For Physicians. By Physicians.™

FREE weekly ObG Insider NewsletterClick here

Antenatal Corticosteroids – When to Administer?

The appropriate use of antenatal corticosteroids improves neonatal outcomes, including decreased severity and/or frequency of respiratory distress syndrome (RDS), intracranial hemorrhage, necrotizing enterocolitis and death. Antenatal corticosteroids, when appropriate, are administered in a clinical setting where patients are at risk for preterm delivery within 7 days, irrespective of membrane status and fetal number.

Clinical Actions:

Risk of preterm delivery within 7 days

Between 24w0d to 33w6d – ‘Recommended’

    • Single course of corticosteroids

Between 22w0d and 23w6d – ‘May be Considered’

  • 23w0d to 23w6d
    • Single course of corticosteroids
  • 22w0d to 22w6d
    • Single course of corticosteroids

Note: ACOG and SMFM revised recommendation states

Antenatal corticosteroids may be considered at 22 0/7 weeks to 22 6/7 weeks of gestation if neonatal resuscitation is planned and after appropriate counseling

Some families may choose to forgo resuscitation and support after appropriate counseling

Between 20w0d and 21w6d – ‘Not Recommended’

  • Antenatal corticosteroids are not recommended due to lack of data suggesting benefit

Late preterm (34w0d – 36w6d)


  • If no previous corticosteroids
    • Single course of betamethasone
    • Not indicated in women diagnosed with clinical chorioamnionitis


  • Single course of betamethasone in specific populations
    • Population included in ALPS trial: Recommended
      • Nonanomalous singleton gestation
      • High risk for preterm delivery (medically indicated or spontaneous)
      • No prior antenatal steroids
    • Select populations not in the original ALPS trial: Suggest consideration for use in the following clinical scenarios
      • Multiple gestations reduced to a singleton gestation ≥14w0d
      • Fetal anomalies
      • Expected to deliver in less than 12 hours
    • Low likelihood of delivery <37 weeks: Recommend against
    • Pregestational diabetes: Recommend against due to risk for worsening neonatal hypoglycemia

Repeat or Rescue Courses

  • Regularly scheduled repeat courses or serial (> 2) courses
    • Not recommended
  • If a patient has received one prior course of corticosteroids > 14 days ago, is less than 34w0d gestation and is at risk of preterm delivery within 7 days
    • a single repeat course of corticosteroids should be considered (change from previous ‘may’)
    • Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario (based on Cochrane meta-analysis)
  • Preterm prelabor rupture of membranes (PPROM)
    • There is insufficient evidence to make a recommendation for or against repeat or rescue courses

Dose and Regimen: give first dose even if 2nd dose unlikely

  • Betamethasone: 12 mg IM, 2 doses 24 hours apart
  • Dexamethasone:  6 mg IM, 4 doses 12 hours apart

Learn More – Primary Sources

ACOG Committee Opinion 713: Antenatal Corticosteroid Therapy for Fetal Maturation

ACOG Practice Advisory: Use of Antenatal Corticosteroids at 22 Weeks of Gestation

ACOG Practice Bulletin No. 171 : Management of Preterm Labor

Society for Maternal-Fetal Medicine (SMFM) Consult #58: Use of Antenatal Corticosteroids for Individuals at Risk for Late Preterm Delivery

Society for Maternal-Fetal Medicine Special Statement: Quality metrics for optimal timing of antenatal corticosteroid administration – American Journal of Obstetrics & Gynecology (

Remove or Retain Cervical Cerclage After PPROM?


