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Department of Reproductive Health and Research (RHR), World Health Organization

Sexually transmitted and other reproductive tract infections

A guide to essential practice

 

 
    

Annexes
Annex 4. Medications


 

Medications in pregnancy

During pregnancy, the mother and the fetus form one biological unit, and the health of the fetus depends on the health of the mother. It is important to treat the mother whenever needed, while protecting the unborn baby to the greatest possible extent.

Drugs can have harmful effects on the fetus at any time during pregnancy. During the first trimester, drugs may produce congenital malformations (teratogenesis); the greatest risk is between the third and the eleventh week of pregnancy. Few drugs have been shown conclusively to be teratogenic in humans but no drug is safe beyond all doubt in early pregnancy.

Drugs should be prescribed for a pregnant woman only if the expected benefits to her are thought to be greater than the risk to the fetus. All drugs should be avoided, if possible, during the first trimester. Drugs that have been used extensively in pregnancy and appear to be usually safe should be prescribed in preference to new or untried drugs and the smallest effective dose should be used. The following list includes information about use of some common drugs in pregnancy. Absence of a drug from the list does not imply that it is safe.

acyclovir

Not known to be harmful; limited absorption from topical preparations

amoxicillin

No evidence of teratogenicity

ampicillin

Not known to be harmful

azithromycin

Limited data in pregnancy; use only if potential benefit outweighs risk.

benzathine benzylpenicillin

Not known to be harmful

benzylpenicillin

Not known to be harmful

cefixime

Single dose of cefixime is considered safe in pregnancy

ceftazidime

Not known to be harmful

ceftriaxone

Not known to be harmful

chloramphenicol

Third trimester: neonatal "grey baby" syndrome

ciprofloxacin

Avoid—arthropathy in animal studies; safer alternatives available

clindamycin

Not known to be harmful

clotrimazole

Not studied in first trimester. Used vaginally during second and third trimester not shown to cause birth defects.

cloxacillin

Not known to be harmful

doxycycline

Contraindicated in pregnancy and breastfeeding:

First trimester: effects on skeletal development in animal studies

Second and third trimesters: dental discoloration in children; maternal hepatotoxicity with large parenteral doses

erythromycin

Not known to be harmful

famciclovir

Animal studies did not show any risk for fetus—use only when potential benefit outweighs risk

fluconazole

Avoid in first trimester—multiple congenital abnormalities reported with long-term high doses

gentamicin

Second and third trimesters: auditory or vestibular nerve damage; risk probably very small, but use only if potential benefit outweighs risk (if given, monitoring of serum gentamicin concentration essential)

metronidazole

First trimester: avoid

Second and third trimesters: avoid high-dose regimens (>1g)

nystatin

No information available, but absorption from gastrointestinal tract negligible

ofloxacin

Avoid—arthropathy in animal studies; safer alternatives available

podophyllum resin

Avoid—neonatal death and teratogenesis have been reported

streptomycin

Second and third trimesters: auditory or vestibular nerve damage; avoid unless essential (if given, monitoring of serum streptomycin concentration essential)

sulfamethoxazole + trimethoprim

First trimester: theoretical teratogenic risk (trimethoprim is a folate antagonist)

Third trimester: neonatal haemolysis and methaemoglobinaemia; suggestion of increased risk of kernicterus in neonates appears to be unfounded

tinidazole

Manufacturer advises to avoid in first trimester

Second and third trimesters: avoid high-dose regimens (>1g)

tetracycline

Contraindicated in pregnancy and breastfeeding:

First trimester: effects on skeletal development in animal studies

Second and third trimesters: dental discoloration in children; maternal hepatotoxicity with large parenteral doses

trimethoprim

First trimester: theoretical teratogenic risk (folate antagonist)

valaciclovir

Animal studies did not show any risk for fetus—use only when potential benefit outweighs risk;

vancomycin

Use only if potential benefit outweighs risk—monitoring of plasma vancomycin concentration essential to reduce risk of fetal toxicity

zidovudine and other antiretrovirals

Avoid if possible in first trimester; benefit of treatment considered to outweigh risk in second and third trimesters

 

Antibiotic treatments for gonorrhoea

 

WHO recommended treatments for urogenital and rectal gonorrhoea

Dosage

Safe in pregnancy?

