Management of Chlamydia Trachomatis in Pregnancy
Treat immediately with azithromycin 1 g orally as a single dose—this is the first-line therapy for pregnant women with chlamydia, achieving 94-100% cure rates with superior compliance compared to all alternatives. 1, 2, 3
First-Line Treatment
Azithromycin 1 g orally as a single dose is the preferred regimen recommended by the American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention for pregnant women with chlamydia. 1, 2
This single-dose regimen eliminates compliance concerns entirely—the medication can be directly observed in the clinic, ensuring the patient actually receives treatment. 2
Azithromycin achieves cure rates of 94-100% in pregnancy, significantly superior to erythromycin (64-77%) and equivalent to amoxicillin (58-64%). 2, 3, 4
Alternative Regimen (If Azithromycin Cannot Be Used)
Amoxicillin 500 mg orally three times daily for 7 days is the next best option when azithromycin is contraindicated or unavailable. 1, 2, 5
Amoxicillin has fewer gastrointestinal side effects than erythromycin and achieves comparable efficacy to azithromycin (58% vs 64%, not statistically different). 5, 4
Secondary Alternatives (Use Only When First Two Options Are Unsuitable)
Erythromycin base 500 mg orally four times daily for 7 days can be used but has significantly lower efficacy (64-77%) and causes frequent gastrointestinal side effects that reduce compliance. 1, 5, 3
Alternative erythromycin regimens include:
Erythromycin base 500 mg four times daily has only 61% completion rates and should be avoided when compliance is questionable. 2
Absolutely Contraindicated Medications in Pregnancy
Doxycycline is absolutely contraindicated due to teratogenic effects. 1, 2, 5
All fluoroquinolones (ofloxacin, levofloxacin) are contraindicated due to fetal harm. 1, 2, 5
Erythromycin estolate is contraindicated due to drug-related hepatotoxicity in pregnancy. 1, 5
Mandatory Follow-Up: Test-of-Cure
All pregnant women require mandatory test-of-cure 3-4 weeks after completing therapy, preferably by culture—this requirement differs from non-pregnant adults. 1, 2, 5
The rationale is that alternative regimens (erythromycin, amoxicillin) have lower efficacy than doxycycline, and gastrointestinal side effects of erythromycin often lead to non-compliance. 1
If using nucleic acid amplification tests (NAATs), wait at least 3-4 weeks post-treatment to avoid false-positive results from residual DNA. 1
Gonorrhea Co-Infection Management
Test for gonorrhea, syphilis, and HIV at the initial visit. 1
If gonorrhea is confirmed or suspected, treat both infections concurrently with ceftriaxone 250 mg IM single dose PLUS azithromycin 1 g orally single dose. 1, 2
This dual therapy addresses the 20-40% co-infection rate and prevents treatment failure. 2
Partner Management
All sexual partners from the preceding 60 days must be evaluated, tested, and treated empirically. 1, 2, 5
Non-pregnant partners should receive doxycycline 100 mg orally twice daily for 7 days or azithromycin 1 g single dose. 2
Failure to treat partners leads to reinfection in up to 20% of cases. 1, 2
The patient must abstain from sexual intercourse for 7 days after initiating treatment and until all partners have completed treatment. 1, 2, 5
Neonatal Risk if Untreated
Untreated chlamydial infection leads to perinatal transmission causing neonatal conjunctivitis (5-12 days postpartum) and subacute pneumonia (1-3 months of age). 2, 5
Neonatal ocular prophylaxis with silver nitrate or antibiotic ointments does not prevent chlamydial transmission but should be continued to prevent gonococcal ophthalmia. 5
Critical Pitfalls to Avoid
Do not use erythromycin estolate—it causes hepatotoxicity in pregnancy. 1, 5
Do not omit the test-of-cure—it is mandatory in all pregnant patients regardless of regimen. 1, 2
Do not use tetracyclines or fluoroquinolones—they are teratogenic. 1, 2, 5
Do not assume partners were treated—directly verify or provide expedited partner therapy. 2