Can a woman with chlamydia (Chlamydia trachomatis) deliver vaginally at the time of delivery?

Vaginal Delivery with Chlamydia at Time of Delivery

Yes, vaginal delivery is appropriate for women with chlamydia infection at the time of delivery, as chlamydia is not considered an indication for cesarean section. 1, 2

Risk of Transmission and Complications

• Nearly two-thirds of infants born vaginally to mothers with chlamydial infection become infected during delivery 2
• 15-25% of exposed infants develop chlamydial conjunctivitis despite prophylaxis 2
• 3-16% develop chlamydial pneumonia, which can lead to abnormal pulmonary function later in childhood 2
• Transmission can occur regardless of delivery mode, though rates are somewhat lower with cesarean section after membrane rupture 3

Management Approach

Maternal Treatment

• Pregnant women diagnosed with chlamydia should receive prompt antibiotic treatment

• Recommended regimens for pregnant women 1:

  • Erythromycin base 500 mg orally four times a day for 7 days, OR
  • Amoxicillin 500 mg orally three times a day for 7 days

• Alternative regimens 1:

  • Erythromycin base 250 mg orally four times a day for 14 days, OR
  • Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days, OR
  • Erythromycin ethylsuccinate 400 mg orally four times a day for 14 days, OR
  • Azithromycin 1 g orally in a single dose

• Note: Doxycycline and ofloxacin are contraindicated during pregnancy 1

• Important: Erythromycin estolate is contraindicated during pregnancy due to drug-related hepatotoxicity 1

Neonatal Management

• All newborns exposed to maternal chlamydia should be monitored for signs of:

  • Conjunctivitis (typically develops 5-12 days after birth)
  • Pneumonia (typically onset 1-3 months of age)

• If infection occurs, recommended treatment 1:

  • Erythromycin 50 mg/kg/day orally divided into four doses daily for 10-14 days
  • Topical antibiotic therapy alone is inadequate and unnecessary when systemic treatment is administered

• Follow-up is recommended as treatment efficacy is approximately 80%, and a second course may be required 1

Prevention Strategies

1. Prenatal Screening:

   • Screen all pregnant women under 25 years of age
   • Screen pregnant women with new or multiple sex partners
   • Ideally screen during both first prenatal visit and third trimester 1, 2

2. Partner Treatment:

   • Treat all sexual partners to prevent reinfection 1
   • Timely treatment of partners is essential for decreasing reinfection risk

3. Postpartum Follow-up:

   • Repeat testing 3 weeks after completion of therapy is recommended during pregnancy 1
   • Monitor for postpartum complications, as infected women are at risk for postpartum PID and endometritis 1, 2

Key Points for Clinicians

• Chlamydia infection is not an indication for cesarean delivery 1
• The risk of transmission exists regardless of delivery mode, though slightly lower with cesarean section 3
• Proper treatment of the mother before delivery is the best prevention strategy
• If chlamydia is diagnosed at delivery, treatment should be initiated immediately for both mother and partners
• Neonatal prophylaxis with silver nitrate or antibiotic ointments does not prevent chlamydial transmission but should be continued for prevention of gonococcal ophthalmia 1

Common Pitfalls to Avoid

• Assuming cesarean section will prevent transmission - evidence shows transmission can occur even with intact membranes 4
• Relying on topical treatment alone for infected infants - systemic treatment is necessary 1
• Failing to treat partners, which leads to high reinfection rates
• Using doxycycline or ofloxacin in pregnant women, which are contraindicated 1
• Inadequate follow-up of treated pregnant women and their infants

By following these guidelines, clinicians can appropriately manage pregnant women with chlamydia at delivery while minimizing complications for both mother and infant.