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CHLAMYDIAL INFECTION
Chlamydial
trachomatis is an obligate intracellular bacterium that has several serotypes including those that cause lymphogranuloma venereum. The most commonly
encountered strains are those that attach only to columnar or
transitional cell epithelium and cause cervical infection. It is the
most commonly reported infectious
disease in the United States with
1.4 million cases reported in 2012 .
It is estimated however that there are
approximately 2.8 million new cases annually although most are
undiagnosed . In 2012 the incidence of chlamydial infection
among women was 2 ½ times greater
than among men. Selective prenatal
screening clinics in 2011 reported a median chlamydial infection rate of 7.7
percent .
Although most
pregnant women have asymptomatic infection a third have urethral syndrome , urethritis or Bartholin gland infection . Mucopurulent Cervicitis may be due to chlamydial or gonococcal infection or both.
It may also
represent normal hormonally stimulated endocervical glands
with abundant mucus production.
Other chlamydial infections not usually seen in pregnancy are endometritis salpingitis
peritonitis reactive arthritis and Reiter syndrome.
The
risk of chlamydail infection in pregnancy
complication remains
controversial . A few studies
have reported a direct association
between C trachomatis and
miscarriage whereas most
show no correlation.
It is disputed whether untreated cervical infection increases the risk of preterm delivery preterm
ruptured membranes and perinatal mortality reported a twofold risk for low birth weight infants.
Chlamydial
infection has not been associated with an increased risk of chorioamnionitis or with pelvic infection after cesarean delivery .
Conversely delayed postpartum uterine infection has
been described by Hoyme and associates . The
syndrome which develops 2 to 3
weeks postpartum is distinct from early postpartum
metritis .
It is characterized by vaginal bleeding or discharge ., low grade fever lower abdominal pain and uterine tenderness.
There is
vertical transmission to 30-- 50
percent of neonates delivered vaginally from infected women. Perinatal
transmission of newborn can
cause pneumonia . Moreover
C trachomatis is the most commonly identifiable infectious cause of ophthalmia neonatorum.
Screening and treatment
Prenatal
screening for C trachamatis is a complex
issue although there is little
evidence for its effectiveness in asymptomatic
women who are not in high
risk groups . Identification and treatment of asymptomatic infected women
may prevent neonatal infections but evidence of adverse pregnancy
outcome prevention is lacking .
Currently
the U.s Preventive Services Task
Force and the CDC recommend prenatal
screening at the first prenatal
visit for women at increased
risk for chlamydial infection
and again during the third trimester if high risk behavior continues.
In a
systematic review of repeat chlamydial
infection among women. Hosenfeld and coworkers
reported a reinfection rate of 14 percent and most
recurred within the first 8 to 10 months.
Interestingly in another
study Sheffield and colleagues found that almost half of pregnant women with asymptomatic
cervical Chlamydia underwent
spontaneous resolution of
infection.
Diagnosis Diagnosis is made predominantly by culture or NAAT cultures are more expensive and less accurate than newer NNATs including PCR. Roberts and associates evaluated nucleic acid amplification testing of urine
compared with cervical secretions in
more than 2000 pregnant women and found
them to be equivalent.
Currently recommended treatment regimens for chlamydial infections are shown . Azithromycin is first line treatment
and has been found to be safe and
effective in pregnancy. The fluoroquinolones
and doxycycline are avoided in pregnancy
as is erythromycin estolate because of
drug related hepatotoxicity . Repeat
chlamydial testing 3 to 4 weeks
after completion of therapy is recommended
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