Patients at increased risk, for example, Aboriginal women, should have a further test in the third trimester.
Additional antenatal screening is required in high-risk communities during syphilis outbreaks:
- first antenatal visit [routine]
- 28 weeks
- 36 weeks
- at birth
- 6-week post-natal check
The Communicable Disease Control Branch, SA Health issues public health alerts when a syphilis outbreak occurs.
Positive tests during pregnancy should be evaluated rapidly on history and examination, with testing of contacts and, if unresolved a further RPR [two weeks after the first test].
Syphilis in pregnancy should be treated with the standard regimen used for the same clinical stage of syphilis in non-pregnant people.
The only exception is early syphilis diagnosed in the third trimester of pregnancy, which should be treated with:
Benzathine penicillin G 1.8 gm [2.4 million units] im weekly for two weeks.
Coordination of pre-natal and post-natal care is vital. When syphilis is diagnosed in the second half of pregnancy an ultrasound evaluation for congenital syphilis should be done, but should not delay treatment.
If active syphilis cannot be reasonably excluded by this process the patient should be treated for early syphilis, as a safeguard against foetal infection.
Pregnant patients with a history of penicillin allergy should be desensitised and treated with penicillin. No proven alternatives for maternal or foetal infection exist.
Treatment for syphilis in pregnancy should have follow-up RPR at 28 to 32 weeks gestation and at delivery, and beyond for their clinical stage of syphilis.
Treatment during the second half of pregnancy involves a risk of premature labour and foetal distress, due to a Jarisch-Herxheimer reaction. Patients over 20 weeks of pregnancy requiring treatment for syphilis should be discussed with the attending Obstetrician prior to treatment, but treatment should not be delayed.
HIV testing should be offered to all patients with syphilis, including pregnant patients.
If the patient completes treatment with penicillin more than four weeks before delivery, risk to the infant is minimal, and follow up of the infant involves clinical examination at birth, serology at birth and thereafter three monthly until RPR is negative.
If maternal treatment was:
- inadequate
- unknown
- with a non-penicillin regimen
- completed less than four weeks prior to delivery
- or if adequate follow-up of the infant cannot be assured.
The infant should be treated at birth and have repeat serology three-monthly until the RPR becomes negative. The CSF should be examined before treatment if there is a substantial risk of congenital syphilis.
Aqueous crystalline penicillin G 50,000 units/kg i.v. 12 hourly for the first seven days of life and every eight hours thereafter for a total of ten days
OR
Aqueous procaine penicillin G 50,000 units/kg im in a single daily dose for ten days.
For asymptomatic infants with normal CSF and for whom follow up cannot be guaranteed:
Benzathine penicillin G 50,000 units/kg im as one dose.
Further information
For further information on the management of syphilis during pregnancy contact Adelaide Sexual Health Centre.
Disclaimer
These guidelines are based on a review of current literature, current recommendations of the United States Centers for Disease Control and Prevention, World Health Organization, the British Association for Sexual Health and HIV and local expert opinion.
They are written primarily for use by Adelaide Sexual Health Centre staff and some flexibility is required in applying them to certain private practice situations.
Syphilis can seriously complicate pregnancy and result in spontaneous abortion, stillbirth, non-immune hydrops, intrauterine growth restriction, and perinatal death, as well as serious sequelae in liveborn infected children. While appropriate treatment of pregnant women often prevents such complications, the major deterrent has been inability to identify the infected women and get them to undergo treatment. Screening in the first trimester with non-treponemal tests such as rapid plasma reagin [RPR] or venereal disease research laboratory [VDRL] test combined with confirmation of reactive individuals with treponemal tests such as the fluorescent treponemal antibody absorption [FTA-ABS] assay is a cost effective strategy. Those at risk should be retested in the third trimester. Treatment during pregnancy should be with penicillin. In determining a penicillin regimen, the clinician must consider the stage of the maternal infection and the HIV status of the mother. Patients who are allergic to penicillin should be desensitised before treatment. Despite appropriate treatment, as many as 14% will have a fetal death or deliver infected infants. Treatment may further be complicated by the Jarich–Herxheimer reaction, a complex allergic response to antigens released from dead micro-organisms, which can cause fetal distress and uterine contractions. Thanks to effective intervention strategies and inexpensive penicillin, syphilis rarely complicates pregnancy in the Western world today. In parts of the world where the traditional sexually transmitted diseases have not been controlled, the magnitude of problems associated with syphilis during pregnancy is reminiscent of that faced by the West during the early 1900s.
- syphilis
- pregnancy
- syphilis
- pregnancy
Epidemiology
Syphilis during pregnancy in the Western world is rare today. In this era, the prevalence of seropositivity in pregnancy is between 0.02–4.5% in northern Europe and the United States after accounting for biological false reactive tests.1–6 Thanks to effective intervention strategies and the availability of penicillin, few of these pregnancies result in congenital syphilis—for example, an average of 30 cases per 100 000 live births in the United States in 1996.7 The demographic profile of women who deliver syphilitic babies represents that of women with other sexually transmitted diseases [STDs] as well as those who fail to get adequate prenatal care.2, 3, 8 These women are more likely to be adolescent and unmarried. A disproportionate number of cases among childbearing women and their infants occur among minority groups—for example, African and Latin Americans in large urban areas. A major contributor to the increased occurrence is the use of crack cocaine2 and the exchange of sex for money with multiple partners.9
Incidence of syphilis increased dramatically in the former Iron Curtain countries during the past decade.10 For example, in Russia, the incidence of syphilis increased from