  • Vitner et al. (Archives of Gynecology and Obstetrics, 2020) compared PPROM pregnancy outcomes when cerclage was removed vs when it was retained


  • Two-center retrospective cohort study
  • Participants
    • Singleton pregnancy
    • PPROM at < 34w0d
    • Cervical cerclage in situ
  • Exposures
    • Retention of cerclage until onset of delivery
    • Removal of cerclage within 24 hours of PPROM
  • Primary outcome
    • Time from PPROM to delivery


  • 70 women included
    • Cerclage retained in situ: 67.1% (47 women)
    • Cerclage removed: 32.9% (23 women)
  • Women in the cerclage retention group had a higher PPROM-to-delivery interval (p = 0.03)
    • Retained: 7.0 ± 7.2 days
    • Removed: 6.0 ± 10.9 days
  • Women in the retention group were more likely to have a longer latency period
    •  > 48 h (p = 0.03)
      • Retain: 87.2%
      • Remove: 65.2%
      • Adjusted odds ratio (aOR) 3.9 (95% CI, 3.1 to 4.9)
    • > 7 days (p = 0.04)
      • Retain: 29.8%
      • Remove: 8.7%
      • aOR 7.0 (95% CI, 2.5 to 19.6)
  • Chorioamnionitis rate was lower in the retention group
    • aOR 0.7 (95% CI, 0.5 to 1.0)
  • No differences found for the following
    • Early neonatal sepsis
    • Sever brain injury
    • Composite neonatal outcome


  • Retention of cerclage in situ vs removal
    • May increase the latency between rupture and delivery in pregnancies <34 weeks
    • May be associated with lower rates of chorioamnionitis
    • Increase in neonatal morbidity was not evident
  • There were no differences in risk of neonatal morbidities associated with either removal or retention
  • The authors state that

Further research on how best to address this clinical scenario is needed which could include a randomized clinical trial

Learn More – Primary Sources:

Removal vs. retention of cervical cerclage in pregnancies complicated by preterm premature rupture of membranes: a retrospective study

ACOG Guidance Update: Diagnosis and Management of PROM (Prelabor Rupture of Membranes)


ACOG guidance on Prelabor Rupture of Membranes (PROM) addresses current literature especially related to management of late preterm PROM (34w0d to 36w6d). Following appropriate counseling, expectant management or delivery is appropriate. The use of ‘prelabor’ is in keeping with reVITALize terminology (see ‘Related ObG Topics’ below) and is defined as the ‘spontaneous rupture of membranes that occurs before the onset of labor’.


  • Most cases can be diagnosed based on history and physical examination 
  • Avoid digital examination due to infection risk, unless delivery appears to be immediate  
  • Speculum examination  
    • Visualization of amniotic fluid (AF) leaking through the cervix  
    • Vaginal pooling
    • Fern test of dried vaginal fluid seen under microscope
    • pH testing 
      • Normal: 3.8 to 4.5
      • AF: 7.1 to 7.3 
      • False positives: Blood or semen, alkaline antiseptics or BV  
      • False negatives: Minimal remaining AF following rupture 
  • If above inconclusive  
    • Ultrasound for AFV may be helpful but not diagnostic  
    • Fetal fibronectin is sensitive with high negative predictive value but positive result is not diagnostic
    • Amniotic protein tests have high sensitivity for PROM but false-positive rates may be as high as 19–30%
    • ACOG states that “These test kits should be considered ancillary to standard methods of diagnosis”
  • Conclusive test – dye instillation
    • Ultrasound guided dye with passage into the vagina and detected with tampon or pad stain  
    • Maternal urine may turn blue following instillation of indigo carmine
    • See ‘Related ObG Topics’ below for alternatives to indigo carmine  

PROM at < 24 Weeks

Clinical Considerations

  • Survival with PROM ≥ 22 weeks is significantly higher (57.7%) than <22 weeks (14.4%)
    • Survival rates are likely overestimated
    • Combination of birthweight, gestational age and sex will impact morbidity/mortality
      • Individualize risks
  • Maternal complications: infection | endometritis | abruption | retained placenta  
    • Maternal sepsis risk of 1%  
  • Latency  
    • 40-50% will deliver within 1 week and 70-80% will deliver within 2-5 weeks  
  • Pulmonary hypoplasia 
    • Will occur in approximately 10-20% of cases  
    • Insufficient data to recommend ultrasound for determination of lung volumes or function   
  • Oligohydramnios can result in Potter’s deformation sequence   
    • Low-set ears | recessed chin | prominent bilateral epicanthal folds  
    • Limb contractures 
    • Skeletal malformations   


