CONSULTATION DRAFT
7 Maternal health screening
This section discusses the evidence for offering women tests for anaemia, haemoglobin disorders,
gonorrhoea, trichomoniasis, Group B streptococcus, cytomegalovirus, toxoplasmosis, cervical
abnormalities and thyroid function during pregnancy. Module I of the Guidelines includes discussion
about tests for human immunodeficiency virus (HIV), chlamydia, syphilis, rubella, hepatitis B, hepatitis C,
asymptomatic bacteriuria, bacterial vaginosis and vitamin D deficiency.
Recommendations are based on evidence about the diagnostic accuracy of available tests, the
effectiveness of interventions to prevent mother-to-child transmission of infection or other effects on the
unborn baby, and the availability of treatments to improve the mother’s health and wellbeing. For
some conditions, testing is recommended for all women. For others, testing is recommended only for
women who may be at higher risk.
For notifiable infections (HIV, hepatitis B, hepatitis C, rubella, syphilis, chlamydia, gonorrhoea),
diagnoses are required to be reported to the National Notifiable Diseases Surveillance System (NNDSS).
This allows analysis of trends in jurisdictions and groups at risk, although data quality varies for the
different conditions and reporting of Indigenous status is incomplete in some States and for some
conditions. Evidence on the prevalence and incidence of other conditions is generally from
observational studies and may not be representative of the Australian population or groups within the
population. While incidence or prevalence data are not always available, each chapter includes a
brief discussion that aims to give health professionals an indication of the likelihood that women in their
community will be affected.
Table 7.1 summarises advice on maternal health screening tests considered a priority for inclusion in
these Guidelines. Advice on testing for blood group and rhesus D status is included in the NICE
Guidelines (NICE 2008).
Table 7.1: Summary of advice on offering certain tests during pregnancy1
Screening offered to all woman
Condition
Test(s)
Follow-up
Anaemia
Haemoglobin
concentration
Specific tests and consideration of other
possible nutrient deficiencies are required for
women with low haemoglobin concentrations
Error!
Reference
source
not found.
Haemoglobin
disorders
Full blood count
Further investigations are required for women
with abnormal red cell indices, family history or
origin in a high-risk country
Error!
Reference
source
not found.
Group B
streptococcus*
Self-collected vaginalrectal swab culture
Identification of colonisation allows treatment
during labour to prevent transmission to the
baby
Error!
Reference
source
not found.
HIV**
EIA and Western blot
Blood-based rapid
tests
Antiretroviral treatment in pregnancy reduces
risk of transmission
Module I
8.1
Hepatitis B**
Blood test for HbsAg#
Vaccination of newborn reduces risk of
infection
Module I
8.2
Rubella
Blood test for rubella
antibody
Vaccination after birth protects future
pregnancies
Inadvertent vaccination in early pregnancy is
Module I
8.4
1
Section
Screening tests are offered in the context of engagement and consultation with women. When conducting
screening tests, health professionals must use standard precautions for infection prevention and control.
Screening tests evolve with advances in technology.
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Condition
Test(s)
Follow-up
Section
highly unlikely to harm the baby
Syphilis#
Treponemal EIA tests
Onsite tests
Treatment benefits mother and prevents
congenital syphilis
Module I
8.6
Asymptomatic
bacteriuria
Midstream urine
culture
Treatment reduces risk of pyelonephritis
Module I
8.7
Notes:
* According to organisational policy.
** Specialist care and psychosocial support are required for women with HIV or hepatitis B.
# Psychosocial support, partner testing and contact tracing is required for women with a sexually
transmitted infection.
The 2012 Australasian Society for HIV Medicine National Hepatitis B testing policy is available at
http://testingportal.ashm.org.au/hbv.
EIA=enzyme immunoassay; HbsAg=hepatitis B surface antigen; HIV=human immunodeficiency virus.
Screening offered to woman at increased risk
Condition
Offer test to:
Test(s)
Follow-up
Section
Gonorrhoea*
Women with known
risk factors or living in
areas where
prevalence is high
Vaginal, urine or
endocervical
specimens
PCR
Treatment may prevent
neonatal infection
Error!
Reference
source
not found.
Trichomoniasis*
Women with
symptoms
Culture or PCR
testing of vaginal
swabs
Treatment may prevent
certain infections in the
newborn but is associated
with adverse effects
Error!
Reference
source
not found.
Toxoplasmosis
Women may request
testing based on
exposure to sources
Studies into tests
are limited and
inconclusive
Insufficient evidence on
treatment. Advice on
prevention may reduce
the risk of infection
Error!
Reference
source
not found.
