26 September 2018

Congenital syphilis deaths spark calls for more STI testing

Clinical Communicable Disease O&G

A seventh Australian baby is reported to have died of congenital syphilis, prompting calls for widespread STI testing throughout early and late pregnancy. 

Reports of a new neonatal death from the easily treatable and preventable infection have led experts to suggest more needs to be done in testing women of reproductive age, even in those previously considered “low risk”. 

“I think that’s a national tragedy, because it’s completely treatable,” Western Australian GP and sexual health expert Dr Richelle Douglas told the audience at RANZCOG’s Annual Scientific Meeting in Adelaide last week. 

The medical director of Sexual Health Quarters said that the rise of cases of gonorrhoea in heterosexuals in urban areas underscored the need for doctors to consider any person having unprotected sex as having a higher risk of an STI that could harm them and their child. 

Despite improvements in technology, chances were most pregnant women sitting across from a clinician have had unprotected sex at least once, she added. 

Dr Douglas called on the college to update its guidelines to recommend screening for STIs such as chlamydia, gonorrhoea and syphilis, particularly in high-risk populations, at the first antenatal visit, and for another test in the third trimester as well. 

“We can’t assume that all women will have the same partner at the end of the pregnancy as they did at the beginning of the pregnancy,” she said. 

“And we need to be really careful about contact-tracing for those women with a positive diagnosis early on in the pregnancy.

“If we don’t start to take this epidemic seriously, we are going to begin to see more cases, not only of congenital syphilis, but also gonococcal conjunctivitis and blindness,” Dr Douglas said. 

Almost no women were getting tested for STIs more than once in pregnancy, and STIs were not looked for in cases of adverse pregnancy outcomes like premature rupture of membranes and pre-term delivery, she said. 

GBS was routinely screened at 36 weeks and at this time gonococcal and chlamydia swabs could also be taken. 

“GBS is common because it is looked for, and I feel that we really need to begin to look for other organisms,” she said. 

This was especially important for gonococcal pelvic inflammatory disease, which was more likely to cause serious consequences than other organisms.  

“Seven years after the diagnosis of pelvic inflammatory disease, 21% of women have recurrent pelvic inflammatory disease, 19% of women suffer from infertility and 42% chronic pelvic pain,” she said. 

One in 20 women experience pelvic inflammatory disease in their lifetime.

“It is underdiagnosed, often misdiagnosed and the implications are serious,” Dr Douglas said. 

As an example of how woeful accurate diagnosis was in some parts of the country, Dr Douglas pointed to audits that clinicians had performed in their own practices. 

In one evaluation of 655 Aboriginal women living in Central Australia, one in five women presented with recurrent abdominal pain. Of the 95 cases which had signs and symptoms associated with pelvic inflammatory disease, only 15 diagnoses of the disease were made and none was treated in accordance with antibiotic guidelines. 

One audit of a practice in the Kimberley found that Aboriginal women aged 15 to 35 were just as likely to have their appendix removed for pelvic inflammatory disease as they were for gonorrhoea, and that gonorrhoea accounted for 72% of the pelvic inflammatory-related appendectomies.