Mothers with syphilis infection should be treated with penicillin and advised regular follow up. The treatment of the neonate depends on the clinical presentation and managment varies with the severity of the infection.
Medical Therapy
Management during Antenatal Period
CDC Recommendations for management of pregnant woman with Syphilis infection
Pregnant women with reactive treponemal screening tests should have confirmatory testing with nontreponemal tests with titers to monitor treatment response.
In populations in which use of prenatal care is not optimal, RPR test screening and treatment (if the RPR test is reactive) should be performed at the time that pregnancy is confirmed.
For communities and populations in which the prevalence of syphilis is high and for patients at high risk, serologic testing should be performed twice during the third trimester (ideally at 28-32 weeks' gestation) and at delivery.
No infant should leave the hospital without the maternal serologic status having been determined at least once during pregnancy.
Quantitative maternal nontreponemal titer, especially if >1:8, might be a marker of early infection and bacteremia. However, risk for fetal infection is still significant in pregnant women with late latent syphilis and low titers.
Seropositivepregnant women should be considered infected unless an adequate treatment history is documented clearly in the medical records and sequential serologicantibody titers have declined.
Serofast low antibodytiters might not require treatment; however, persistent higher titer antibody tests might indicate reinfection, and treatment might be required.
Recommended Regimen for Treatment
Pregnant women should be treated with the penicillin regimen appropriate for their stage of infection.[4]
Penicillin is effective for preventing maternal transmission to the fetus and for treating fetal infection.[5]Evidence is insufficient to determine optimal, recommended penicillin regimens.[6]
Additional Considerations
Some evidence suggests that additional therapy can be beneficial for pregnant women in some settings (e.g., a second dose of benzathine penicillin 2.4 million units IM administered 1 week after the initial dose for women who have primary, secondary, or early latent syphilis). [7]
When syphilis is diagnosed during the second half of pregnancy, management should include a sonographic fetal evaluation for congenital syphilis, but this evaluation should not delay therapy.
Sonographic signs of fetal or placental syphilis (i.e., hepatomegaly, ascites, hydrops, fetal anemia, or a thickened placenta) indicate a greater risk for fetal treatment failure;[3] such cases should be managed in consultation with obstetric specialists. Evidence is insufficient to recommend specific regimens for these situations.
Women treated for syphilis during the second half of pregnancy are at risk for premature labor and/or fetal distress if the treatment precipitates the Jarisch-Herxheimer reaction.[8] These women should be advised to seek obstetric attention after treatment if they notice any fever, contractions, or decrease in fetal movements.
Stillbirth is a rare complication of treatment, but concern for this complication should not delay necessary treatment.
Pregnant women taking treatment for late latent syphilis should not miss any dose, else she must repeat the whole course of therapy.[9]
All patients who have syphilis should be offered testing for HIV infection.
In patients with Penicillin Allergy
For treatment of syphilis during pregnancy, no proven alternatives to penicillin exist.
Data are insufficient to recommend ceftriaxone for treatment of maternal infection and prevention of congenital syphilis.
Pregnant Woman with HIV Infection
Placental inflammation from congenital infection might increase the risk for perinatal transmission of HIV.
All HIV-infected women should be evaluated for syphilis and receive treatment as recommended.
Data are insufficient to recommend a specific regimen for HIV-infected pregnant women.
Follow Up
Coordinated prenatal care and treatment are vital.
Serologic titers should be repeated at 28-32 weeks' gestation and at delivery as recommended for the disease stage. Providers should ensure that the clinical and antibody responses are appropriate for the patient's stage of disease, although most women will deliver before their serologic response to treatment can be assessed definitively.
Inadequate maternal treatment is likely if delivery occurs within 30 days of therapy, if clinical signs of infection are present at delivery, or if the maternal antibody titer at delivery is fourfold higher than the pretreatment titer.
Serologic titers can be checked monthly in women at high risk for reinfection or in geographic areas in which the prevalence of syphilis is high.[4]
Management of a Neonate or an Infant with Congenital Syphilis
Other tests as clinically indicated (e.g., long-bone radiographs, chest radiograph, liver-function tests, neuroimaging, ophthalmologic examination, and auditory brain stem response)
Preferred regimen 1:Aqueous crystalline penicillin G 100,000-150,000 U/kg/day, administered as 50,000 U/kg/dose IV q12h during the first 7 days of life and q8h thereafter for a total of 10 days Preferred regimen 2:Procaine penicillin G 50,000 U/kg/dose IM q24h for 10 days
Note: If more than 1 day of therapy is missed, the entire course should be restarted. Data are insufficient regarding the use of other antimicrobial agents (e.g., ampicillin). When possible, a full 10-day course of penicillin is preferred, even if ampicillin was initially provided for possible sepsis. The use of agents other than penicillin requires close serologic follow-up to assess adequacy of therapy. In all other situations, the maternal history of infection with T. pallidum and treatment for syphilis must be considered when evaluating and treating the infant
Clinical senario 2
Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer the same or less than fourfold the maternal titer and with one of the following:
Mother was not treated or inadequately treated, or has no documentation of having received treatment or
Mother was treated with erythromycin or another non-penicillin regimen or
Mother received treatment less than 4 weeks before delivery.