  • Counsel regarding risks and benefits of expectant management vs immediate delivery  
    • Immediate delivery should be offered as an option
    • Consider MFM and neonatology consultation   
  • If patient chooses expectant management and no infection  
    • Outpatient surveillance is an option following inpatient assessment  
      • Give information to return to hospital immediately if signs or symptoms of bleeding, labor or infection (self-monitor temperature) 
      • Advise return to hospital at time of viability  
  • Corticosteroids and latency antibiotics 
    • Offering antibiotics as early as 20w0d is an option
    • Corticosteroids between 22w0d and 23w6d – “May be Considered … if neonatal resuscitation is planned and after appropriate counseling”
      • 22w0d to 22w6d: Single course of corticosteroids
      • 23w0d to 23w6d: Single course of corticosteroids 
  • GBS prophylaxis not recommended prior to viability  
  • Tocolysis is not recommended prior to viability 
  • Neuroprotection (magnesium sulfate) is not recommended prior to viability

Preterm PROM at 24w0d-33w6d

  • Expectant management is recommended and will usually include hospital admission with monitoring for
      • Infection | Hemorrhage (abruption) | Umbilical cord compression | Fetal assessment | Evidence of labor
    • If there are maternal and/or fetal contraindications to expectant management, delivery is recommended  
  • Antenatal (single course) corticosteroids are recommended | Insufficient evidence regarding rescue course  
  • Latency antibiotics are recommended
    • Eunice Kennedy Shriver NICHD MFMU Network trial regimen  
      • IV ampicillin [2 g every 6 hours] and erythromycin [250 mg every 6 hours] for 48 hours followed by oral amoxicillin [250 mg every 8 hours] and erythromycin base [333 mg every 8 hours] for an additional 5 days (7 days total) 
      • Azithromycin (e.g., 1 g single dose) “is a suitable alternative” to replace erythromycin if unavailable or poorly tolerated
    • Amoxicillin–clavulanic acid  
      • Not recommended due to increased risk for necrotizing enterocolitis 
    • Allergy to β-lactam antibiotics 
      • “May be reasonable to consider another agent against GBS” | Choice based on severity of allergic reaction and susceptibility profiling 
    • Unclear as to whether cerclage should be removed or retained but if retained, antibiotic therapy should not be extended beyond 7 days

Note: There are multiple regimens in use | There is no evidence to support a single optimal regimen for latency antibiotics    

  • Patients with PROM before 32w0d and imminent delivery are candidates for fetal neuroprotective treatment with magnesium sulfate (if no contraindications)
  • Obtain vaginal/rectal swab for GBS | Administer GBS prophylaxis as indicated
  • HSV infection and Preterm PROM
    • Risk of vertical transmission is 30-50% with primary HSV and 3% with recurrent HSV   
    • Recurrent active HSV  
      • Expectant management is recommended <34w0d
      • Initiate HSV therapy 
      • Corticosteroids | Antibiotics | Magnesium sulfate per indications
      • Cesarean section is indicated if active disease or prodromal symptoms are present at time of delivery   
    • Primary HSV
      • Management less clear due to high risk of vertical transmission  
      • HSV therapy is recommended  
      • Cesarean delivery recommended if active lesions are present  
  • HIV infection and Preterm PROM 
    • Optimal management is uncertain due to concern of vertical transmission with PROM 
    • Management should include a physician with expertise in the management of HIV in pregnancy and standard HIV guidelines should be followed   
    • Most recent data suggest that vertical transmission risk my not be increased if the patient is on highly active antiretroviral therapy with a low viral load and has received antepartum and intrapartum zidovudine 
    • Management should be individualized 
      • If gestational age is early, but patient is on appropriate therapy with a low viral load expectant management may be appropriate  

Late Preterm (34w0d to 36w6d)

