Gonorrhoea During Pregnancy: Risks And Management

Understanding gonorrhoea

Gonorrhoea is a common sexually transmitted infection caused by the bacterium Neisseria gonorrhoeae. This bacterial infection also referred to as ‘the clap’, is primarily transmitted through sexual contact and is one of 30 sexually transmitted infections (STIs).¹ Although gonorrhoea is usually sexually transmitted, it can also develop during pregnancy through direct contact with another individual's infected eyes, urethra, vagina, mouth, penis, or anus. Gonorrhoea poses significant health risks, particularly during pregnancy, as the infection can be passed from an infected mother to her baby in childbirth. Worldwide reported cases reached approximately 82.4 million in 2020, highlighting the need for vigilant screening and management.² If left untreated during pregnancy, gonorrhoea can lead to an increased risk of miscarriage, preterm delivery, and pelvic inflammatory disease (PID). Moreover, gonorrhoea also increases the risk of an ectopic pregnancy and complications during delivery. Some STIs are commonly screened for during the first prenatal visit, but further screening at future appointments might be necessary.

Causes of gonorrhoea

Gonorrhoea is primarily transmitted through sexual contact including vaginal, anal, and oral sex. Vertical transmission (transmission from mother to offspring) can occur during childbirth or in utero. Other factors that increase the risk of developing gonorrhoea include:³

• Having multiple sexual partners
• Having a partner with a past history of  STIs
• Not using a condom during sex
• Use of alcohol or illegal substances

Despite this infection being highly contagious, it is important to note the following do not cause gonorrhoea :

• Kissing, hugging, or holding hands.
• Sharing food, drinks, or cutlery.
• Using a toilet after someone else (i.e., toilet seats).

Symptoms of gonorrhea in pregnant women 

Half of infected women with gonorrhoea are asymptomatic (do not present any symptoms).⁴ However, some common symptoms that usually appear 2 weeks after infection include: 

• Unusual vaginal discharge, including greenish or yellow discharge
• Pain or burning sensation during urination
• Pain during sexual intercourse
• Bleeding after sexual intercourse
• Severe pain in the lower abdomen (if the infection spreads to the fallopian tubes and uterus area)
• Fever (if the infection spreads to the fallopian tubes and uterus area)
• Abnormal uterine bleeding

Risk factors and complications of gonorrhoea during pregnancy

Maternal health risks

Research indicates that the delayed treatment of gonorrhoea during pregnancy is associated with serious and often permanent conditions, such as pelvic inflammatory disease (PID). PID occurs when the infection spreads from the cervix to the upper genital tract, causing inflammation and damage to the reproductive organs. You are also more likely to experience complications the more you contract gonorrhoea. Prompt treatment significantly reduces the risk of such complications.⁵ Other health issues related to PID include:

• Ectopic Pregnancy: This occurs when a fertilised egg implants outside the uterus, often in a fallopian tube. PID can cause scarring in the fallopian tubes, increasing the likelihood of an ectopic pregnancy. This complication can be life-threatening if not treated promptly
• Pelvic Pain: Chronic pelvic pain is a common consequence of PID. The inflammation and scarring can lead to persistent discomfort and pain in the pelvic region, which significantly impacts quality of life
• Infertility: PID can cause damage and blockages in the fallopian tubes, preventing the fertilization of the sperm and egg. This can lead to infertility, making it difficult for a woman to conceive naturally.
• Inflammatory Response: The body's immune response to gonorrhoea involves inflammation, which usually results in tissue damage and scarring. This inflammation is responsible for many of the complications associated with PID, such as chronic pelvic pain and infertility
• Complications During Delivery: Infections like gonorrhoea can complicate the delivery process, increasing the risk of infections and other complications for the mother and the baby⁶

Foetal and neonatal health risks

Gonorrhea also poses significant risks to the foetus or newborn. One of the most concerning complications is the transmission of the infection from the mother to the baby during delivery, as this can lead to several severe health issues:

