It’s often hard to get the information we need about STIs — everything’s so hush-hush and can feel stigmatized. But the truth is, STIs are incredibly common (one in two sexually active people will contract one before the age of 25, according to the American Sexual Health Association — yes, that’s half of sexually active people), and just like any other infection, they’re nothing to be ashamed of. Since having an STI can sometimes affect pregnancy and birth, we’re here to take a look at the facts. That way, you can make decisions that are right for you and your pregnancy, whether you’re trying to conceive, currently pregnant, or are thinking about it down the road.
First off, why are we calling them STIs? Is STD out of style?
Well, in a way, it is. And there’s an important reason why. Even though STD (sexually transmitted disease) has been the more common term, a disease generally refers to a medical problem with obvious signs or symptoms. But the “i” in STI stands for infection — infections often have mild symptoms that can be overlooked, or no symptoms at all. That means many folks have STIs they don’t even know about. The term STI is thought to be more broad and inclusive, and underlines the importance of getting tested.
Just because you don’t have any symptoms doesn’t mean you don’t have an STI that could affect pregnancy and birth. While that may sound scary, knowing your sexual health information is part of making empowered decisions. The vast majority of STIs can be cleared up by 1) knowing you have an STI in the first place and 2) taking medication to resolve it. (For STIs that can’t be cleared with medication, we’ll talk through the options for healthy pregnancy and birth.)
Which STIs can affect pregnancy and birth? What do I need to know? Dr. Donna Crowe filled us in on all the details. First, we’ll focus our attention on the STIs that can be resolved with a course of medication. Then, we’ll talk about options for a healthy pregnancy and delivery for STIs that people manage long-term — ones that can’t be completely cleared.
MF: What’s your general philosophy when it comes to STIs and pregnancy?
Dr. Crowe: To start off with, we never judge people based on STIs. The bacteria, viruses, and parasites that can be sexually transmitted are simply looking for a less crowded neighborhood in which to live. If you have unprotected intercourse with someone and could get pregnant, you can get a sexually transmitted disease — one your partner may not be aware they have.
We follow CDC guidelines for screening patients for STIs. We screen for diseases that can be treated and cured preconceptually (such as gonorrhea and chlamydia).
MF: So, let’s take a look at those two (gonorrhea and chlamydia) as well as any others that could be tested for and then completely cleared. How could they affect pregnancy and birth?
Dr. Crowe: Among others, that list would include chlamydia, gonorrhea, and syphilis.
Chlamydia is the most common STI currently in the United States. The dangers to the pregnancy with chlamydia are preterm labor, preterm rupture of membranes, or babies who are small for their gestational age. The dangers to the baby from exposure at delivery include eye and lung infections that can cause lifelong damage. The most common symptoms of chlamydia are discharge and pelvic pain, but patients do not always have symptoms. Thankfully, chlamydia is easily cured with antibiotics and all our patients are screened for this infection at their first appointment.
Gonorrhea is a common infection that may tag along with chlamydia. Gonorrhea is linked to miscarriage, preterm delivery, premature rupture of membranes and infections of the water and sac surrounding the baby. During delivery, like with chlamydia, infants can get an infection in their eyes. Gonorrhea is easily treated with antibiotics and we also screen all patients for gonorrhea at their first visit.
Syphilis is a bacterial infection that is currently on the rise in the United States. This infection can also be cured with antibiotics. If left untreated, it can have profound long-standing effects on the baby including developmental delays, preterm birth, and stillbirth, as well as vision and hearing difficulties. As with chlamydia and gonorrhea, we screen all women for syphilis at their first appointment and treat accordingly.
MF: OK, so for the list above, screening happens very early on and the infections can be completely cleared with antibiotics. Let’s talk about viral STIs and what you recommend to your patients.
Dr. Crowe: Sure. We’ll cover herpes simplex virus (HSV), human immunodeficiency virus (HIV), human papillomavirus (HPV), and hepatitis B.
Herpes simplex virus (HSV) is a viral infection that can live in the genital area as well as in the oral area. There are two types HSV-1 and HSV-2 (clever naming, right?). These viruses can live in either place, although historically, HSV-1 was more likely oral and HSV-2 was more likely genital. A herpes infection is associated with itching and burning followed by blisters and sores. Herpes is more likely to be transmitted to the baby if it’s a mother's first exposure to the virus. A herpes infection can be devastating to a newborn, involving skin infections, severe brain infections and multiple organ infections. Since HSV can be so damaging to the baby, a Cesarean section is recommended for mothers with an active herpes outbreak. If a mother is a known carrier of herpes, we put her on antiviral suppression medications during the last few weeks to decrease her likelihood of outbreak.
Human immunodeficiency virus (HIV) is the virus that causes AIDS. It can be transmitted sexually or through blood and body fluid interactions such as needle sharing. Babies can be infected during pregnancy, birth, or breast feeding and then require a lifetime of medication to keep the virus in check. When a mother is diagnosed before or during pregnancy, multiple steps can be taken that lower the risk of transmission to around 2 percent. Mothers who are HIV positive should be cared for in partnership with doctors who specialize in HIV care. It is important to have ongoing treatment to bring the rate of transmission down as low as possible. All women are screened for HIV at their first prenatal visit and are offered screening again at 28 weeks.
Hepatitis B is a viral infection of the liver that circulates through the bloodstream. It can also be transmitted sexually or through blood exposure, like from shared needles. For infants who are infected with hepatitis B during pregnancy and delivery, 40 percent will develop chronic active hepatitis, a debilitating chronic liver disease. And 25 percent of those infants with chronic active hepatitis will die from liver disease. There is treatment during pregnancy that can considerably lower the risk to the baby. Antiviral medications can lower the amount of virus in the mother's blood stream to decrease transmission. In addition, giving the baby the hepatitis B vaccine and additional immunoglobulin (virus-fighting particles made by the body in response to an infection) specific for hepatitis B can markedly decrease transmission. We screen all women for hepatitis B and coordinate care with high risk doctors and pediatricians for mothers who carry the virus.
And finally, let’s talk about human papillomavirus (HPV). HPV is a set of viruses that can cause warts and/or precancerous changes to some cells. Many warts can actually grow in response to the hormones of pregnancy. If the warts obstruct the birth canal, a Cesarean section is indicated. Genital warts can cause a rare laryngeal papillomatosis in the newborn that requires surgical therapy–a Cesarean section decreases that risk significantly.
MF: Great. Thanks so much, Dr. Crowe.
OK — that’s a lot of info. So what’s the takeaway here?
Basically, the more information you have, the better. Your care provider will likely test for the whole gamut of STIs during your first prenatal appointment. And, like Dr. Crowe said, many of these STIs can be completely cleared with antibiotics. As for the ones that can’t, it’s all about minimizing risk, and a trusted professional can you help make those decisions (like helping get antivirals ready to reduce the risk of an HPV outbreak, or coordinating a high-risk doctor to help navigate delivery with hepatitis B).
Beyond all of the precautions and planning, it’s also incredibly important to have support. Project Accept is an online community for folks with HSV and HPV. Also, hearing stories from others who are going through similar situations can make all the difference — we love this essay in Marie Claire about a woman conceiving with herpes. With nearly 20 million new STIs occurring every year, you’re absolutely not alone if you’re conceiving with an STI.