What is the recommended treatment for Chlamydia (Chlamydia trachomatis) in a pregnant patient experiencing a miscarriage?

Chlamydia Treatment During Miscarriage

Treat chlamydia immediately during miscarriage with azithromycin 1 g orally as a single dose to prevent post-abortion endometritis, which develops in 10-28% of untreated pregnant women undergoing induced abortion. 1

Critical Rationale for Treatment

The evidence is unequivocal that untreated chlamydial infection during pregnancy procedures carries substantial morbidity risk:

• Endometritis develops in 10-28% of pregnant women with untreated chlamydial infection who undergo induced abortion, and possibly salpingitis as well 1
• This represents a preventable complication with immediate antibiotic treatment 1
• The risk extends to any pregnancy termination, whether spontaneous (miscarriage) or induced 1

Recommended Treatment Regimen

First-line option:

• Azithromycin 1 g orally as a single dose 1, 2, 3
  • 97% efficacy rate 2, 3
  • Single-dose directly observed therapy eliminates compliance concerns 2, 3
  • Safe in pregnancy if miscarriage is incomplete or ongoing 2, 4

Alternative if azithromycin unavailable:

• Erythromycin base 500 mg orally four times daily for 7 days 1, 5, 4
• Amoxicillin 500 mg orally three times daily for 7 days 2, 3, 4

Avoid these medications:

• Doxycycline is absolutely contraindicated during pregnancy and should only be used if pregnancy has definitively ended 2, 3
• All fluoroquinolones (ofloxacin, levofloxacin) are contraindicated in pregnancy 2, 3

Treatment Timing and Execution

• Administer treatment immediately upon diagnosis, do not delay for completion of miscarriage 1
• Dispense medication on-site and directly observe the first dose when possible 1, 2
• Treatment prevents ascending infection during the vulnerable post-miscarriage period when the cervix may be dilated 1

Partner Management

All sexual partners from the preceding 60 days must be treated empirically 2, 6:

• Partners receive azithromycin 1 g orally single dose OR doxycycline 100 mg orally twice daily for 7 days 6
• Treat partners even without testing to prevent reinfection 6
• Patient should abstain from sexual intercourse for 7 days after treatment and until all partners are treated 2, 6

Follow-Up Considerations

• Test-of-cure is NOT routinely recommended after treatment with azithromycin unless symptoms persist 2, 3
• Retest at 3 months post-treatment due to high reinfection rates (up to 39% in some populations) 2, 3
• Screen for concurrent STIs including gonorrhea, syphilis, and HIV 3

Common Pitfalls to Avoid

• Do not withhold treatment waiting for pregnancy confirmation if chlamydia is diagnosed during miscarriage evaluation 1
• Do not assume partners were treated—directly verify or provide expedited partner therapy 2, 6
• Do not use doxycycline if any possibility of ongoing pregnancy remains 2, 3
• Do not skip partner treatment, as this leads to reinfection in up to 20% of cases 3