Chlamydia and Gonorrhoea Cervicitis
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Direct answer
Chlamydia and gonorrhoea cervicitis is inflammation of the endocervix producing mucopurulent discharge, friable mucosa and contact bleeding, caused most often by Chlamydia trachomatis or Neisseria gonorrhoeae. Diagnosis rests on nucleic acid amplification testing of a vaginal or endocervical swab, which outperforms culture and antigen tests. In pregnancy, azithromycin replaces doxycycline for chlamydia, gonorrhoea is treated with single-dose ceftriaxone plus azithromycin, and untreated infection at delivery exposes the newborn to conjunctivitis and pneumonia.
What you must remember
- Mucopurulent cervicitis: yellow or green cervical discharge, a red friable cervix and bleeding on touch; most women are asymptomatic and the sign is found on routine speculum examination.
- Diagnosis: NAAT on a vaginal or endocervical swab, or on first-catch urine; culture is kept for gonococcal susceptibility testing.
- Chlamydia in pregnancy: azithromycin 1 g orally as a single dose; tetracyclines are avoided, and amoxicillin is the alternative.
- Gonorrhoea treatment: ceftriaxone 500 mg intramuscularly once, with azithromycin added to cover coexisting chlamydia when it has not been excluded (current CDC advice is ceftriaxone alone for gonorrhoea; the dual regimen is retained in many Indian syndromic protocols).
- Test of cure: repeat NAAT about four weeks after chlamydia treatment in pregnancy, and retest within three months.
- Neonatal ophthalmia: gonococcal conjunctivitis appears in the first days after birth and is severe; chlamydial inclusion conjunctivitis appears later, usually between five and fourteen days.
- Partner management: treat partners, and advise abstinence until seven days after single-dose therapy is completed.
A worked pathway from speculum finding to the newborn eye
A 24-year-old attends for a routine booking visit at 14 weeks. The speculum examination shows a red, friable cervix with mucopurulent discharge, and she mentions contact bleeding after intercourse.
- Name the syndrome. The clinical diagnosis is mucopurulent cervicitis, and pelvic examination should also exclude bacterial vaginosis and trichomoniasis, because they can look similar.
- Send the NAAT. A NAAT on a vaginal swab is taken, with a urine sample if she prefers.
- Treat chlamydia. If the NAAT is positive for chlamydia alone, azithromycin 1 g orally, observed in clinic, is the treatment, and doxycycline is withheld because tetracyclines are avoided in pregnancy.
- Check cure and reinfection. A repeat NAAT at four weeks checks cure, and a further test within three months detects reinfection from an untreated partner.
- Complete the plan. Partner notification and HIV and syphilis screening complete the plan.
If the result is gonorrhoea instead, ceftriaxone 500 mg intramuscularly once is given, with azithromycin for presumed coinfection, and culture is sent if susceptibility testing is required.
The question at delivery then turns to the newborn. An untreated gonococcal infection may produce severe ophthalmia within days of birth, while chlamydial infection presents later with inclusion conjunctivitis and may progress to pneumonia. Prophylactic erythromycin eye ointment at birth is aimed mainly at gonococcal disease and does not reliably prevent chlamydial conjunctivitis, and examiners expect the candidate to link the maternal treatment decision with the infant's eyes.
Where the examiner tries to catch you
Most errors here come from the drug choice and the timing of neonatal eye disease.
- Trap: reaching for doxycycline, because it is the drug students remember from pelvic inflammatory disease and STI lists. Correct: in pregnancy it is wrong, and azithromycin is the correct answer.
- Trap: mistiming the neonatal eye infection. Correct: gonococcal ophthalmia is early and dangerous, while chlamydial conjunctivitis is later and milder, so a ten-day-old infant with purulent discharge points to chlamydia, whereas onset within the first five days favours gonococcus.
- Trap: skipping the test of cure after chlamydia in pregnancy. Correct: a pregnant woman treated for chlamydia needs a repeat NAAT, not a clinical review alone.
A positive NAAT explains the discharge, but a negative one should prompt a search for bacterial vaginosis, trichomoniasis or Mycoplasma genitalium, because mucopurulent cervicitis is a syndrome rather than a single diagnosis.
Frequently asked questions
Which test confirms chlamydia or gonorrhoea in a pregnant woman?
NAAT on a vaginal swab, endocervical swab or first-catch urine confirms chlamydia and gonorrhoea in pregnant women. Culture remains useful for gonococcal antimicrobial susceptibility testing, while serology plays no part in diagnosing these infections.
Why is doxycycline avoided for chlamydia in pregnancy?
Doxycycline is avoided in pregnancy because tetracyclines are deposited in developing fetal bones and teeth. Azithromycin 1 g as a single oral dose is the standard alternative for chlamydia in pregnant women, with amoxicillin as another option.
How do gonococcal and chlamydial neonatal conjunctivitis differ?
Gonococcal neonatal conjunctivitis appears within the first few days after birth and is severe enough to threaten the cornea. Chlamydial inclusion conjunctivitis appears later, typically between five and fourteen days, and is usually milder. Erythromycin eye ointment at birth is aimed mainly at gonococcal disease and does not reliably prevent chlamydial conjunctivitis.
When should a test of cure be done after chlamydia treatment in pregnancy?
A test of cure for chlamydia in pregnancy is repeated by NAAT about four weeks after treatment, and every pregnant woman with chlamydia is retested within three months. Retesting picks up reinfection from an untreated partner.