What is the most suitable recommendation for health promotion and illness prevention in a pregnant woman with a history of multiple sexually transmitted diseases (STDs) at 37 weeks gestation to prevent conjunctivitis and blindness in the newborn?

Azithromycin Administration for Maternal Treatment

The most suitable approach for health promotion and illness prevention in this pregnant woman at 37 weeks gestation with a history of multiple STDs is immediate azithromycin administration to treat presumed chlamydial infection and prevent neonatal ophthalmia. 1

Clinical Reasoning

The clinical scenario describes a high-risk presentation: a young woman with multiple prior STDs presenting late in pregnancy (37 weeks) without prenatal care. The obstetrician's concern about conjunctivitis and blindness in the newborn specifically points to Chlamydia trachomatis, which is the most frequent identifiable infectious cause of ophthalmia neonatorum. 1

Why Maternal Treatment is Critical

• Neonatal ocular prophylaxis alone does NOT prevent perinatal transmission of C. trachomatis from mother to infant, though it does prevent gonococcal ophthalmia. 1
• Prenatal screening and treatment of pregnant women can prevent chlamydial infection among neonates, making maternal treatment the most effective preventive strategy. 1
• C. trachomatis infection of neonates results from perinatal exposure to the mother's infected cervix, with conjunctivitis developing 5-12 days after birth and potential for pneumonia at 1-3 months of age. 1

Recommended Treatment Regimen

For pregnant women with suspected or confirmed chlamydial infection, azithromycin 1 g orally as a single dose is the recommended first-line treatment. 1

Alternative Regimens if Azithromycin is Unavailable

• Amoxicillin 500 mg orally three times daily for 7 days 1
• Erythromycin base 500 mg orally four times daily for 7 days 1
• Erythromycin base 250 mg orally four times daily for 14 days 1

Critical Contraindications in Pregnancy

• Doxycycline, ofloxacin, levofloxacin, and quinolones are absolutely contraindicated in pregnant women. 1
• Erythromycin estolate is contraindicated during pregnancy due to drug-related hepatotoxicity. 1

Why Other Options Are Inadequate

Reassurance Alone

• This is inappropriate given the high-risk presentation and the preventable nature of neonatal ophthalmia through maternal treatment. 1
• The prevalence of C. trachomatis infection among pregnant women is typically greater than 5%, regardless of race/ethnicity or socioeconomic status. 1

Newborn Screening After Delivery

• This is reactive rather than preventive and misses the critical window for preventing transmission during delivery. 1
• While neonatal treatment with erythromycin (50 mg/kg/day divided into 4 doses for 14 days) is only 80% effective and may require a second course, maternal treatment prevents infection entirely. 1

Referral to Infectious Disease Clinic

• This delays treatment unnecessarily when the diagnosis is clinically apparent and treatment is straightforward. 1
• At 37 weeks gestation, delivery is imminent, making immediate treatment essential.

Additional Management Considerations

• Test for co-infection with N. gonorrhoeae, as patients infected with gonorrhea are often co-infected with chlamydia. 1
• If gonococcal infection is confirmed, add ceftriaxone 250 mg IM as a single dose. 1
• Repeat testing 3 weeks after completion of therapy is recommended for all pregnant women to ensure therapeutic cure, given the potential sequelae for mother and neonate if infection persists. 1
• Sexual partner(s) must be evaluated and treated to prevent reinfection. 1
• The patient should abstain from sexual intercourse until she and her partner(s) have completed treatment. 1

Common Pitfalls to Avoid

• Do not delay treatment waiting for culture results in this late-presenting pregnant patient at term. 1
• Do not rely solely on neonatal prophylaxis with silver nitrate or antibiotic ointments, as these do not prevent chlamydial transmission. 1
• Do not prescribe doxycycline or fluoroquinolones to pregnant women under any circumstances. 1
• Do not forget to address partner treatment, as this is essential for preventing maternal reinfection before delivery. 1