Gonorrhoea

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.

41.1 Background

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 USPSTF 2005.

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) (The Kirby Institute 2017a). 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) (The Kirby Institute 2017b). 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 (The Kirby Institute 2017a). 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 (The Kirby Institute 2017a). 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 WHO 2012.
• 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 (Goldenberg et al 2005) (range 0.2–4%) CDC 2004, 3.3% in a developing country setting (Sullivan et al 2004) and 3.4% among adolescent women in a low-income area in the United States (Niccolai et al 2003).
• 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 USPSTF 2005.

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 Hollier & Workowski 2005, USPSTF 2005.

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 (Brocklehurst 2009). 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 (Brocklehurst 2009). The risk of transmission from an infected mother is between 30% and 47% Galega et al 1984, Fransen et al 1986.

41.2 Testing for gonorrhoea

While testing all women for gonorrhoea during pregnancy is recommended in Canada PHAC 2008, a number of bodies in the United States recommend testing only women at high risk AAP 2002, ACOG 2003, AAFP 2004, USPSTF 2005. The Royal Australian College of General Practitioners (RACGP) also supports testing only women considered to be at risk RACGP 2009. 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.

41.2.1 Diagnostic accuracy of tests

In Australia, culture methods for detection of N. gonorrhoeae have been increasingly replaced by NAATs, especially in remote areas (Smith et al 2005). 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 (Schachter et al 2005). 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 (Smith et al 2005). 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) (Miller et al 2003). In the United States USPSTF 2005 and Canada PHAC 2008, 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 USPSTF 2005, Darling 2009. Potential harms of testing include false-positive results, anxiety and unnecessary antibiotic use USPSTF 2005. 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 USPSTF 2005.

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 (Brocklehurst 2009). In a systematic review (n=346) (Brocklehurst 2009), 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.

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 

When

A woman has risk factors for gonorrhoea infection, lives in an area of high prevalence or has come from a country with high prevalence.

Who

• Midwife
• GP
• obstetrician
• Aboriginal and Torres Strait Islander Health Practitioner
• Aboriginal and Torres Strait Islander Health Worker
• multicultural health worker
• sexual health worker.

What

• 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.

41.5 Resources

• AGSP (2011) Australian Gonococcal Surveillance Programme Annual Report, 2010. Commun Dis Intell 35(3): 229–36.
• ASHA (2016) Australian STI Management Guidelines for Use in Primary Care. Australasian Sexual Health Alliance. Accessed: 23 October 2017. stiguidelines.org.au
• Papp JR, Schachter J, Gaydos CA et al; Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC (2014) Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae - 2014. MMWR Recomm Rep 263(RR-02): 1–19.
• PHAC (2016) Canadian Guidelines on Sexually Transmitted Infections, 2016 Edition. Ottawa, ON: Public Health Agency of Canada.
• Remote Primary Health Care Manuals. (2017). Sexual health. In: Women’s Business Manual (6th edition). Alice Springs, NT: Centre for Remote Health.
• Workowski KA & Berman S (2010) Sexually transmitted diseases treatment guidelines, 2010. Centers for Disease Control and Prevention. MMWR Recomm Rep 59(RR-12): 1–110.