• Neonatal Conjunctivitis (Ophthalmia Neonatorum): Newborns can contract gonorrhoea as they pass through the birth canal. This can result in severe conjunctivitis, which manifests as redness, swelling, and discharge from the baby's eyes. If not treated promptly with the appropriate antibiotics, it can lead to blindness
• Neonatal Sepsis: Gonorrhoea can cause systemic infections (i.e., affecting the entire body) in newborns, leading to neonatal sepsis. This is a life-threatening condition characterised by a severe widespread infection, that can cause organ failure or even death if not treated promptly
• Preterm Birth and Low Birth Weight: Gonorrhoea infection during pregnancy can trigger premature labour, resulting in preterm birth. Babies born prematurely often have low birth weight and are at higher risk for various health conditions, including respiratory issues, developmental delays, and infections
• Increased Risk of Premature Labour: The inflammatory response to gonorrhoea can induce premature labour, putting both the mother and the baby at risk. Preterm labour can also lead to a host of complications for the newborn, including underdeveloped organs and systems⁷

Diagnosis

Screening recommendations 

While early diagnosis (within the first 2 weeks) may not be possible due to a lack of symptoms, early detection is crucial in the prevention of further complications. A timely diagnosis allows for appropriate treatment, reducing the risk of adverse outcomes for both the mother and the baby. A swab test is usually undertaken to collect a sample from the vagina, cervix, or urethra to diagnose gonorrhoea during pregnancy. Self-testing using a swab test is also possible. Other diagnostic methods include nucleic acid amplification tests (NAATs) and culture tests, which have proven to be highly effective in detecting these types of infections.⁸

Management and treatment protocols for gonorrhoea in pregnant women 

The recommended treatment for gonorrhoea in pregnant women involves antibiotics such as ceftriaxone and azithromycin, which are safe during pregnancy. Ceftriaxone leads to the weakening of the bacterial cell wall, causing it to rupture and ultimately resulting in the death of the bacteria.⁹ Ceftriaxone is usually administered as an injection. On the other hand, Azithromycin works by preventing the bacteria from producing essential proteins required for their growth and replication, leading to bacterial death. Azithromycin is administered orally as a tablet, which provides a convenient and effective method of delivering the antibiotic.¹⁰  

Effective treatment eradicates the infection and reduces the risk of transmission to the baby. Babies with signs of a gonorrhoea infection at birth or those with an increased risk of infection will usually be given antibiotics immediately after they are born. You will be advised to avoid sexual contact until you have completed the course of antibiotics and have tested negative.

Management of newborns

• Immediate Antibiotic Administration: Babies born to mothers with gonorrhoea or those showing signs of infection at birth are given antibiotics immediately. This aims to prevent the onset of neonatal conjunctivitis (ophthalmia neonatorum) and other systemic infections
• Monitoring: Newborns receiving antibiotic treatment are closely monitored for any signs of adverse reactions or complications, ensuring prompt intervention if necessary¹¹

Preventative measures

• Screening: Routine screening for gonorrhoea during prenatal visits is essential for early detection and treatment. Pregnant women at high risk for STIs are typically screened during the first prenatal visit, and again in the third trimester¹²
• Education and Counseling: Educating pregnant women about the risks of STIs,  the importance of completing antibiotic treatments, and avoiding high-risk activities (e.g., unprotected sex) is crucial for preventing gonorrhoea and other infections¹³

FAQs

How can I reduce my risk of Gonorrhoea during pregnancy?

Taking extra care during sex can greatly reduce the risk of contracting gonorrhoea. Some steps to decrease your risk include :

• Use a condom or another form of external protection during sex (note that the use of internal contraceptive methods, such as the pill, does not offer STI protection).
• Avoid sex with someone who has an active infection or symptoms of gonorrhoea and STIs.
• Limiting sexual partners.
• Get tested for gonorrhoea and have your partners get tested.

When should I see a doctor?

It is important to get tested for gonorrhoea or any STIs promptly, as symptoms are not always present. You should contact your healthcare provider as soon as you suspect you may have gonorrhoea, but you may be advised to wait up to a week.

Summary

Gonorrhoea poses significant risks to both maternal and neonatal health, particularly during pregnancy. Prompt diagnosis and effective treatment with antibiotics, such as ceftriaxone and azithromycin, are essential to mitigate these risks. Routine screening, education, and counselling play critical roles in preventing gonorrhoea and ensuring the health and safety of both mother and baby. Understanding the mechanisms of transmission, symptoms, and complications of gonorrhoea, facilitates its treatment and management during pregnancy, ultimately improving outcomes for both the mother and newborn.