  • “Either expectant management or immediate delivery is a reasonable option”
    • Data suggests when comparing these 2 options
      • No difference in neonatal sepsis
      • Newborn: Increased respiratory distress, mechanical ventilation, ICU stay in the immediate group
      • Maternal: Increased hemorrhage and infection in expectant management group
  • Administer single-course corticosteroids if
    • Not previously given
    • Delivery expected in >24 hours and ≤7 days
    • No chorioamnionitis
  • Screen for GBS and administer prophylaxis as indicated
  • Chorioamnionitis: Treat and plan for delivery
  • ACOG states (PB 831)

Care should be individualized through shred decision making, and expectant management should not extend beyond 37 0/7 weeks of gestation

Outside the scenario of unknown GBS status, latency antibiotics are not appropriate in this setting

Term (≥37w0d)

  • Induction is recommended vs expectant management | Short period of expectant management (12 to 24 hours) “may be appropriately offered”
    • If no spontaneous labor, induce labor with oxytocin 
      • Allow adequate time (12-18 hours) for latent phase to progress before performing a cesarean section for failed induction of labor  
    • Induction with prostaglandins equally as effective as oxytocin but may have higher rates of chorioamnionitis  
    • Insufficient data to recommend for or against cervical ripening with mechanical methods such as a Foley balloon 
    • Insufficient evidence to recommend antibiotic prophylaxis beyond GBS indications  
  • If a patient declines delivery and requests expectant management, counsel regarding risks and benefits 
    • If fetal and maternal status are reassuring, expectant management ‘may be acceptable’   
  • Screen for GBS and administer prophylaxis as indicated
  • Chorioamnionitis: Treat and plan for delivery

Key Points:

PROM-Related Risks 

  • Preterm birth 
    • 50% of patients will deliver within 1 week 
    • Risks associate with prematurity include RDS, sepsis, IVH and NEC  
  • Infection
    • Preterm PROM and intrauterine inflammation are associated with increased risk of neurologic injury   
    • Intraamniotic infection (15-25%) 
    • Postpartum infection (15-20%) 
  • Abruption (2-5%) 
  • Infection and umbilical cord accidents are associated with a 1 to 2% chance for fetal demise  

Additional Clinical Considerations

  • Membranes may reseal spontaneously leading to good outcomes   
  • Hospital admission is recommended if the fetus is viable to monitor for signs of infection, abruption and fetal compromise   
    • Acceptable strategy includes periodic ultrasound for fetal growth and FH monitoring (precise timing not established) 
    • No clinical utility evidence for the use of serial WBC counts or other infectious markers  
  • Use of tocolysis  
    • Tocolytic therapy is not recommended at 34w0d to 36w7d gestation
    • Can be considered for steroid benefit at earlier gestational age and during maternal transport
  • GBS as per standard protocol 
    • GBS prophylaxis should be given based on prior culture results or intrapartum risk factors if cultures not performed or unavailable 

PROM Following Amniocentesis 

  • Risk of PROM following amniocentesis is 1%   
  • Outpatient, expectant management  
  • Monitor regularly with ultrasound and counsel patients to watch for signs of infection, bleeding and/or miscarriage  
  • Contrary to spontaneous PROM, good outcomes have been reported   
    • AF fluid reaccumulated within 1 month in 72% of patients 
    • Perinatal survival rate was 91%  

Preterm PROM and Future Pregnancies  

  • Increased risk of recurrent PROM and preterm birth  
  • Offer progesterone supplementation starting at 16-24 weeks 
  • Consider cervical length screening  
  • Consider cerclage for women with the following  
    • Current singleton pregnancy 
    • Prior spontaneous preterm birth < 34 weeks  
    • Cervical length < 25 mm prior to 24 weeks  

Learn More – Primary Sources:  

ACOG Practice Bulletin 217: Prelabor Rupture of Membranes

ACOG: Use of Antenatal Corticosteroids at 22 Weeks of Gestation 

ACOG Practice Bulletin 831: Medically Indicated Late-Preterm and Early-Term Deliveries

Potter’s Sequence

Can Azithromycin Be Used in Place of Erythromycin for Preterm PROM?


