Sandbox:Reddy 2: Difference between revisions
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*Pregnant women should be treated with the [[penicillin]] regimen appropriate for their stage of infection.<ref name="urlSexually Transmitted Diseases Treatment Guidelines, 2010">{{cite web|url=http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm |title=Sexually Transmitted Diseases Treatment Guidelines, 2010 |format= |work= |accessdate=2012-12-19}}</ref> | *Pregnant women should be treated with the [[penicillin]] regimen appropriate for their stage of infection.<ref name="urlSexually Transmitted Diseases Treatment Guidelines, 2010">{{cite web|url=http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm |title=Sexually Transmitted Diseases Treatment Guidelines, 2010 |format= |work= |accessdate=2012-12-19}}</ref> | ||
* [[Penicillin]] is effective for preventing maternal transmission to the fetus and for treating fetal infection.<ref name="pmid9916946">Alexander JM, Sheffield JS, Sanchez PJ, Mayfield J, Wendel GD (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9916946 Efficacy of treatment for syphilis in pregnancy.] ''Obstet Gynecol'' 93 (1):5-8. PMID: [http://pubmed.gov/9916946 9916946]</ref>Evidence is insufficient to determine optimal, recommended penicillin regimens. | * [[Penicillin]] is effective for preventing maternal transmission to the fetus and for treating fetal infection.<ref name="pmid9916946">Alexander JM, Sheffield JS, Sanchez PJ, Mayfield J, Wendel GD (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9916946 Efficacy of treatment for syphilis in pregnancy.] ''Obstet Gynecol'' 93 (1):5-8. PMID: [http://pubmed.gov/9916946 9916946]</ref>Evidence is insufficient to determine optimal, recommended penicillin regimens.<ref name="pmid11686978">Walker GJ (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11686978 Antibiotics for syphilis diagnosed during pregnancy.] ''Cochrane Database Syst Rev'' (3):CD001143. [http://dx.doi.org/10.1002/14651858.CD001143 DOI:10.1002/14651858.CD001143] PMID: [http://pubmed.gov/11686978 11686978]</ref> | ||
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!'''Additional Considerations''' | !'''Additional Considerations''' | ||
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*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. | *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]], [[anemia|fetal anemia]], or a thickened placenta) indicate a greater risk for fetal treatment failure;<ref name="pmid11384701">Hollier LM, Harstad TW, Sanchez PJ, Twickler DM, Wendel GD (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11384701 Fetal syphilis: clinical and laboratory characteristics.] ''Obstet Gynecol'' 97 (6):947-53. PMID: [http://pubmed.gov/11384701 11384701]</ref> such cases should be managed in consultation with obstetric specialists. Evidence is insufficient to recommend specific regimens for these situations. | *Sonographic signs of fetal or placental syphilis (i.e., [[hepatomegaly]], [[ascites]], [[hydrops]], [[anemia|fetal anemia]], or a thickened placenta) indicate a greater risk for fetal treatment failure;<ref name="pmid11384701">Hollier LM, Harstad TW, Sanchez PJ, Twickler DM, Wendel GD (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11384701 Fetal syphilis: clinical and laboratory characteristics.] ''Obstet Gynecol'' 97 (6):947-53. PMID: [http://pubmed.gov/11384701 11384701]</ref> 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]]. | *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]].<ref name="pmid2304710">Klein VR, Cox SM, Mitchell MD, Wendel GD (1990) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=2304710 The Jarisch-Herxheimer reaction complicating syphilotherapy in pregnancy.] ''Obstet Gynecol'' 75 (3 Pt 1):375-80. PMID: [http://pubmed.gov/2304710 2304710]</ref> 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. | *[[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.<ref name="pmid8355931">{{cite journal| author=Nathan L, Bawdon RE, Sidawi JE, Stettler RW, McIntire DM, Wendel GD| title=Penicillin levels following the administration of benzathine penicillin G in pregnancy. | journal=Obstet Gynecol | year= 1993 | volume= 82 | issue= 3 | pages= 338-42 | pmid=8355931 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8355931 }} </ref> | *Pregnant women taking treatment for late latent syphilis should not miss any dose, else she must repeat the whole course of therapy.<ref name="pmid8355931">{{cite journal| author=Nathan L, Bawdon RE, Sidawi JE, Stettler RW, McIntire DM, Wendel GD| title=Penicillin levels following the administration of benzathine penicillin G in pregnancy. | journal=Obstet Gynecol | year= 1993 | volume= 82 | issue= 3 | pages= 338-42 | pmid=8355931 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8355931 }} </ref> | ||
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*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. | *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. | *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. | *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.<ref name="urlSexually Transmitted Diseases Treatment Guidelines, 2010">{{cite web|url=http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm |title=Sexually Transmitted Diseases Treatment Guidelines, 2010 |format= |work= |accessdate=2012-12-19}}</ref> | ||
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Revision as of 14:18, 9 February 2017
Overview
Congenital Syphilis is caused by Treponema pallidum, its transmitted to the fetus in utero from an infected mother via the placenta. The severity of the disease is dependent on the stage of maternal infection and the duration of exposure to the fetus. Transmission is typically in the second trimester and the highest rates of transmission are seen in women with primary syphilis. The rates of transmission decrease with the increasing duration of the maternal infection, as the concentration of spirochetes in the blood stream decreases. Syphilis infection to the fetus in utero can result in stillborn, miscarriage and a live birth with severe manifestations of hydrops. Prenatal screening for syphilis during the first trimester is recommended to all pregnant women and adequate treatment with penicillin prevents the transmission to the fetus.