Cytomegalovirus
Women who have
frequent contact
with large numbers
of very young
children
Studies into tests
are limited and
inconclusive
Insufficient evidence on
treatment. Advice on
prevention may reduce
the risk of infection
Error!
Reference
source
not found.
Cervical
abnormalities
Women who have
not had a Pap
smear in the past
2 years
Pap smear
Allows detection of
precancerous cervical
abnormalities
Error!
Reference
source
not found.
Thyroid function
Women with
symptoms or risk
factors
Blood test for
thyroid-stimulating
hormone
Treatment improves
obstetric outcomes
Error!
Reference
source
not found.
Chlamydia*
Women younger
than 25 years
All pregnant women
in areas of high
prevalence
First pass urine
PCR
Treatment may reduce
the risk of preterm birth,
premature rupture of the
membranes and low birth
weight
Module I
8.5
Hepatitis C**
Women with a
history of risk factors
for hepatitis C
Blood test for
hepatitis antibody
RNA if antibodies
detected
No interventions are
currently proven to
prevent transmission
Module I
8.3
Asymptomatic
bacterial
vaginosis
Women with a
previous preterm
birth
High vaginal swab
Amsel’s criteria
Nugent’s criteria
Early treatment (<20 wks)
may reduce risk of
premature rupture of the
membranes and low birth
weight
Module I
8.8
Vitamin D
Women considered
Blood test for
Women at high risk of
Module I
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Condition
Offer test to:
Test(s)
Follow-up
deficiency
to be at risk
serum 25-OHD
deficiency may benefit
from supplementation
Notes:
Section
8.9
*
Psychosocial support, partner testing and contact tracing is required for women with a sexually
transmitted infection.
** Specialist care and psychosocial support are required for women with hepatitis C.
25-OHD=25-hydroxyvitamin D; PCR=polymerase chain reaction; RNA=ribonucleic acid.
Considerations before testing
Before tests are carried out, it is essential that:
•
women are informed that it is their choice to have tests;
•
women are able to give informed consent — verbal discussion should cover the reasons for testing,
harms and benefits and associated treatments and be supported by appropriate resources
(eg written materials, audio or video);
•
women have opportunities to ask questions about tests and treatments;
•
women are reassured that test results remain confidential (unless the condition is notifiable);
•
discussions about consent are documented by the health professional involved;
•
women who decline testing are offered the opportunity to discuss any concerns they may have
without being coerced to reconsider the test; and
•
there are processes for follow-up of women with a positive test result, their babies and, in some
situations, partners.
Discussion of testing should be approached with sensitivity, particularly when there is a potential for
testing to raise maternal anxiety or if testing is for a sexually transmitted infection.
Considerations after a positive test result
•
Referral for specialist care: For some conditions, such as haemoglobin disorders and thyroid
dysfunction, specialist involvement will be required.
•
Psychosocial support: Diagnosis of a condition that may affect pregnancy and/or the health of the
baby can be distressing, particularly if there are no interventions that can change outcomes.
Women should be given information about available supports and assisted to access these.
•
Sexually transmitted infections: If a sexually transmitted infection is identified, there is an increased
risk of other sexually transmitted infections. Partner testing and contact tracing are also advisable.
•
Blood-borne infections: Specific supports are likely to be required for women identified as using
intravenous drugs.
•
Notification: State/Territory legislation on notification of communicable diseases must be followed.
Type of test
The tests discussed in this section are those currently in use in Australia. With continuous advances in
technology and testing, techniques change rapidly. The most appropriate test may also depend on
the particular clinical setting.
Testing in rural and remote areas
It is acknowledged that in Australia, access to tests may vary (eg due to distance from pathology
services), storing tests and samples appropriately may be challenging (eg due to high temperatures or
humidity) and there may be difficulties in recalling women to receive test results. In these situations,
resources should be focused on responding to local needs (eg ensuring that tests are available to
identify highly prevalent conditions).
Screening for diabetes during pregnancy
Diabetes diagnosed during pregnancy (gestational diabetes) is a complex area and approaches to
screening, diagnosis and treatment are currently being reviewed by a number of relevant organisations
including the World Health Organization, Australasian Diabetes in Pregnancy Society, Royal Australian
and New Zealand College of Obstetricians and Gynaecologists, the Royal Australian College of
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Pathologists and the New Zealand Ministry of Health. Consequently an additional review of
the gestational diabetes literature was not conducted as part of the development of these Guidelines.
It is anticipated that a separate evidence-based guideline on diabetes and pregnancy will be need to
be prepared in the future and that a summary of relevant guidance be included in future versions of
these Guidelines.