Gonorrhea

The incidence of gonorrhea in the United States for 2002 was 125 cases per 100,000 persons (Centers for Disease Control and Prevention, 2003b). The highest rates in women of any ethnicity were in the 15- to 24-year age groups. The prevalence of gonorrhea in sentinel, study prenatal clinics in 2002 was 0.9 percent. Risk factors included single marital status, adolescence, poverty, drug abuse, prostitution, other STDs, and lack of prenatal care. Gonococcal infection is also a marker for concomitant chlamydial infection in about 40 percent of infected pregnant women (Christmas and colleagues, 1989). In most pregnant women, gonococcal infection is limited to the lower genital tract -  the cervix, urethra, and periurethral and vestibular glands.

Acute salpingitis is rare in pregnancy, but pregnant women account for a disproportionate number of disseminated gonococcal infections (Ross, 1996; Yip and associates, 1993). A screening test for gonorrhea is recommended at the first prenatal visit or prior to an induced abortion. In high-risk populations, the Centers for Disease Control and Prevention (2002d) and Miller and co-workerss (2003) have recommended that a repeat culture be obtained after 28 weeks’ gestation.

Ickovics and associates (2003) and Mahon and associates (2002) also recommend postpartum screening in the at-risk teenage population. For women who test positive, screening for syphilis and Chlamydia trachomatis should precede treatment, if possible. If chlamydial testing is unavailable, presumptive therapy is given. In addition, offering HIV testing is wise.

EFFECT ON PREGNANCY.
Gonococcal infection may have deleterious effects in any trimester. There is an association between untreated gonococcal cervicitis and septic abortion as well as infection after voluntary abortion (Burkman and co-workers, 1976). Preterm delivery, prematurely ruptured membranes, chorioamnionitis, and postpartum infection are more common in women infected with Neisseria gonorrhoeae at delivery (Alger and associates, 1988). Expectant management of culture-positive women is reasonable even with prematurely ruptured membranes as long as antimicrobial treatment is given promptly (Maxwell and Watson, 1992).

Sheffield and colleagues (1999) reviewed clinical outcomes of 25 pregnant women admitted to Parkland Hospital for disseminated gonococcal infection. Their mean gestational age at presentation was 25 weeks, and all of the women promptly responded to appropriate antimicrobial therapy. One stillborn neonate and one spontaneous abortion, however, were attributed to gonococcal sepsis.

TREATMENT.
Antimicrobial resistance of N gonorrhoeae, particularly to penicillin, tetracycline, and quinolones, has rendered most ?-lactam drugs ineffective (Centers for Disease Control and Prevention, 2002d). As shown in

Table 59-2, ceftriaxone and cefixime are recommended for uncomplicated infection during pregnancy, although cefixime may not be available in 2004 (Brocklehurst, 2003). Ramus and associates (2001), in a study of 62 pregnant women with probable endocervical gonorrhea, reported that intramuscular ceftriaxone (125 mg) and oral cefixime (400 mg) resulted in a cure rate of 95 percent and 96 percent, respectively. Spectinomycin is recommended for women allergic to penicillin or ?-lactam antimicrobials. Treatment is recommended for sexual contacts. A test-of-cure is unnecessary if symptoms resolve, but because gonococcal reinfection is common, a second screening in late pregnancy should be considered for women treated earlier during pregnancy (Centers for Disease Control and Prevention, 2002d; Miller and co-workers, 2003).

Disseminated Gonococcal Infections. Gonococcal bacteremia may lead to petechial or pustular skin lesions, arthralgias, septic arthritis, or tenosynovitis. The Centers for Disease Control and Prevention (2002d) have recommended ceftriaxone, 1000 mg intramuscularly or intravenously every 24 hours. Treatment should be continued for 24 to 48 hours after improvement and then therapy changed to an oral agent to complete a week of therapy.

For gonococcal endocarditis, antimicrobials should be continued for at least 4 weeks, and for meningitis, 10 to 14 days (Centers for Disease Control and Prevention, 2002d). Endocarditis rarely complicates pregnancy, but it may be fatal (Bataskov and colleagues, 1991).

Treatment of Neonates. Gonococcal conjunctivitis is frequently severe in the neonates. N gonorrhoeae can penetrate intact corneal epithelium and cause keratitis, ulceration, perforation, and blindness. All newborns are given prophylaxis against conjunctivitis. Neonates born to untreated infected women are given ceftriaxone, 25 to 50 mg/kg, either intravenously or intramuscularly for one dose. Mortality results from systemic involvement, and those who develop gonococcal ophthalmia should be hospitalized and evaluated for disseminated infection. Both parents also should be treated for gonorrhea and evaluated for chlamydial infection.

Provided by ArmMed Media
Revision date: June 22, 2011
Last revised: by Jorge P. Ribeiro, MD