Gonorrhoea in pregnancy

Gonococcal infection during pregnancy is associated with preterm birth and low birth weight (1):

• intrapartum infection of the infant occurs in 30-42% of vaginal deliveries in women with gonorrhoea, most commonly resulting in purulent conjunctivitis (ophthalmia neonatorum), which may progress to blindness, and occasionally disseminated infection which can be fatal
• globally, the prevalence of gonorrhoea in pregnancy is estimated to be 1.85%, with higher rates among women in low-income countries, in women living with HIV, and in young people

Management:

• seek specialist advice - this may involve sending the patient to a sexual health clinic
• in gonococcal infection in pregnancy;
  • intramuscular ceftriaxone monotherapy is the recommended first-line regimen in pregnant women, preferably given under direct observation (2). (Consult an infectious disease specialist if the patient has a cephalosporin allergy or there are any other considerations that preclude treatment with this regimen)
  • Note - intramuscular spectinomycin given at a single dose of 2g is also occasionally used if no suitable alternatives are available. However, It is not known if it is excreted in breastmilk and should be used with caution in those who are breastfeeding
  • azithromycin 2 g may be given as a single oral dose as an alternative if ceftriaxone cannot be given for any reason. However, the manufacturer of azithromycin advises this should only be used if adequate alternatives are not available and the isolate is known to be susceptible to it.
    • tetracyclines and fluoroquinolones should be avoided in pregnancy
  • consider concurrent chlamydia infection - about 50% of women with gonococcal infection harbour concurrent chlamydial infection (3)

References:

1. Ross S, Pinto-Sander N, Iwuji C. Diagnosis and management of gonorrhoea. BMJ 2025; 389 :e084789.
2. Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187.
3. Fifer H et al. BASHH National Guideline for the Management of Gonorrhoea. British Association for Sexual Health and HIV. 22 November 2024