CONSULTATION DRAFT
7.3
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.
7.3.1
Background
Gonorrhoea is a sexually acquired infection caused by Neisseria gonorrhoea. 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 screening tests can accurately detect gonorrhoea infection and that antibiotics are effective in its treatment ( USPSTF 2005 ).
Diagnoses of gonorrhoea in Australia
Data on diagnoses of gonorrhoea are incomplete and may provide a distorted view of population rates in Australia. Differences in rates of diagnosis between areas and populations may reflect a range of factors, including variations in approaches to offering testing, the uptake of testing, access to services, and recording of Indigenous status. Rates reported vary by community and will be higher if local screening programs are in place or research is being carried out.
• Rates of diagnosis: In 2011, rates of diagnoses of gonorrhoea per 100,000 population were 52 in the general population overall; 22 among non-Indigenous Australians and 673 among Aboriginal and
Torres Strait Islanders living in states and territories other than ACT and NSW ( Kirby Inst 2012 ). The rate of diagnosis was lowest in inner regional areas and increased with remoteness among both non-
Indigenous Australians and Aboriginal and Torres Strait Islanders ( Kirby Inst 2012 ).
• 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 ).
• Age distribution: Among women, approximately 75% of diagnoses of gonorrheoa in 2011 were in the 15–29 year age group ( Kirby Inst 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 ).
Risks associated with gonorrhoea in pregnancy
Untreated gonorrhoea during pregnancy is associated with adverse obstetric outcomes including ectopic pregnancy, septic spontaneous abortion, 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 ).

CONSULTATION DRAFT
7.3.2
Screening for gonorrhoea
While screening all women for gonorrhoea during pregnancy is recommended in Canada ( PHAC 2008 ), a number of bodies in the United States recommend screening only women at high risk ( AAP 2002; ACOG
2003; AAFP 2004; USPSTF 2005 ). The Royal Australian College of General Practitioners (RACGP) also supports screening 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.
Summary of the evidence
Diagnostic accuracy of tests
In Australia, culture methods for detection of N. gonorrhoeae have been increasingly replaced by nucleic acid detection tests, 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.
Harms and benefits of screening
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 screening include false-positive test 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 screening women at increased risk ( USPSTF 2005 ).
No evidence on the cost-effectiveness of screening for gonorrhoea in pregnancy was identified.
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.
Consensus-based recommendation xii
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 live in or come from areas where prevalence is high.

CONSULTATION DRAFT
7.3.3
Discussing gonorrhoea
Discussion to inform a woman’s decision-making about gonorrhoea screening should take place before testing takes place and include:
• it is the woman’s choice whether she has the test or not;
• 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 abortion, 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; and
• repeat testing for gonorrhoea may be needed for women at ongoing risk of infection.
7.3.4
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.
Discuss the reasons for gonorrhoea screening: Explain that it is important to find out whether a woman has gonorrhoea because of the effects that 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.
7.3.5
Resources
AGSP (2011) Australian Gonococcal Surveillance Programme Annual Report, 2010. Commun Dis Intell 35(3): 229–36.
PHAC (2008) Canadian Guidelines on Sexually Transmitted Infections, 2008 Edition. Ottawa, ON: Public Health
Agency of Canada.
Sexually transmitted infections (STIs) in pregnancy. In: Minymaku Kutju Tjukurpa Women’s Business Manual, 4th
edition. Congress Alukura, Nganampa Health Council Inc and Centre for Remote Health. http://www.remotephcmanuals.com.au
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.
7.3.6
References
AAFP (2004) Recommendations for Periodic Health Examinations, August 2004. American Academy of Family
Physicians. http://www.aafp.org/x24975.xml.
AAP (2002) Guidelines for Perinatal Care 5th ed. Elk Grove Village, IL: American Academy of Pediatrics, Washington,
DC: American College of Obstetricians and Gynecologists.
ACOG (2003) Primary and preventive care: periodic assessments. American College of Obstetricians and
Gynecologists Committee Opinion. Obstet Gynecol 102: 1117–24.
Aledort JE, Hook EW 3rd, Weinstein MC et al (2005) The cost effectiveness of gonorrhea screening in urban emergency departments. Sex Transm Dis 32(7):4 25–36.

