Treatment of Sexually Transmitted Diseases During Pregnancy
Penicillin remains the only proven effective treatment for syphilis in pregnancy, and pregnant women with penicillin allergies should undergo desensitization rather than receiving alternative antibiotics. For chlamydia, azithromycin is now the first-line treatment during pregnancy, while specific regimens exist for other STDs to balance maternal treatment with fetal safety.
Syphilis Treatment in Pregnancy
Primary Recommendation
- Penicillin is the only proven effective treatment for preventing maternal transmission of syphilis to the fetus 1
- Appropriate regimen depends on stage of infection:
- Primary, secondary, or early latent syphilis: Benzathine penicillin G 2.4 million units IM in a single dose
- Late latent syphilis or syphilis of unknown duration: Benzathine penicillin G 2.4 million units IM weekly for 3 weeks
Special Considerations
- For women in second half of pregnancy, sonographic fetal evaluation for congenital syphilis is recommended but should not delay therapy 1
- Women treated during second half of pregnancy should be advised to seek obstetric attention if they experience fever, contractions, or decreased fetal movement due to potential Jarisch-Herxheimer reaction 1
- Some experts recommend an additional dose of benzathine penicillin 2.4 million units IM one week after initial dose for primary, secondary, or early latent syphilis 1
- Penicillin-allergic patients must undergo desensitization as no alternatives have proven effective during pregnancy 1
- Tetracycline, doxycycline, and erythromycin are contraindicated (erythromycin does not reliably cure an infected fetus) 1
Follow-up
- Serologic titers should be repeated in the third trimester and at delivery 1
- Monthly serologic testing may be appropriate in high-risk women or high-prevalence areas 1
- No infant should leave the hospital without maternal serologic status documented at least once during pregnancy 1
Chlamydia Treatment in Pregnancy
Primary Recommendation
- Azithromycin 1g orally in a single dose is now the first-line treatment for chlamydial infections in pregnant women 2
- Offers high compliance rate, demonstrated safety in pregnancy, and proven efficacy
Alternative Regimens
- Amoxicillin 500mg orally three times daily for 7 days 1, 2, 3
- Clinical cure rate approximately 92% 3
- Erythromycin base 500mg orally four times daily for 7 days 1, 4
- Clinical cure rate approximately 86% 3
- May cause gastrointestinal side effects affecting compliance
Contraindicated Treatments
- Doxycycline and fluoroquinolones (ofloxacin, levofloxacin) are contraindicated during pregnancy 1, 2
- Erythromycin estolate is contraindicated due to risk of maternal hepatotoxicity 1, 2
Follow-up
- Test of cure recommended 3 weeks after treatment completion 2
- Partners from previous 60 days should be evaluated and treated 1, 2
- Patients should abstain from sexual intercourse until both they and their partners have completed treatment 1
Gonorrhea Treatment in Pregnancy
Primary Recommendation
- Ceftriaxone 250mg IM as a single dose 2, 5
- For co-infection with chlamydia, add azithromycin 1g orally as a single dose 2
Contraindications
- Fluoroquinolones are contraindicated during pregnancy despite good safety records after accidental use 5
Trichomoniasis and Bacterial Vaginosis
Treatment Recommendations
- Metronidazole 500mg twice daily for 7 days for trichomoniasis 5
- Earlier concerns about teratogenesis not confirmed by recent data
- For bacterial vaginosis in women with risk factors for preterm delivery: oral metronidazole 1g/day for 5 days 5
General Considerations for STD Management in Pregnancy
Screening
- All pregnant women should be screened serologically for syphilis early in pregnancy 1
- Pregnant women <25 years of age should be screened for chlamydia 2
- Consider screening for other STDs based on risk factors and local prevalence
Partner Management
- Treatment of sex partners is essential to prevent reinfection 1, 2
- All patients with STDs should be offered HIV testing 1
Test of Cure
- Recommended for most STDs in pregnancy due to:
Pitfalls and Caveats
- Never substitute alternative antibiotics for penicillin in treating syphilis during pregnancy - desensitization is required for penicillin-allergic patients
- Do not delay treatment of syphilis due to concerns about Jarisch-Herxheimer reaction
- Avoid erythromycin estolate due to risk of maternal hepatotoxicity
- Remember that neonatal ocular prophylaxis does not prevent perinatal transmission of chlamydia 2
- Every diagnosis of an STD warrants full screening for concomitant genital infections 5