Finneran et. al. (American Journal of Perinatology, 2017) assessed the impact of substituting a single dose of azithromycin in place of the standard erythromycin regimen used to prolong pregnancy in preterm PROM (PPROM)


  • Retrospective cohort study of 162 women with PPROM between 22 and 33 6/7 weeks
  • Subjects were categorized as:
    • Received standard antibiotic regimen (7 days of erythromycin and ampicillin/amoxicillin)
    • Received a single oral dose of azithromycin substituted for erythromycin in this regimen
  • Primary outcome
    • latency from PPROM to delivery defined as the time of first antibiotic administration to delivery
  • Secondary outcomes included
    • rates of cesarean delivery, intrauterine infection (chorioamnionitis or funisitis), Apgar scores, positive neonatal blood cultures, respiratory distress syndrome, necrotizing enterocolitis, and neonatal death


  • Tocolytic therapy was more frequent in the azithromycin group compared with erythromycin group (33.3 vs. 16.7%, P = 0.01); otherwise, there were no differences in baseline characteristics
    • Tocolytic exposure was included in multivariate analysis
  • When comparing erythromycin to azithromycin
    • There was no difference median latency from PPROM to delivery (6.37 days vs 5.86 days, P = 0.67)
    • There was a higher rate of cesarean delivery (48.8 vs. 29.5%, P = 0.01)
    • There was an increased risk of neonatal sepsis (4.1 vs. 13.6%, P = 0.05)
      • Based on pathogens, unlikely to be related to antibiotic exposure


  • There was no difference in latency when azithromycin was substituted for erythromycin
  • Ease of single dose regimen and cost effectiveness may make azithromycin a good alternative to erythromycin in PPROM

Learn More – Primary Sources

Comparison of Azithromycin versus Erythromycin for Prolongation of Latency in Pregnancies Complicated by Preterm Premature Rupture of Membranes


Should Tocolytics Be Used Following PPROM?


This study by Lorthe et al. (AJOG, 2017) explores if tocolytic therapy following preterm PROM (PPROM) is associated with improved neonatal or obstetric outcomes.


Multi-center, prospective, population-based cohort study


803 women with PPROM at 24-32 weeks’ gestation and singleton pregnancies were included in the study. 73.45% patients received tocolysis. There was no difference in neonatal survival without severe morbidity between women who received tocolysis and those who did not (86.7% vs. 83.9% respectively). When adjusting for confounders, primarily bias due to indication for treatment, tocolysis was not associated with increase survival without severe morbidity (odds ratio, 1.01 [95% CI 0.94-1.09]), latency of ≥48 hours to delivery (1.03 [95% CI 0.95-1.11]), or histological chorioamnionitis (1.03 [95% CI 0.92-1.17]). The choice of tocolytic medication (oxytocin receptor antagonists or calcium-channel blockers) had no impact on outcomes. The authors conclude that at present, there does not appear to be any clinical benefit for the use of tocolytic drugs in the setting of PPROM.

Learn More – Primary Sources:

Tocolysis after preterm premature rupture of membranes and neonatal outcome: a propensity-score analysis

What is the Best Course of Action Following PPROM Between 24 and 37 Weeks?



This study by Bond et al. (Cochrane Database Systematic Review, 2017) compared planned early birth vs. expectant management following preterm pre-labor rupture of the membranes (PPROM) between 24 and 37 weeks gestation.


Systematic Review and meta-analysis


This update of a 2010 Cochrane review included 12 randomized controlled trials, with analyses on a total of 3,617 women and 3,628 infants.