Historical Perspective
- In the 19th century congenital syphilis was believed to be transmitted during conception by the father’s sperm, during delivery in the birth canal, or from infected milk or breasts.[1]
- In 1905, Schaudinn and Hoffmann identified Spirochaeta pallida.
- Transplacental transmission from an asymptomatic infected mother was first described in 1906.[2]
- In 1943, Lentz and Ingraham reported penicillin as treatment for congenital syphilis.
- In 2006, the WHO launched a global effort to eliminate congenital syphilis.
Classification
Congenital Syphilis is classified based on the timing of appearance of signs and symptoms into:[3]
- Early congenital Syphilis: If the signs and symptoms are identified in children aged less than 2 years. It is usually diagnosed in new born or in the first few weeks after birth.[4]
- Late congenital Syphilis: If the signs and symptoms of the disease are identified in children aged more than 2 years. The signs are usually non-specific and more than half the children are asymptomatic. They can present with interstitial keratitis, eighth nerve deafness or clutton's joints.
- Stigmata: These are the scars resulting from early or late congenital syphilis. The features of stigmata in early congenital syphilis include saddle nose deformity, Hutchinson's teeth, rhagades, choriod scarring and onychia. Stigmata secondary to late congenital syphilis include perforation of the palate, corneal opacities, optic atrophy and periosteal changes of tibia.
Causes
The causative pathogen for Congenital syphilis Treponema pallidum.
Pathophysiology
Pathogenesis
- Transmission to the fetus is transplacental, it can also occur during delivery in the presence of maternal genital lesions.[5][6][7]
- The risk of transmission to the fetus is dependent on the stage of the maternal disease(dependent on the spirochete concentration in the blood stream) and the duration of exposure to the fetus in utero.[8]
- The risk of vertical transmission of syphilis from an infected untreated mother decreases as maternal disease duration progresses: transmission risk of 70–100% for primary syphilis and 40% for early latent syphilis to 10% for late latent disease. The variation in the percentages with the duration of infection is because the concentration of spirochetes in the blood stream decrease with the duration of maternal syphilis infection.[9]
- Kassowitz's law describes the an inverse relationship of interval between the disease and pregnancy. Longer the interval between infection and pregnancy more benign is the outcome.[3]
- Transmission of infection typically takes place between the 16th and 28th week of pregnancy, however the transmission can be as early as the first trimester of pregnancy.[10][11][12][13][14][15]
- Inadequate antenatal care
- Multiple sexual partners
- Prostitution
- Illicit drug use
- Unprotected sex
- Residence in highly prevalent areas
- HIV infection
- Presence of other STIs
- Previous history of STIs
- Intravenous drug use
- Health care professionals who are predisposed to occupational risk
- Low socioeconomic status
Screening
Effective prevention and detection of congenital syphilis depends on the identification of syphilis in pregnant women and screening is a key component to decrease the incidence of congenital syphilis. The recommendations for screening are as follows:
Screening Recommendations | |
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Timing of Screening | Test all pregnant women at the first prenatal visit. |
Screening Tests |
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High Risk Population |
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Epidemiology, Demographics
Incidence
- It is estimated that every year 2 million pregnant women are infected with syphilis every year.
- In 2005, WHO reported that 460,000 abortions or still birth and 270,000 cases of congenital syphilis every year can be attributed to maternal syphilis.
- The incidence of congenital syphilis in United States in the year 2014 is 11.6 cases per 100,000 live births. The incidence of congenital syphilis has increased when compared to the numbers from 2008 to 2012 and the change is attributed to the increase in the number of women with primary and secondary syphilis.[16][17]
Race
- Congenital syphilis is ten times and three times more prevalent in black population compared to whites and Hispanics respectively.
