Keep Screening! Maternal Gonococcal Infection and Adverse Birth Outcomes.

TLDR: A large, population-based, retrospective cohort to evaluate the association between maternal NG infection and adverse birth outcomes, and a wide array of potential confounders was evaluated, including maternal socioeconomic status, maternal health, and presence of other maternal co-infections.

Abstract: The association betweenmaternalNeisseria gonorrhoeae (NG) infection and adverse birth outcomes has rarely been adequately evaluated using population-based records. In this issue of Sexually Transmitted Diseases, Heumann et al. used a population-based, retrospective cohort to evaluate the association between maternal NG infection and adverse birth outcomes. Data were gathered from birth certificates and hospital discharge data inWashington State between 2003 and 2014. The study compared outcomes among women identified with “present and/or treated” NG during their pregnancy to those who were not. Primary outcomes included low birth weight, small for gestational age, and preterm delivery. Secondary outcomes included prolonged premature rupture of membranes (PROM), chorioamnionitis, and neonatal intensive care unit admission. Covariates included age, race/ethnicity, education, marital status, parity, maternal smoking, maternal diabetes, use ofWomen, Infants, and Children Program, prior preterm birth, prenatal care, insurance status, and presence of other maternal infections. In their study, maternal NG infection was associated with increased odds of low birth weight and small for gestational age infants. Specifically, maternal NG infection was associated with 40% increased odds of a low birth weight infant, adjusted for maternal smoking and marital status. Women with NG infection during pregnancy also had 60% increased odds of a small for gestational age infant. No confounders were found for the associations. Women with NG infection during pregnancy were more likely to be young, less educated, black, single, multiparous, and smokers. No associations were found between maternal NG infection and preterm delivery, prolonged PROM, chorioamnionitis, or neonatal intensive care unit admission. The study had numerous strengths. The large, population-based sample of 4095 women was a significant advantage. Prior studies evaluating maternal NG infection and adverse birth outcomes were unable to quantify accurately the magnitude of potential risks. The larger sample size provided more precise measures of the risk of NG infection during pregnancy. A second strength of this study was the biological plausibility of the results. During pregnancy, NG may cause a low-grade infection of the placenta, maternal decidua, or fetal membrane, leading to intrauterine growth restriction. Intrauterine growth restriction subsequently may result in low birth weight or small for gestational age infants. Perhaps the most significant strength of this study was that a wide array of potential confounders was evaluated, including maternal socioeconomic status, maternal health, and presence of other maternal co-infections. Those considerations help reduce the likelihood that unrelated factors influenced the findings and strengthen the specificity of the effect. Though the use of birth certificates to collect exposures and outcome measures had advantages in terms of enabling a large study size, it also contributed to several limitations. Exposure was determined based on a checked box identifying a “present and/or treated” NG infection during pregnancy. Since those measures were gathered from hospitals within Washington State, it is likely that most women’s infections were treated according to standard medical practice. Thus, the study actually analyzed the association between treated maternal NG infection and adverse outcomes. Several studies have shown that antibiotic treatment of NG infection during pregnancy improves birth outcomes. Therefore, antibiotic treatment perhaps explains why adverse outcomes previously associated with untreated NG infection, such as preterm delivery, were not found in this study. Since women whose NG infections were presumably cured with antibiotics still experienced adverse birth outcomes, women with untreated NG infections are likely at an even higher risk. The fact that treated NG infections still lead to adverse outcomes reinforces the need for primary prevention and the importance of early pregnancy NG screening.