Gonorrhoea is a sexually transmitted infection that can cause complications in pregnancy. Antenatal care provides opportunities for women from population groups with a high prevalence of the infection to be offered testing.
Gonorrhoea is a sexually acquired infection caused by Neisseria gonorrhoeae. In women it may be asymptomatic, or present as an abnormal vaginal discharge, pelvic pain and/or difficulty urinating. Women with untreated gonorrhoea infection can have high morbidity (eg pelvic inflammatory disease, chronic pelvic pain). In pregnancy, gonorrhoea infection can cause adverse obstetric and neonatal outcomes. There is evidence that tests can accurately detect gonorrhoea infection and that antibiotics are effective in its treatment.
41.1.1 Diagnoses of gonorrhoea in Australia
- Rates of diagnosis: Between 2012 and 2016, there was a 63% increase in notification rates (from 61.9 to 100.8 per 100,000), with a 43% increase among women (from 25.7 to 55.9 per 100,000) . By 2012, most laboratories had switched to using dual chlamydia and gonorrhoea tests where, if a chlamydia test was ordered, a gonorrhoea test would be conducted automatically. The emphasis on testing for chlamydia in young people has therefore led to a substantial rise in the number of tests conducted for gonorrhoea, which may explain the increase in diagnoses in women before 2012 but not since then.
- In 2016, the gonorrhoea notification rate for Aboriginal and Torres Strait Islander women was 15 times that of non-Indigenous women (611.8 vs 41.8 per 100,000; data do not include New South Wales) . However, since 2012, the rate of notification of gonorrhoea decreased by 17% in the Aboriginal and Torres Strait Islander population, compared with a 125% increase in the non-Indigenous population.
- Age: Between 2012 and 2016, the notification rate of gonorrhoea increased in all age groups 20 years and above . Among women, the largest increases were in the 30–39 year (94%), 25–29 year (93%) and 20–24 year (39%) age groups.
- Geographical location: Between 2007 and 2016, gonorrhoea notification rates increased in all jurisdictions except the Northern Territory, where rates fluctuated . In 2016, gonorrhoea notification rates were highest in the Northern Territory (699.6 per 100,000), followed by Western Australia (132.8 per 100,000). Notification rates increased in major cities (99% increase) and inner and outer regional areas (15% increase) but declined in remote and very remote areas (8% decline). In 2016, gonorrhoea notification rates were highest in remote areas (532.5 per 100,000), followed by major cities (101.3 per 100,000) and regional areas (50.7 per 100,000).
- Country of origin: In 2008, the World Health Organization estimated the incidence of gonorrhoea per 1,000 women aged 15–49 years to be 50 in Africa, 35 in the Western Pacific, 19 in the Americas, 16 in South-East Asia and 8 in Europe .
- Incidence in pregnancy: The incidence of gonorrhoea in pregnant women who are not at high risk for infection is generally low. However, it varies by population; approximately 1% among pregnant women in the United States (range 0.2–4%) , 3.3% in a developing country setting and 3.4% among adolescent women in a low-income area in the United States .
- Risk factors: Increased risk of gonorrhoea has been associated with previous gonorrhoea infection or other sexually transmitted infection, new or multiple sex partners and inconsistent condom use, commercial sex work and drug use and living in communities with a high prevalence of gonorrhoea .
41.1.2 Risks associated with gonorrhoea in pregnancy
Untreated gonorrhoea during pregnancy is associated with adverse outcomes including ectopic pregnancy, septic spontaneous miscarriage, chorioamnionitis, premature rupture of membranes, preterm labour and postpartum infection.
N. gonorrhoeae can be transmitted from the mother’s genital tract to the newborn at the time of birth and occasionally, when there is prolonged rupture of the membranes, it can be transmitted to the baby before birth. The usual manifestation of neonatal infection is conjunctivitis (ophthalmia neonatorum), which begins in the first days of life and, if left untreated, may lead to blindness . The risk of transmission from an infected mother is between 30% and 47% .
