Treatment recommendations for women who are pregnant or breastfeeding are based on the National guideline on the diagnosis and treatment of gonorrhoea in adults, published by the British Association for Sexual Health and HIV (BASHH) [BASHH, 2005b], and a European guideline [Bignell, 2009].

Treatment of confirmed gonorrhoea

• There is evidence from a meta-analysis of two comparative randomized controlled trials that cefixime and ceftriaxone are effective in the treatment of confirmed gonorrhoea in pregnant women [Brocklehurst, 2002].
• Amoxicillin (combined with probenecid) has also been shown to be effective, but it is probably not as effective as cephalosporin antibiotics [Brocklehurst, 2002], and is evidence that Neisseria gonorrhoeae is becoming increasingly resistant to penicillin-based antibiotics [GRASP Steering Group, 2007].

Empirical treatment of gonorrhoea

• Empirical treatment aims to provide coverage for both Neisseria gonorrhoeae and Chlamydia trachomatis, as these infections often coexist and cannot be accurately distinguished by clinical features alone [RCGP and BASHH, 2006].
• Azithromycin, erythromycin, or amoxicillin is recommended by BASHH for the treatment of chlamydia in pregnant women [BASHH, 2006]. These antibiotics have been shown to be effective in controlled trials [Brocklehurst and Rooney, 1998] and are not contraindicated in pregnancy or breastfeeding.
• Penicillin has been shown to induce latency in vitro, and some experts are concerned there is a theoretical risk of re-emergence of infection, However, amoxicillin has been found to be as effective as erythromycin in a meta-analysis of trials, and has considerably less adverse effects [BASHH, 2006].

Safety of antibiotics in pregnancy

• The benefits of antibiotics for gonorrhoea outweigh the risks in pregnancy.
• Left untreated, gonorrhoea in pregnancy is associated with spontaneous abortion, premature labour, early rupture of fetal membranes, perinatal mortality, and gonococcal conjunctivitis in the newborn [Handsfield and Sparling, 2005].
• Chlamydia is associated with premature birth and spontaneous abortion in pregnant women [Stamm et al, 2005] and may develop into pelvic inflammatory disease, which increases the risk of ectopic pregnancy, infertility, and chronic pelvic pain in later life [BASHH, 2006].
• Cefixime and ceftriaxone are not specifically licensed in pregnancy but 'are not known to be harmful' [BNF 57, 2009]. Although cephalosporins cross the placenta, no evidence from animal studies indicates that they are toxic to the embryo or the fetus, and no harms have been shown in observational studies of pregnant women who have been exposed to cephalosporins [Schaefer et al, 2007; NTIS, 2008d].
• Amoxicillin is considered to have a good safety profile in pregnancy, and its use is licensed in this setting [ABPI Medicines Compendium, 2008c]. There is extensive experience of using penicillins in pregnancy, with no evidence to suggest that they are associated with an increased risk of malformations or other forms of fetal toxicity [NTIS, 2008c].
• Macrolides are considered to be suitable treatment options in pregnancy where indicated [NTIS, 2008c].
• Erythromycin is generally preferred because there is more experience with it than with other macrolides [NTIS, 2008b]. However, it is probably not as effective as azithromycin in the treatment of chlamydia [Brocklehurst and Rooney, 1998].
• Azithromycin is usually recommended as second-line treatment in pregnancy; animal studies and limited observational data have not indicated an increased risk of congenital malformations [NTIS, 2008a].

Drugs not recommended

• Fluoroquinolones are not recommended in pregnancy or breastfeeding except 'for the treatment of serious or life-threatening conditions unresponsive to standard antibiotic therapy', because there is a theoretical risk of arthropathy in the child [Schaefer et al, 2007; NTIS, 2008c].
• Tetracyclines have been associated with discolouration of teeth and bones, staining of the lenses, and the development of cataracts in newborn babies when used in the second and third trimesters. They are therefore contraindicated in pregnancy and breastfeeding [Schaefer et al, 2007; NTIS, 2008c].