state

policymakers and public health ofcials have been

pursuing policy change to add syphilis testing to early

third trimester care (28-32 weeks). In the last two

legislative sessions, Louisiana,

Georgia,

and Texas

have all expanded their laws to require third trimester

testing in response to rising rates of congenital syphilis.

Another handful of states are currently looking at

scaling up of prenatal syphilis screening through

legislative or regulatory policy. By implementing third

trimester screening policies, the hope is to reduce

incidence of congenital syphilis by eliminating those

cases among mothers who received no prenatal care

in their rst trimester or acquired infections during

pregnancy,

For more information, please contact NCSD’s State

Policy Team at [email protected] or 202-842-

4660.

Centers for Disease Control and Prevention, Syphilis—CDC Fact Sheet, www.

cdc.gov/std/syphilis/stdfact-syphilis-detailed.htm

Id.

U.S. Preventive Services Task Force. Screening for syphilis infection in pregnancy:

reafrmation recommendation statement. Ann Intern Med 2009;150:705–9.

Centers for Disease Control and Prevention, 2015 Sexually Transmitted Diseases

Treatment Guidelines. www.cdc.gov/std/tg2015/

If a woman takes HIV medicines exactly as prescribed throughout pregnancy,

labor, and delivery, and provides HIV medicines to her baby for 4-6 weeks, the

risk of transmitting HIV can be 1% or less. Centers for Disease Control and

Prevention, HIV Among Pregnant Women, Infants, and Children. www.cdc.gov/hiv/

group/gender/pregnantwomen/

US Preventative Services Task Force. Human Immunodeciency Virus (HIV)

Infection: Screening. April 2013. www.uspreventiveservicestaskforce.org/

uspstf13/hiv/hivnalrs.htm

Centers for Disease Control and Prevention, Revised Recommendations for HIV

Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings, www.

cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm

American College of Obstetricians and Gynecologists, Committee Opinion,

No. 635, June 2015, www.acog.org/Resources-And-Publications/Committee-

Opinions/Committee-on-Obstetric-Practice/Prenatal-and-Perinatal-Human-

Immunodeciency-Virus-Testing-Expanded-Recommendations

HIV infections through perinatal transmission have declined more than 90%

since the early 1990s, while the number of HIV-infected women giving birth has

increased. http://www.cdc.gov/hiv/group/gender/pregnantwomen/

Centers for Disease Control and Prevention, Increase in Incidence of Congenital

Syphilis—United States, 2012-2014. Morbidity and Mortality Weekly Report

(MMWR) November 13, 2015, 64(44);1241-1245 www.cdc.gov/mmwr/preview/

mmwrhtml/mm6444a3.htm

Id.

new.dhh.louisiana.gov/assets/oph/Center-PHCH/Center-CH/infectious-epi/

Hepatitis/Act459.pdf