What is the recommended treatment for gonorrhea (Gonococcal infection) in a pregnant woman at 28 weeks gestation?

Treatment for Gonorrhea in Pregnancy at 28 Weeks Gestation

For a pregnant woman at 28 weeks gestation with gonorrhea, the recommended treatment is ceftriaxone 500 mg IM as a single dose, which should be administered together with azithromycin 1 g orally as a single dose. 1, 2, 3

First-Line Treatment

• Recommended regimen:
  • Ceftriaxone 500 mg IM as a single dose
  • PLUS
  • Azithromycin 1 g orally as a single dose

This dual therapy approach is specifically recommended for pregnant women with gonorrhea by the Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists (ACOG) 2, 3.

Rationale for Treatment Choice

• Ceftriaxone remains highly effective against Neisseria gonorrhoeae with low resistance rates
• Dual therapy helps prevent the development of antimicrobial resistance
• Azithromycin addresses possible co-infection with Chlamydia trachomatis, which is common with gonorrheal infections
• This regimen is safe for use during pregnancy, including the third trimester 1, 2

Alternative Treatment Options

If ceftriaxone is unavailable or the patient has severe cephalosporin allergy:

• Alternative regimen:
  • Cefixime 400 mg orally as a single dose 1, 4
  • PLUS
  • Azithromycin 1 g orally as a single dose

For patients with severe beta-lactam allergy:

• Spectinomycin 2 g IM as a single dose (if available) 5, 4

Important Considerations

1. Avoid contraindicated medications:

   • Tetracyclines (including doxycycline) are contraindicated in pregnancy 5, 1
   • Fluoroquinolones (ciprofloxacin, levofloxacin) are contraindicated in pregnancy 1, 4

2. Partner treatment:

   • All sexual partners from the previous 60 days should be evaluated and treated 1
   • Advise abstinence until both patient and partner(s) complete treatment and are symptom-free

3. Follow-up testing:

   • Pregnant women should be retested in the third trimester (if not already in third trimester) 2, 3
   • No test-of-cure is needed if recommended treatment is used and symptoms resolve
   • Retest approximately 3 months after treatment due to high risk of reinfection 2, 3

4. Additional screening:

   • Test for other STIs including HIV, syphilis, and hepatitis B
   • Untreated gonorrhea during pregnancy increases risk of premature rupture of membranes, preterm birth, and vertical transmission to the newborn

Clinical Pearls

• Administer both medications on the same day, preferably simultaneously under direct observation
• Symptoms may include vaginal discharge, dysuria, or pelvic pain, but many pregnant women with gonorrhea are asymptomatic
• Untreated gonorrhea can lead to serious complications including pelvic inflammatory disease and increased risk of HIV transmission
• N. gonorrhoeae has developed resistance to multiple antibiotics including penicillins, tetracyclines, and fluoroquinolones, making adherence to current treatment guidelines essential

By following these evidence-based recommendations, clinicians can effectively treat gonorrhea in pregnant women while minimizing risks to both mother and fetus.