Syphilis management in pregnancy: a review of guideline recommendations from countries around the world

Congenital Syphilis: A Re-Emerging but Preventable Infection

Congenital syphilis presents a significant global burden, contributing to fetal loss, stillbirth, neonatal mortality, and congenital infection. Despite the target established in 2007 by the World Health Organization (WHO) of fewer than 50 cases per 100,000 live births, the global incidence is on the rise, particularly in low- and middle-income regions. Recent data indicate a rate of 473 cases per 100,000 live births, resulting in 661,000 total cases of congenital syphilis, including 355,000 adverse birth outcomes such as early fetal deaths, stillbirths, neonatal deaths, preterm or low-birth-weight births, and infants with clinical congenital syphilis. Alarmingly, only 6% of these adverse outcomes occurred in mothers who were enrolled, screened, and treated. Unlike many neonatal infections, congenital syphilis is preventable through effective antenatal screening and treatment of infected pregnant women. However, despite available screening tools, affordable treatment options, and the integration of prevention programs into antenatal care in various countries, congenital syphilis remains a pressing public health concern worldwide. This review aims to summarize the current epidemiology, transmission, and treatment of syphilis in pregnancy, as well as to explore global efforts to reduce vertical transmission and address the reasons for falling short of the WHO elimination target.

Prevalence and Factors Associated with Syphilis among Mothers with Missed Opportunities for Antenatal Syphilis Testing in Rural Western Uganda: A Cross-Sectional Study

Background

Early prenatal syphilis testing and treatment are essential preventative measures for maternal syphilis and associated adverse pregnancy outcomes of pregnancy; however, data shows that two-thirds of all cases are missed among women who visit prenatal care center at least once but are not tested for syphilis. This study determined the prevalence and factors associated with syphilis infection among mothers with missed opportunities for antenatal syphilis testing in rural western Uganda delivered at Fort Portal Regional Referral Hospital (FRRH).

Methods

A cross-sectional study was done during the period from April 2022 to June 2022. A total of 124 participants had been recruited consecutively from postnatal ward of FRRH. Pretested questionnaires were used to obtain information on data required for analysis. Venous blood sampling (2 ml taken from the forearm using anticoagulant free vacutainer) was done for all mothers who missed opportunity for prenatal syphilis testing using both RPR and TPHA. Descriptive statistics followed by binary logistic regression analysis was done using SPSS version 22.0.

Results

The prevalence of syphilis infection was 27 (21.8%). After adjusted analysis, having more than one sexual partners in the past one year was associated with higher odds of syphilis infection (aOR = 24.922, 95% CI: 4.462-139.201, p < 0.001), and staying with the partner was found to be associated with lower odds of syphilis infection (aOR = 0.213, 95% CI: 0.040-1.142, p = 0.050).

Conclusions

The study identified high prevalence of syphilis infection among mothers with missed opportunities for antenatal syphilis testing, and this was positively associated with having more than one sexual partners in the past one year and negatively associated with not staying with partner.

Syphilis in pregnancy: an ongoing public health threat

Syphilis is a treponemal infection that can be acquired sexually, hematogenously, or via vertical transmission from mother to infant. Despite evidence-based curative treatment options with penicillin, it remains a public health threat with increasing prevalence over recent years. Congenital syphilis, a condition where a fetus acquires the infection during pregnancy, can lead to stillbirth, miscarriage, preterm birth, birth defects, and lifelong physical or neurologic changes. Congenital syphilis rates in the United States increased by 261% from 2013 to 2018 and continue to increase in 2021. The only recommended treatment for syphilis in pregnancy is benzathine penicillin G because evidence of decreased risk of congenital syphilis with other modalities is lacking. Testing for syphilis is complex and includes either the reverse-sequence algorithm or the traditional algorithm. Determination of the clinical stage of syphilis includes incorporation of the previous treatment sequence and physical examination. The goal of this review was to discuss the current evidence about optimal treatment and testing during pregnancy to optimize maternal health and prevent congenital syphilis.

Gestational and congenital syphilis across the international border in Brazil

BACKGROUND

Brazil lacks data from syphilis in its border areas. We aimed to describe the spatial and temporal distribution of acquired syphilis (AS), in pregnancy (SP) and congenital syphilis (CS) in Brazilian municipalities in the arches border contexts.

METHODS

An ecological, cross-sectional study was conducted from 2010 to 2020. The study was based on the cases of syphilis available in the Notifiable Diseases Information System (SINAN), and on the Primary Health Care Information System. The detection rates of AS and SP, and the incidence of CS were estimated, and the time series was analyzed. Data between the border arches were compared.