Resistance

cefixime

400 mg orally as a single dose

Yes

No

ceftriaxone

125 mg by intramuscular injection

Yes

No

ciprofloxacina

500 mg orally as a single dose

No

Extensive quinolone resistance in parts of the WHO South-East Asia and Western Pacific Regions

spectinomycin

2 g by intramuscular injection

Yes

No

Other effective treatments for urogenital and rectal gonorrhoea

cefotaxime

1 g by intramuscular injection

Yes

No

ceftizoxime

1 g by intramuscular injection

Yes

No

cefuroxime

1.5 g by intramuscular injection

Yes

No

levofloxacina

250 mg orally as a single dose

No

Extensive quinolone resistance in parts of the WHO South-East Asia and Western Pacific Regions

norfloxacina

400 mg orally as a single dose

No

ofloxacina

400 mg orally as a single dose

No

trimethoprim/ sulfamethoxazole

80/400 mg orally, 10 tablets as a single dose each day for 3 days

No

Resistance in many regions

a. The use of quinolones should take into consideration the patterns of Neisseria gonorrhoeae resistance, such as in the WHO South-East Asia and Western Pacific Regions.

Treatment of gonorrhoea: 30 regimens, involving 21 antimicrobial drugs have been shown to be effective for rectal and urogenital infections. Few regimens have been shown to be highly effective against pharyngeal infections. Among those antimicrobial agents available for the treatment of uncomplicated gonococcal infections, ceftriaxone (125 mg), cefixime (400 mg), ciprofloxacin (500 mg), and ofloxacin (400 mg) appear to offer the best balance of proven efficacy and safety.

 

____________________________

1 Thirteenth WHO model list of essential drugs. Geneva, World Health Organization, 2003.

 

Contents
html files

 

Infections of the male and female reproductive tract and their consequences:

What are RTIs?

Why STI/RTIs are important?

What can be done about RTIs?

The role of clinical services in reducing the burden of STI/RTI

Preventing STIs/RTIs and their complications

How to prevent STI

How to prevent iatrogenic infections

How to prevent endogenous infections

Detecting STI/RTI

Detecting STI/RTI

Syphilis

Vaginal infections

Cervical infections

Pelvic inflammatory disease

HIV counselling and testing

STI/RTI education and counselling

Key points

Privacy and confidentiality

General skills for STI/RTI education and counselling

Health education

Counselling

Promoting prevention of STI/RTI and use of services

Key points

Reducing barriers to use of services

Raising awareness and promoting services

Reaching groups that do not typically use reproductive health services

STI/RTI Assessment during Routine Family Planning Visits

Key points

Integrating STI/RTI assessment into routine FP services

Family planning methods and STIs/RTIs

STI/RTI Assessment in pregnancy, childbirth and the postpartum period

Key points

Management of symptomatic STIs/RTIs

Syndromic management of STI/RTI

Management of common syndromes

STI case management and prevention of new infections

STI/RTI complications related to pregnancy, miscarriage, induced abortion, and the postpartum period

Key points

Infection in early pregnancy

Infection in lated pregnancy

Infection following childbirth

Vaginal discharge in pregnancy and the postpartum period

Sexual violence

Key points

Medical and other care for survivors of sexual assault

Annex 1. Clinical skills needed for STI/RTI

History-taking

Common STI/RTI symptoms

Examining patients

Annex 2. Disinfection and universal precautions

Preventing infection in clinical settings

High-level disinfection: three steps

Universal precautions

Annex 3. Laboratory tests for RTI

Interpreting syphilis test results

Clinical criteria for bacterial vaginosis (BV)

Wet mount microscopy

Gram stain microscopy of vaginal smears

Use of Gram stain for diagnosis of cervical infection

Annex 4. Medications

Medications in pregnancy

Antibiotic treatments for gonorrhoa

Annex 5.

STI/RTI reference table

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Additionnal resources

 

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