Preferred regimen 1:Aqueous crystalline penicillin G 100,000-150,000 U/kg/day, administered as 50,000 U/kg/dose IV q12h during the first 7 days of life and q8h thereafter for a total of 10 days Preferred regimen 2:Procaine penicillin G 50,000 U/kg/dose IM q24h for 10 days Preferred regimen 3:Benzathine penicillin G 50,000 U/kg/dose IM single dose
Note: If the mother has untreated early syphilis at delivery, 10 days of parenteral therapy can be considered
Before using the single-dose benzathine penicillin G regimen, the complete evaluation (i.e., CSF examination, long-bone radiographs, and CBC with platelets) must be normal, and follow-up must be certain. If any part of the infant's evaluation is abnormal or not performed, if the CSF analysis is uninterpretable because of contamination with blood, or if follow-up is uncertain, a 10-day course of penicillin G is required. If the neonate's nontreponemal test is nonreactive and the provider determines that the mother's risk of untreated syphilis is low, treatment of the neonate with a single IM dose of benzathine penicillin G 50,000 units/kg for possible incubating syphilis can be considered without an evaluation.
Neonates born to mothers with untreated early syphilis at the time of delivery are at increased risk for congenital syphilis, and the 10-day course of penicillin G may be considered even if the complete evaluation is normal and follow-up is certain.
Clinical senario 3
Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer the same or less than fourfold the maternal titer and
Mother was treated during pregnancy, treatment was appropriate for the stage of infection, and treatment was administered >4 weeks before delivery and
Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer the same or less than fourfold the maternal titer and
Mother's treatment was adequate before pregnancy and
Mother's nontreponemal serologic titer remained low and stable before and during pregnancy and at delivery (VDRL <1:2; RPR <1:4)
Recommended evaluation
No evaluation recommended
No treatment is required
Benzathine penicillin G 50,000 U/kg IM single dose might be considered, particularly if follow-up is uncertain
Follow up
All neonates with reactive nontreponemal tests should receive careful follow-up examinations and serologic testing (i.e., a nontreponemal test) every 2–3 months until the test becomes nonreactive.
In the neonate who was not treated because congenital syphilis was considered less likely or unlikely, nontreponemalantibodytiters should decline by age 3 months and be nonreactive by age 6 months, indicating that the reactive test result was caused by passive transfer of maternal IgGantibody.
At 6 months, if the nontreponemal test is nonreactive, no further evaluation or treatment is needed; if the nontreponemal test is still reactive, the infant is likely to be infected and should be treated.
Treated neonates that exhibit persistent nontreponemal test titers by 6–12 months should be re-evaluated through CSF examination and managed in consultation with an expert. Retreatment with a 10-day course of a penicillin G regimen may be indicated.
Neonates with a negative nontreponemal test at birth and whose mothers were seroreactive at delivery should be retested at 3 months to rule out serologically negative incubating congenital syphilis at the time of birth.
Neonates whose initial CSF evaluations are abnormal should undergo a repeat lumbar puncture approximately every 6 months until the results are normal
Note: Treponemal tests should not be used to evaluate treatment response because the results are qualitative and passive transfer of maternal IgG treponemal antibody might persist for at least 15 months
A reactive CSF Venereal Disease Research Laboratory (VDRL) test or abnormal CSF indices that persist and cannot be attributed to other ongoing illness requires retreatment for possible neurosyphilis and should be managed in consultation with an expert.
Penicillin Allergy
Infants and children who require treatment for congenital syphilis but who have a history of penicillin allergy or develop an allergic reaction presumed secondary to penicillin should be desensitized and then treated with penicillin.
If the infant or child has no clinical manifestations of congenital syphilis and the evaluation (including the CSF examination) is normal, treatment with up to 3 weekly doses of benzathine penicillin G, 50,000 U/kg IM can be considered. A single dose of benzathine penicillin G 50,000 units/kg IM up to the adult dose of 2.4 million units in a single dose can be considered after the 10-day course of IV aqueous penicillin to provide more comparable duration of treatment in those who have no clinical manifestations and normal CSF. All of the above treatment regimens also would be adequate for children who might have other treponemal infections.
Follow Up
Careful follow-up examinations and serologic testing (i.e., a nontreponemal test) of infants and children treated for congenital syphilis after the neonatal period (30 days of age) should be performed every 3 months until the test becomes nonreactive or the titer has decreased fourfold.
If the titers increase at any point for more than 2 weeks or do not decrease fourfold after 12–18 months, the infant or child should be evaluated (e.g., through CSF examination), treated with a 10-day course of parenteral penicillin G, and managed in consultation with an expert.
Treponemal tests should not be used to evaluate treatment response, because the results are qualitative and persist after treatment; further, passive transfer of maternal IgGtreponemalantibody might persist for at least 15 months after delivery.
Infants or children whose initial CSF evaluations are abnormal should undergo a repeat lumbar puncture approximately every 6 months until the results are normal. After 2 years of follow-up, a reactive CSFVDRL test or abnormal CSF indices that persists and cannot be attributed to other ongoing illness requires retreatment for possible neurosyphilis and should be managed in consultation with an expert.
Penicillin Allergy
Infants and children who require treatment for congenital syphilis but who have a history of penicillin allergy or develop an allergic reaction presumed secondary to penicillin should be desensitized and treated with penicillin