RESULTS

In 2020, data showed 7,603 cases of AS (detection rate 64.8/100,000 inhabitants), 3,960 cases of SP (detection rate of 21.6/1,000 live births) and 836 cases of CS (incidence of 4.6/1,000 live births) in the border region. Between 2010 and 2020, the mean annual increase of detection rate of SP was 53.4% in Brazil, 48.0% in the border region, 59.6% in the North Arch, 28.8% in the Central and 67.2% in the South. Annual variation on the incidence of CS for the same period was 31.0% in Brazil 38.4% at the border, in the North and South Arcs 18.3% and 65.7% respectively. The Central Arch showed an increase only between 2010 and 2018 (62.7%). A total of 427 (72.6%) municipalities has primary health care coverage ≥ 95% of the population. In 2019, 538 (91.8%) municipalities reported using rapid tests for syphilis, which decreased to 492 (84%) in 2020. In 2019, 441 (75.3%) municipalities reported administering penicillin, and 422 (72%) in 2020.

CONCLUSION

Our data show syphilis reman problem at the Brazilian border, rates in pregnant are high. It was observed a reduction in the detection rates, SP and the incidence of CS between 2018 and 2020. Syphilis should be included on the agenda of all management levels, aiming at expanding access and quality care.

Clinical Protocols and Treatment Guidelines for the Management of Maternal and Congenital Syphilis in Brazil and Portugal: Analysis and Comparisons: A Narrative Review

(1) Background: Maternal syphilis (MS) and congenital syphilis (CS) are serious public health problems worldwide due to their high morbidity and mortality rates. (2) Objective: Evaluating the applicability of Clinical Protocols and Treatment Guidelines on case incidence trends in Brazil and Portugal. (3) Methods: The review was done through bibliographic research in two public databases and government websites from both countries, published between 2007 and 2022. All guidelines that contained CS and MS were selected. (4) Results and discussion: After evaluation, we found that Brazil and Portugal have adequate protocols for screening and treating congenital and maternal syphilis. (5) Conclusion: The results suggest that CS and MS incidence are notably higher in Brazil than in Portugal due to economic, cultural, and social disparities and the differences in territory size. Therefore, these demographic and socioeconomic factors could strongly influence efforts to fight against syphilis and thus control the infection.

Sexually transmitted infections in pregnant women from sub-Saharan Africa

Background

Sexually transmitted infections (STIs) are a major health problem in most countries of the world, particularly in developing countries where the resources and technology to diagnose and treat them are limited. Currently, there is limited data on STIs and risk factors for these infections in pregnant women living with human immunodeficiency virus (HIV), especially in sub-Saharan Africa (SSA). This review provides data on the prevalence and risk factors for STIs in pregnant women living with HIV from SSA. This review also describes the association between STIs and HIV on pregnancy and birth outcomes as well as highlights the importance of laboratory-based diagnosis of STIs.

Method

An electronic search of online databases was used to find and collect relevant research articles connected to the prevalence, adverse pregnancy and birth outcomes, health complications and risk factors associated with STIs and HIV in pregnant women from SSA. The search was limited to articles published in English. Relevant studies were identified by searching literature from January 2001 to date. The search yielded 4709 results.

Results

In SSA, STIs are highly prevalent in pregnant women and are widely known to be linked with an increased risk of poor maternal and neonatal outcomes. These infections are often asymptomatic and highly prevalent in pregnant women. The screening of STIs in pregnant women living with HIV can reduce the risk of mother-to-child transmission (MTCT) and screening and treatment for STIs can also prevent adverse perinatal outcomes. It is important to recognise regional and national STI epidemics in order to promote STI prevention and control interventions considering the test and treat approach as opposed to syndromic management.

Conclusion

This review highlights the need to use diagnostic screening methods instead of syndromic STI management in SSA. Moreover, more research into effective prevention and treatment measures for STIs in pregnant women is urgently required.

Assessment of the efficiency of synergistic photocatalysis on penicillin G biodegradation by whole cell Paracoccus sp

Background

The Paracoccus sp. strain isolated from sludge was identified and evaluated for catalytic activity in the degradation of penicillin G.

Results

High degradation efficiency and synergistic catalytic effects of the whole cell and visible light without additional catalysts were observed. The key factors influencing the degradation and kinetics of penicillin G were investigated. The results showed the phenylacetic acid, which was produced during penicillin G biodegradation, exhibited stronger inhibiting effects on KDSPL-02. However, this effect was reduced by visible light irradiation without any additional photocatalyst; furthermore, the rate of penicillin G biodegradation was accelerated, reaching a 100% rate in 12 h at a penicillin G concentration of 1.2 g/L. Four key intermediates produced during penicillin G degradation were isolated and identified by LC–MS, ¹H NMR, and ¹³C NMR. Enzymes involved in the PAA pathway were proposed from a genomic analysis of KDSPL-02.

Conclusions

These results provide a new method for bio-degrading of penicillin or other antibiotic pollutants using photoaccelerating biocatalysts with greater efficiency and more environmentally friendly conditions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13036-021-00275-4.

Estimation of benzathine penicillin G demand for congenital syphilis elimination with adoption of dual HIV/syphilis rapid diagnostic tests in eleven high burden countries

BACKGROUND

WHO recommends use of rapid dual HIV/syphilis tests for screening pregnant women (PW) during antenatal care to prevent mother-to-child transmission. Scale-up of testing implies a need to accurately forecast and procure benzathine penicillin (BPG) to treat the additionally identified PW with syphilis.

