What is the recommended treatment for cervicitis in a pregnant female?

Treatment of Cervicitis in Pregnancy

Azithromycin 1 g orally as a single dose is the preferred treatment for cervicitis in pregnant women, as doxycycline is contraindicated in pregnancy. 1, 2

Recommended Treatment Regimen

First-line therapy:

• Azithromycin 1 g orally as a single dose is the treatment of choice in pregnancy, providing directly observed therapy and ensuring compliance 1, 3
• This regimen effectively covers Chlamydia trachomatis, the most common identifiable cause of cervicitis 4, 1

Alternative regimen if azithromycin is not tolerated:

• Erythromycin base 500 mg orally four times daily for 7 days 2, 3
• For women who cannot tolerate this regimen: erythromycin 500 mg orally every 12 hours or 250 mg four times daily for at least 14 days 2
• Erythromycin is FDA-approved for urogenital infections during pregnancy due to C. trachomatis 2

Critical Contraindications in Pregnancy

Avoid these medications:

• Doxycycline is absolutely contraindicated in pregnancy despite being a standard treatment outside pregnancy 1, 3
• Fluoroquinolones (including ofloxacin and levofloxacin) are contraindicated during pregnancy despite good safety records after accidental use 3

When to Treat Presumptively

Treat immediately without awaiting test results if:

• The patient is at high risk (age <25 years, new or multiple sex partners, unprotected sex) 4
• Follow-up cannot be ensured 4, 1
• The patient is in a high-prevalence setting for chlamydia 1

Consider awaiting NAAT results if:

• The patient is in a low-prevalence setting and likely to return for follow-up 1

Concurrent Gonococcal Coverage

Add treatment for N. gonorrhoeae if:

• Local prevalence is >5% in the patient population 4
• Recommended regimen: Ceftriaxone 125-250 mg intramuscularly as a single dose 3
• Alternative: Cefixime 400 mg orally 3

Essential Diagnostic Testing

Obtain before or concurrent with treatment:

• Nucleic acid amplification tests (NAATs) for both C. trachomatis and N. gonorrhoeae - these are the most sensitive and specific tests available 4, 1
• Test for bacterial vaginosis and trichomoniasis, treating if present 4
• Syphilis serology and HIV testing 1

Treatment of Concurrent Infections

If trichomoniasis is identified:

• Metronidazole 500 mg orally twice daily for 7 days is safe in pregnancy and should be given, as T. vaginalis is linked to increased risk of preterm birth 3

If bacterial vaginosis is present:

• Treat with metronidazole 1 g/day for 5 days, particularly in women with risk factors for preterm delivery (history of preterm birth or low maternal weight) 3

Partner Management

Critical steps to prevent reinfection:

• Notify and treat all sexual partners within the preceding 60 days 1
• Partners receive the same treatment regimen as the index patient 4, 1
• Patients and partners must abstain from sexual intercourse for 7 days after single-dose therapy or until completion of 7-day regimens 4

Follow-Up Protocol

Test of cure is particularly important in pregnancy:

• Retest 3-4 weeks after treatment completion, as partner notification and treatment are often less efficient during pregnancy 3
• The impact of inadequately treated or recurrent disease is greater because of added risk to the fetus 3
• Return for reevaluation if symptoms persist after completing therapy 4, 1

Maternal-Fetal Implications

Why treatment is critical in pregnancy:

• Chlamydial cervicitis is associated with premature rupture of membranes and increased fetal morbidity and mortality 5
• Infants infected during passage through an infected cervix are at risk for respiratory complications and conjunctivitis 5
• Untreated cervicitis can lead to upper genital tract infection (endometritis) 4

Common Pitfalls to Avoid

• Do not use doxycycline - this is the most common error, as it's standard therapy outside pregnancy but contraindicated in pregnant women 1, 3
• Do not withhold treatment while awaiting culture results in high-risk populations or when follow-up is uncertain 1
• Do not assume compliance with multi-day regimens - single-dose azithromycin is preferred because pregnant women are more reluctant to take prescribed medication in full doses 3
• Do not forget partner treatment - reinfection rates are higher when partners are not adequately treated 4, 3