Natural History, Complications and Prognosis
Natural History
Syphilis is a sexually transmitted disease and is prevalent in high risk population. Women with syphilis infection can transmit the infection to the fetus in utero resulting in a wide spectrum of outcomes. The risk of transmission is higher in pregnant women who do not undergo regular antenatal screening or in women who are untreated or adequately treated during the period of gestation. The risk of transmission to the fetus is dependent on the stage of syphilis infection in the mother (primary, secondary, tertiary or latent), duration of maternal infection and the exposure to fetus in utero. The transmission of infection typically occurs during the second trimester but early transmission also occurs. Syphilis can complicate the outcome of pregnancy and is dependent on the severity of infection in the fetus, severe infection has adverse outcomes in the new born.[18][19]
Complications
- Severe infection in the fetus can result in spontaneous abortion, stillbirth, non-immune hydrops, intrauterine growth restriction, and perinatal death, and serious sequelae in liveborn infected children.[20]
Prognosis
- Adequate treatment of infected mother during the period of gestation can prevent the transmission of disease significantly and treatment of the mother with one dose of pencillin is proven to improve outcomes in the fetus.[21]
- In newborns and infants with congenital syphilis treatment with penicillin has a good prognosis with normal development.[22]
Diagosis
History and Symptoms
A combination of maternal risk factors and symptoms in the baby are essential to suspect congenital syphilis. The most common symptoms in the new born include: [23] [24]
- Skin rash occurs in 70% of affected cases
- Yellowish discoloration of the skin
- Abdominal distension
- Generalized edema
- Irritability
- Low birth weight
- Failure to thrive
- Fever
- Difficulty breathing
Late Syphilis: It is diagnosed in children aged greater than 2 years. The symptoms are non specific.
Physical Examination
The physical examination findings suggestive of congenital syphilis include:[25]
- Vesiculobullous or maculopapular rash occurring on the palms and soles is present in 70% of the children with congenital syphilis. Other patterns of rash such as vesiculobullous lesions, condylomata lata lesions, annular lesions, and erythema multiforme-like targetoid lesions are present in affected infants.[26]
- Low birth weight with signs of prematurity
- Nonimmune hydrops : It is characteristic of congenital syphilis and the features of non-immune hydrops include ascites, pericardial effusion, pleural effusion and skin edema, however Rh incompatability should be ruled out as a cause of hydrops.[27]
- Jaundice
- Hepatosplenomegaly
- Rhinitis
- Lympadenopathy
- Pseudoparalysis of an extremities
Laboratory Findings
Prenatal Diagnosis
- Detection of IgM antibodies aganist T.pallidum in the blood collected by chordocentesis.[28][29]
- PCR of the amniotic fluid to detect the T. pallidum DNA.[30]
- Antenatal ultrasound is commonly done and the findings suggestive of congenital syphilis include: hydrops fetalis characterised by scalp oedema, placental thickening, serous cavity effusion, and polyhydramnios. Other additional findings inlcude hepatosplenomegaly, placentomegaly, non-continuous gastrointestinal obstruction and dilatation of the small bowel.[31][32][33]
Postnatal Diagnosis
- Examination of the placenta or umbilical cord using a silver stain demonstrates spirochetes or a T. pallidum PCR test can be done.
- The use of serological tests to identify the infection in infants less than 15months of age born to infected mothers is not performed as passive transfer of IgG antibodies to the fetus occurs during the pregnancy.
- Other laboratory findings in the new born include:[34]
- Elevated liver enzymes
- Leucocytosis
- Coombs negative hemolytic anaemia
- Thrombocytopenia
- Hypoalbuminemia
- Hyperbilirubinemia
Imaging Studies
X-Ray
- Skeletal survey in a still born, typical osseous lesions are demonstrated in congenital syphilis.
Long Bone Radiographs
- Radiographs typically demonstrate bilateral, symmetric, and polyostotic lesions in femur, humerus, and tibia.[35][36]
- Common findings on radiographs include:
- Metaphyseal lucent bands
- Symmetric localized demineralization and osseous destruction of proximal tibial metaphysis
- Metaphyseal serration
Ultrasound
Antenatal sonographic features include:[37][38]
- Fetal hepatosplenomegaly
- Placentomegaly
- Fetal ascites
In severe cases findings include:
- Fetal hydrops
- Bent fetal long bones
Doppler Studies
Doppler ultrasound of the uterine and umbilical arteries show increases in the mean systolic to diastolic ratios in mothers infected with syphilis indicating an increased resistance to perfusion of the placenta secondary to vasculitis, placental villitis and obliterative arteritis caused by syphilis.[39]
Other Diagnostic Studies
CSF Analysis
Indications : Lumbar puncture is indicated in the following situations.[40]
- If the infant or child has signs and symptoms of congenital Syphilis.
- If there is no documentation of treatment for maternal infection during the period of gestation.
- If the mother was treated within 4 weeks of delivery.
- If the mother was inadequately treated or documentation of the treatment is incomplete.
- A four-fold decline in titer following therapy in the mother is not documented.
CSF Findings:
- Reactive CSF VDRL. [41]
- CSF pleocytosis(>25 white blood cells [WBC]/microL for infants <1 month)
- Elevated CSF protein (>150 mg/dL in term infants <1 month of age and >170 mg/dL in preterm infants <1 month of age)
Treatment
Medical Therapy
Management during the period of gestation
CDC Recommendations for management of pregnant woman with Syphilis infection | |
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Approach during the Prenatal Period |
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Recommended Regimen for Treatment |
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Additional Considerations |
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In patients with Penicillin Allergy |
Secondary Prevention
References
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