Primary outcomes:

  • There was no significant difference in rates of neonatal sepsis or proven neonatal infection
  • Early birth was associated with
    • Increased rate of RDS (Relative Risk 1.26, 95% CI 1.05 to 1.53)
    • Increased rate of c-section (Relative Risk  1.26, 95% CI 1.11 to 1.44)

Secondary outcomes:

  • There was no significant difference in rates of overall perinatal mortality or intrauterine deaths between the two groups
  • Early birth was associated with the following maternal outcomes
    • Decreased rate of chorioamnionitis (Relative Risk 0.50, 95% CI 0.26 to 0.95)
    • Decreased hospital stay with a mean difference of -1.75 days (95% CI -2.45 to -1.05)
    • Increased rate of endometritis (Relative Risk 1.61, 95% CI 1.00 to 2.59)
  • Early birth was associated with the following neonatal outcomes
    • Higher rates of neonatal death (Relative Risk 1.26, 95% CI 1.11 to 1.44)
    • Higher rates of ventilation (Relative Risk 1.27, 95% CI 1.02 to 1.58)
    • Delivery at lower gestational ages with a mean difference of -0.48 weeks (95% CI -0.57 to -0.39)
    • Higher rates of NICU admission (Relative Risk 1.16, 95% CI 1.08 to 1.24)
  • Subgroup analyses:
    • Improved maternal and infant outcomes in expectant management greater than 34 weeks gestation for RDS and maternal infections
    • Antibiotics reduce maternal infections in the expectant management group

Authors’ conclusions:

  • If there are no contraindications, overall the expectant management group with careful monitoring had better outcomes for mother and baby
  • Further research needed for subgroup analysis as to who would not benefit from expectant management
  • Long term neurodevelopment was not addressed in this study

Learn More – Primary Sources:

Planned early birth versus expectant management for women with preterm prelabour rupture of membranes prior to 37 weeks’ gestation for improving pregnancy outcome

Vasa Previa: Diagnosis and Management

Vasa previa is defined as fetal vessels that run through the fetal membranes, over or near the endocervical os (2 cm or less) and are unprotected by placenta or umbilical cord.


Deliver by cesarean section before the onset of labor and before rupture of membranes

  • Scheduled delivery 34w0d to 37w0d
  • Deliver by cesarean section in the case of PPROM and viability
  • Antenatal corticosteroids 28 to 32 weeks gestation
  • SMFM guidance states to consider hospitalization at 30 to 34 weeks
    • Benefit is unproven and there have been good outcomes reported with outpatient management
    • When considering hospitalization, individualize based on the following
      • Symptoms
      • History of preterm birth
      • Logistics in getting to hospital with transfusion capabilities
    • Patients with normal cervical lengths are the best candidates for possible outpatient management
  • Repeat ultrasound in the third trimester is suggested if vasa previa is suspected in the second trimester, as approximately 20% of apparent vasa previa will resolve by the late third trimester


Vasa previa occurs in 1/2500 to 1/5000 pregnancies and is associated with an increased risk of preterm birth and the associated complications of prematurity. There is a 97% survival rate when diagnosed by prenatal ultrasound and a 44% survival rate when the diagnosis is made intrapartum.


  • Risk factors:
    • Velamentous cord insertion (Type 1 vasa previa)
    • Succinturate or bilobed placenta connecting vessels (Type 2 vasa previa)
    • Placenta previa or low lying placenta in the second trimester
    • Multiple gestation
    • IVF (1/250 risk of Type 1 vasa previa)
  • In cases of low lying placenta, bilobed placenta, succinturate placenta or velamentous cord insertion, a targeted ultrasound for vasa previa should be performed
  • Screening possible at 2nd trimester fetal anatomy ultrasound
    • If detected on 2nd trimester ultrasound, 20% will resolve
    • Document cord insertion site if possible
  • Diagnosis is made by ultrasound, ideally with transvaginal and color flow Doppler
  • Ultrasound findings include a linear tubular echolucent body overlying the endocervical os with color flow doppler demonstrating flow through the structure and pulsed doppler showing fetal vascular wave forms
  • Risk of perinatal loss due to fetal exsanguination – watch for sinusoidal pattern on FHT tracing
  • Plan for delivery at a center that can perform neonatal transfusion if required
    • Note: Center should have negative blood available for neonate in case rapid transfusion is necessary

Learn More – Primary Sources:

SMFM: Diagnosis and management of vasa previa

ACOG/SMFM Committee Opinion 831: Medically Indicated Late-Preterm and Early-Term Deliveries

Society for Maternal-Fetal Medicine (SMFM) Consult Series #44: management of bleeding in the late preterm period

Abnormal Placentation: Placenta Previa, Vasa Previa, and Placenta Accreta

Locate a Maternal Fetal Medicine Specialist:

Maternal-Fetal Medicine Specialist Locator-SMFM

Chlamydia: CDC Recommendations for Diagnosis and Treatment


Annual screening of all sexually active women aged <25 years for chlamydia is recommended, as is screening of older women at increased risk for infection (e.g., those who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has an STD).

