What are the treatment options for pregnant women with Sexually Transmitted Diseases (STDs)?

STD Treatment in Pregnancy

Pregnant women with sexually transmitted diseases require specific antimicrobial regimens that differ from non-pregnant patients, with penicillin G for syphilis (after desensitization if allergic), azithromycin for chlamydia, ceftriaxone plus azithromycin for gonorrhea, and metronidazole for trichomoniasis—all selected to prevent devastating fetal outcomes while avoiding teratogenic agents like doxycycline and fluoroquinolones. 1, 2

Syphilis Treatment

Parenteral penicillin G is the only proven effective treatment for syphilis in pregnancy and must be given at least 1 month before delivery to prevent congenital infection. 1

• Benzathine penicillin G 2.4 million units intramuscularly is the treatment of choice, with dosing frequency depending on disease stage 2, 3
• Women with penicillin allergy must be desensitized and treated with penicillin—no alternative regimens exist that adequately treat fetal infection 1
• High-risk women require repeat screening in the third trimester and at delivery 1

Chlamydia Treatment

Azithromycin 1 gram orally as a single dose is the preferred treatment for chlamydial infection in pregnancy, offering superior compliance and proven safety. 1, 4

• Azithromycin is preferable to 7-day erythromycin courses due to better tolerability and adherence 2
• Doxycycline is absolutely contraindicated in pregnancy 5
• Third-trimester screening is recommended for women under 25 years or those with new/multiple partners to prevent neonatal conjunctivitis and pneumonia 1
• Test of cure is advisable several weeks after treatment due to less efficient partner notification during pregnancy 2

Gonorrhea Treatment

Ceftriaxone 125-250 mg intramuscularly plus azithromycin 1 gram orally treats gonorrhea while simultaneously addressing frequent chlamydial co-infection. 2, 3

• Oral cefixime 400 mg is an alternative to intramuscular ceftriaxone 2, 4
• Fluoroquinolones (ciprofloxacin, ofloxacin) are contraindicated in pregnancy despite good safety records after accidental exposure 1, 2
• The dual therapy approach addresses emerging antibiotic resistance and high co-infection rates 3
• Repeat testing in the third trimester is indicated for women at continued risk 1

Trichomoniasis Treatment

Metronidazole 500 mg orally twice daily for 7 days is recommended for symptomatic trichomoniasis in pregnancy, as this infection increases preterm birth risk. 2

• Earlier teratogenicity concerns have been disproven by recent data 2
• The single 2-gram dose should not be used in pregnancy as it results in higher serum levels that reach fetal circulation 6
• Treatment should not be given during the first trimester 6

Pelvic Inflammatory Disease in Pregnancy

Pregnant women with suspected PID must be hospitalized and treated with parenteral antibiotics—this is non-negotiable given the risks of maternal morbidity, fetal loss, and preterm delivery. 5

• Recommended regimen: Ceftriaxone (extended-spectrum cephalosporin) plus azithromycin, as doxycycline cannot be used 5
• Continue parenteral therapy until 24 hours after clinical improvement, with expected improvement within 3 days 5
• If no improvement within 72 hours, re-evaluate for tubo-ovarian abscess and consider surgical intervention 5
• Male partners who had sexual contact within 60 days before symptom onset must be examined and treated 5

Bacterial Vaginosis

Treatment of bacterial vaginosis should be reserved for symptomatic women or those with specific risk factors for preterm delivery (history of preterm birth, low maternal weight). 1, 2

• Oral metronidazole 1 gram daily for 5 days is the treatment of choice when indicated 2
• Universal screening and treatment is not recommended as current evidence does not support improved outcomes in low-risk asymptomatic women 1, 2

Genital Herpes Management

Antiviral therapy with acyclovir or valacyclovir is safe in pregnancy and recommended for primary HSV infection or severe disease. 1, 4

• Suppressive therapy from 36 weeks' gestation reduces viral shedding at delivery in women at risk of active lesions 4
• No increased risk of major birth defects has been demonstrated with prenatal acyclovir exposure 1
• Routine serial cultures are not indicated for women with recurrent herpes in the absence of third-trimester lesions 1
• Cesarean section is indicated only for active lesions at delivery, not for history alone 1

Critical Screening Recommendations

All pregnant women require:

• Syphilis serology at first prenatal visit, with repeat testing in third trimester and at delivery for high-risk women 1
• Hepatitis B surface antigen testing at first prenatal visit 1
• HIV testing offered at first prenatal visit 1
• Gonorrhea testing at first visit for at-risk women or those in high-prevalence areas 1
• Chlamydia testing in third trimester for women under 25 or at increased risk 1

Common Pitfalls to Avoid

Never use doxycycline, tetracyclines, or fluoroquinolones in pregnant women—these are absolutely contraindicated. 1, 5, 2

• Do not rely on single-dose metronidazole (2 grams) in pregnancy due to excessive fetal exposure 6
• Do not discharge any infant without maternal syphilis status documented at least once during pregnancy 1
• Do not assume partner notification will be as effective during pregnancy—test of cure and re-testing are more critical 2
• Do not treat penicillin-allergic pregnant women with syphilis using alternative antibiotics—desensitization is mandatory 1