41.2 Testing for gonorrhoea
While testing all women for gonorrhoea during pregnancy is recommended in Canada RACGP) also supports testing only women considered to be at risk . The prevalence of gonorrhoea is regionally variable and, in some areas, high prevalence may occur with that of other sexually transmitted infections, such as chlamydia. It is important for health professionals to be aware of the rates of sexually transmitted infection in their community and develop local protocols accordingly., a number of bodies in the United States recommend testing only women at high risk . The Royal Australian College of General Practitioners (
41.2.1 Diagnostic accuracy of tests
In Australia, culture methods for detection of N. gonorrhoeae have been increasingly replaced by nucleic acid detection tests (NAATs), especially in remote areas. These tests can be performed on self-collected vaginal swabs, urine and endocervical specimens. The sensitivity and specificity of vaginal swabs are similar whether collected by the woman (96.1%; 99.3%) or health professional (96.2%; 99.3%), identifying as many infections as endocervical swabs and more than first-catch urine samples . These tests are evolving and guidelines for laboratories on their use and interpretation have been developed to reduce the high risk of false positives associated with some tests . Where possible, positive results should be confirmed with culture for antibiotic sensitivity testing and to exclude false positives, particularly in low-risk individuals.
In a retrospective study, repeat testing of women at high risk at 34 weeks identified additional women with infection (n=751). In the United States and Canada , testing is recommended in the first trimester, with testing in subsequent trimesters (Canada) or in the third trimester (United States) for women at continued risk or with a new risk factor.
41.2.2 Harms and benefits of testing
There is some evidence that testing and subsequent treatment of pregnant women at high risk of gonorrhoea may prevent complications associated with gonococcal infection during pregnancy. Potential harms of testing include false-positive results, anxiety and unnecessary antibiotic use . There is insufficient evidence to quantify the magnitude of these harms but it is likely that they are outweighed by the benefits of testing women at increased risk .
No evidence on the cost-effectiveness of testing for gonorrhoea in pregnancy was identified.
41.2.3 Effect of treatments on risks associated with gonorrhoea
The aim of treating gonorrhoea during pregnancy is to eradicate the infection and prevent neonatal infection, postpartum sepsis for the mother and transmission to sexual partners. In a systematic review (n=346) , all tested antibiotic regimens (penicillins, spectinomycin or ceftriaxone) demonstrated a high level of effectiveness as judged by ‘microbiological cure’, with eradication rates of between 89% and 97%. However, the effects of treatment on substantive outcomes such as ophthalmia neonatorum have not been reported and may vary between different antibiotics.
Do not routinely offer gonorrhoea testing to all women as part of antenatal care. Offer gonorrhoea testing to pregnant women who have known risk factors or who live in or come from areas where prevalence is high.
Approved by NHMRC in June 2014; expires June 2019
41.3 Discussing gonorrhoea
Discussion to inform a woman’s decision-making should take place before testing takes place and include:
- it is possible to have gonorrhoea without experiencing symptoms
- risk factors for sexually transmitted infection
- the possibility of false positive results
- gonorrhoea causes problems with the pregnancy including spontaneous miscarriage, preterm birth and infection of the newborn
- treatment of gonorrhoea may prevent pregnancy complications associated with infection
- testing and treatment of partners is advisable if infection is identified and the couple should abstain from sex until treatment is complete and symptoms have resolved
- testing for other sexually transmitted infections may be needed
- a second test may be given a week later if symptoms remain
- repeat testing for gonorrhoea may be needed for women at ongoing risk of infection.
41.4 Practice summary: gonorrhoea
A woman has risk factors for gonorrhoea infection, lives in an area of high prevalence or has come from a country with high prevalence.
- Aboriginal and Torres Strait Islander Health Practitioner
- Aboriginal and Torres Strait Islander Health Worker
- multicultural health worker
- sexual health worker.
- Discuss the reasons for gonorrhoea testing
Explain that it is important to find out whether a woman has gonorrhoea because of the effects that the infection can have on the pregnancy and the baby.
- Take a holistic approach
If a woman is found to have gonorrhoea infection, other considerations include counselling, contact tracing, partner testing, testing for other sexually transmitted infections and follow-up.
- Document and follow-up
If a woman is tested for gonorrhoea, tell her the results and note them in her antenatal record. Have a follow-up system in place so that infected women receive timely treatment or referral. Consider repeat testing for women who may be at ongoing risk of infection.
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