Syphilis management during pregnancy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]
Overview
- All women should be screened serologically for syphilis early in pregnancy.
- Most states mandate screening at the first prenatal visit for all women;[1] antepartum screening by nontreponemal antibody testing is typical, but in some settings, treponemal antibody testing is being used.
- Pregnant women with reactive treponemal screening tests should have confirmatory testing with nontreponemal tests with titers.
- 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.
- Any woman who delivers a stillborn infant after 20 weeks' gestation should be tested for syphilis.
- No infant should leave the hospital without the maternal serologic status having been determined at least once during pregnancy.
Diagnostic considerations
- Seropositive pregnant women should be considered infected unless an adequate treatment history is documented clearly in the medical records and sequential serologic antibody titers have declined.
- Serofast low antibody titers might not require treatment; however, persistent higher titer antibody tests might indicate reinfection, and treatment might be required.
Treatment
Penicillin is effective for preventing maternal transmission to the fetus and for treating fetal infection.[2] Evidence is insufficient to determine optimal, recommended penicillin regimens.[3]
CDC Recommendations: Pharmacotherapy [3]
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Recommended Regimen1. Pregnant women should be treated with the penicillin regimen appropriate for their stage of infection. |
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Other Management 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).[4]
- 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;[1] 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.[5] 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.
- All patients who have syphilis should be offered testing for HIV infection.
References
- ↑ 1.0 1.1 Hollier LM, Harstad TW, Sanchez PJ, Twickler DM, Wendel GD (2001) Fetal syphilis: clinical and laboratory characteristics. Obstet Gynecol 97 (6):947-53. PMID: 11384701
- ↑ Alexander JM, Sheffield JS, Sanchez PJ, Mayfield J, Wendel GD (1999) Efficacy of treatment for syphilis in pregnancy. Obstet Gynecol 93 (1):5-8. PMID: 9916946
- ↑ Walker GJ (2001) Antibiotics for syphilis diagnosed during pregnancy. Cochrane Database Syst Rev (3):CD001143. DOI:10.1002/14651858.CD001143 PMID: 11686978
- ↑ Wendel GD, Sheffield JS, Hollier LM, Hill JB, Ramsey PS, Sánchez PJ (2002) Treatment of syphilis in pregnancy and prevention of congenital syphilis. Clin Infect Dis 35 (Suppl 2):S200-9. DOI:10.1086/342108 PMID: 12353207
- ↑ Klein VR, Cox SM, Mitchell MD, Wendel GD (1990) The Jarisch-Herxheimer reaction complicating syphilotherapy in pregnancy. Obstet Gynecol 75 (3 Pt 1):375-80. PMID: 2304710