To diagnose a chlamydia infection:

  • Obtain nucleic acid amplification testing (NAAT), which detects genetic material of C. trachomatis
    • Highly sensitive in first-catch urine samples and endocervical or vaginal swabs
    • Can be collected by a provider or a self-collected vaginal swab
    • Certain NAATs have been FDA-cleared for use on liquid-based cytology specimens (collected for Pap smears), however sensitivity may be lower than swabs


Chlamydial infection is the most frequently reported infectious disease in the United States, and prevalence is highest in persons aged ≤24 years. Several sequelae can result from C. trachomatis infection in women, the most serious of which include PID (pelvic inflammatory disease), ectopic pregnancy, and infertility. Some women who receive a diagnosis of uncomplicated cervical infection already have subclinical upper-reproductive–tract infection.


Chlamydia treatment should be provided promptly for all persons testing positive for infection; treatment delays have been associated with complications

  • Recommended Regimens
    • Azithromycin 1 g orally in a single dose or
    • Doxycycline 100 mg orally twice a day for 7 days
  • Alternative Regimens
    • Erythromycin base 500 mg orally four times a day for 7 days or
    • Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days or
    • Levofloxacin 500 mg orally once daily for 7 days or
    • Ofloxacin 300 mg orally twice a day for 7 days
  • Routine pharyngeal screening for chlamydia is not recommended, but if C. trachomatis is detected in an oropharyngeal specimen treat with azithromycin or doxycycline
  • Directly observe patient receiving therapy when single dose therapy is given
  • To minimize disease transmission to sex partners, persons treated for chlamydia should be instructed to abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen and resolution of symptoms if present
  • To minimize risk for reinfection, patients also should be instructed to abstain from sexual intercourse until all of their sex partners are treated
  • Persons who receive a diagnosis of chlamydia should be tested for HIV, gonococcal infection, and syphilis
  • Test-of-cure to detect therapeutic failure is not advised unless therapeutic adherence is in question, symptoms persist, or reinfection is suspected
    • Chlamydial NAATs at <3 weeks after completion of therapy is not recommended because the continued presence of nonviable organisms can lead to false-positive results
  • Retest after 3 months
    • Recurrence may not be treatment failure but rather reinfection
    • In States where legally allowed (see ‘Related OBG Topics’ below), consider Expedited Partner Therapy (EPT) which allows the patient herself to provide medications to her partner when there are limited public health services to treat a partner, or concern that the partner will not have access to treatment
  • Treat women with HIV with the same recommended regimen


Risks in pregnancy include preterm labor, premature rupture of membranes and low birth weight with neonates at risk for conjunctivitis (ophthalmia neonatorum) and pneumonia. It is therefore imperative to screen and treat pregnant women with the following:

  • Recommended Regimens
    • Azithromycin 1 g orally in a single dose
  • Alternative Regimens
    • Amoxicillin 500 mg orally three times a day for 7 days or
    • Erythromycin base 500 mg orally four times a day for 7 days or
    • Erythromycin base 250 mg orally four times a day for 14 days or
    • Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days or
    • Erythromycin ethylsuccinate 400 mg orally four times a day for 14 days
  • Test-of-cure (preferably by NAAT) recommended at 3 to 4 weeks after completion of therapy and again after 3 months
  • Diagnosis code: Chlamydia: A74.9  (pregnant) or A56.02 (nonpregnant)

Learn More – Primary Sources:

CDC: Chlamydial Infections in Adolescents and Adults

CDC: Chlamydia Fact Sheet for Your Patients