CONSULTATION DRAFT
Brocklehurst P (2009) Antibiotics for gonorrhoea in pregnancy. Cochrane Database Sys Rev 2002, Issue 2. Art. No.:
CD000098. DOI: 10.1002/14651858.CD000098.
CDC (2004) Sexually Transmitted Disease Surveillance Report 2003. Atlanta: Centers for Disease Control and
Prevention.
Darling E (2009) Prenatal screening for chlamydia and gonorrhea: an evidence based approach. Can J Midwifery
Res Pract 8(2): 6-14.
Fransen L, Nsaze H, Klauss V et al (1986) Ophthalmia neonatorum in Nairobi, Kenya, the role of Neisseria gonorrhoea and Chlamydia trachomatis. J Infect Dis 153: 862–69.
Galega FP, Heymann DL, Nasah BT (1984) Gonococcal ophthalmia neonatorum: the case of prophylaxis in tropical
Africa. Bull WHO 61: 95–98.
Goldenberg RL, Culhane JF, Johnson DC (2005) Maternal infection and adverse fetal and neonatal outcomes. Clin
Perinatol 32: 523–59.
Hollier LM & Workowski K (2005) Treatment of sexually transmitted infections in pregnancy. Clin Perinatol 32(3): 629–
56.
Mehta SD, Bishai D, Howell MR et al (2002) Cost-effectiveness of five strategies for gonorrhea and chlamydia control among female and male emergency department patients. Sex Transm Dis 29(2): 83–91.
Miller JM Jr, Maupin RT, Mestad RE et al (2003) Initial and repeated screening for gonorrhea during pregnancy. Sex
Transm Dis 30(9): 728–30.
NCHECR (2009) Annual Surveillance Report. National Centre for HIV Epidemiology and Clinical Research. Sydney:
University of New South Wales.
NCHECR (2010) Bloodborne Viral and Sexually Transmitted Infections in Aboriginal and Torres Strait Islander People:
Surveillance and Evaluation Report 2010. Sydney: National Centre in HIV Epidemiology and Clinical
Research, The University of New South Wales.
Niccolai LM, Ethier KA, Kershaw TS et al (2003) Pregnant adolescents at risk: sexual behaviors and sexually transmitted disease prevalence. Am J Obstet Gynecol 188(1): 63–70.
PHAC (2008) Canadian Guidelines on Sexually Transmitted Infections, 2008 Edition. Ottawa, ON: Public Health
Agency of Canada.
RACGP (2009) Guidelines for Preventive Activities in General Practice 7th edition. Melbourne: Royal Australian
College of General Practitioners.
Schachter J, Chernesky MA, Willis DE et al (2005) Vaginal swabs are the specimens of choice when screening for
Chlamydia trachomatis and Neisseria gonorrhoeae: results from a multicenter evaluation of the APTIMA assays for both infections. Sex Transm Dis 32(12): 725–28.
Smith DW, Tapsall JW, Lum G (2005) Guidelines for the use and interpretation of nucleic acid detection tests for
Neisseria gonorrhoeae in Australia: A position paper on behalf of the Public Health Laboratory Network.
Comm DIs Intel 29(4): 358–65.
Sullivan EA, Koro S, Tabrizi S et al (2004) Prevalence of sexually transmitted diseases and human immunodeficiency virus among women attending prenatal services in Apia, Samoa. Int J STD AIDS 15(2): 116–19.
USPSTF (2005) Screening for gonorrhea: recommendation statement. United States Preventive Services Task Force.
Am Fam Physician 72(9): 1783–86.
WHO (2012) Global Incidence and Prevalence of Selected Curable Sexually Transmitted Infections - 2008. Geneva:
World Health Organization.