METHODS

Country-reported ANC coverage, PW syphilis screening and treatment coverage values in 2019 were scaled linearly to EMTCT targets by 2030 (constant increasing slope from 2019 figures to 95% in 2030) for 11 focus countries. Antenatal syphilis screening coverage was substituted with HIV screening coverage to estimate potential contribution of rapid dual HIV/syphilis tests in identifying additional PW with syphilis. BPG demand was calculated for 2019-2030 accordingly.

RESULTS

The estimated demand for BPG (in 2.4 million unit vials) using current maternal syphilis prevalence and treatment coverage will increase from a baseline of 414,459 doses in 2019 to 683,067 doses (+65%) in 2021 assuming immediate replacement of single HIV test kits with rapid dual HIV/syphilis tests for these 11 countries. Continued scale up of syphilis screening and treatment coverage to reach elimination coverage of 95% will result in an estimated demand increase of 160%, (663,969 doses) from 2019 baseline for a total demand of 1,078,428 BPG doses by 2030.

CONCLUSIONS

Demand for BPG will increase following adoption of rapid dual HIV/syphilis test kits due to increases in maternal diagnoses of syphilis. To eliminate congenital syphilis, MNCH clinical programs will need to synergize with disease surveillance programs to accurately forecast BPG demand with scale up of antenatal syphilis screening to ensure adequate treatment is available for pregnant women diagnosed with syphilis.

Algorithm to guide re-exposure to penicillin in allergic pregnant women with syphilis: Efficacy and safety

Background

Gestational syphilis is underdiagnosed and undertreated, leading to stillbirth, prematurity, low birthweight, neonatal death, and congenital syphilis. Most patients who label as allergic to penicillin are misdiagnosed.

Objective

To assess the efficacy and safety of an algorithm to guide re-exposure to penicillin in pregnant women with syphilis and reporting allergy to the antibiotic.

Methods

We performed a prospective study assessing pregnant women with syphilis and labeled as allergic to penicillin. Based on clinical history, patients were divided in two groups: high-risk and low-risk to penicillin allergy. Low-risk patients with negative skin testing and negative serum specific IgE to penicillin underwent drug provocation test. The remaining patients underwent desensitization.

Results

Ninety-one patients were enrolled. Allergy to penicillin was confirmed in 7.69% of pregnant women with syphilis and clinical history of allergy to penicillin; in all cases the diagnosis was made through intradermal testing, which predicted 100% of the breakthrough reactions observed during rapid drug desensitization (p < 0.001). Risk stratification based on the initial clinical reaction and skin testing to guide penicillin re-introduction through drug challenge or desensitization was safe (97.8%) and effective (97.8%).

Conclusion

We developed and showed the efficacy and safety of an algorithm to guide re-exposure to penicillin in pregnant women with syphilis and labeled as allergic to this drug. Intradermal test is an excellent biomarker in the diagnosis of immediate hypersensitivity reaction to penicillin and to predict breakthrough reaction during rapid drug desensitization. Further studies may confirm the greater safety of the intravenous protocol compared to the oral protocol.

Early limb paralysis in infants: do not forget about congenital syphilis

We describe the case of a 2-month-old baby with congenital syphilis, presenting with limb paralysis. The radiological investigations showed periosteal thickenings of the limb. Despite negative maternal serology during the first trimester of pregnancy, clinical and radiological features led to the suspicion of pseudoparalysis of Parrot, which was confirmed by blood tests. Delayed diagnoses or misdiagnoses are possible when uncommon presentations of forgotten diseases occur. The needing for a second screening for syphilis in high-risk pregnant women should be evaluated.

Temporal trend and spatial distribution of syphilis in pregnancy and congenital syphilis in Goiás, Brazil, 2007-2017: an ecological study

OBJECTIVE

To analyze temporal trend and spatial distribution of syphilis in pregnancy and congenital syphilis in Goiás State, Brazil, between 2007 and 2017.

METHODS

This was an ecological time series and spatial distribution study with data obtained from the Notifiable Health Conditions Information System. Prais-Winsten Regression was used to analyze indicator trends by health macro-region. Descriptive spatial analysis was performed to verify case distribution in three different years in the period.

RESULTS

Between 2007 and 2017, 7,679 cases of syphilis in pregnancy and 1,554 congenital syphilis cases were reported. A rising trend was found in the rates of syphilis in pregnancy (annual percent change [APC] = 18.0 - 95% confidence interval [95%CI] 15.3;20.8) as well as in congenital syphilis rates (APC=16.8 - 95%CI 20.1;33.8); and a 326% increase in the number of municipalities with a congenital syphilis incidence rate >0.5/1,000 live births.

CONCLUSION

Growth in syphilis in pregnancy and congenital syphilis detection rates was identified, as was growth in the number of municipalities reporting cases.