Treatment of syphilis in pregnancy and prevention of congenital syphilis

British Association of Sexual Health and HIV (BASHH) UK guidelines for the management of syphilis in pregnancy and children 2024

This new guideline details the specific management of syphilis in pregnancy and in children. It is to be used in clinical practice alongside the BASHH UK guidelines for the management of syphilis 2024.

Factors influencing the implementation of integrated screening for HIV, syphilis, and hepatitis B for pregnant women in Nepal: A qualitative study

In Nepal, national guidelines recommend free HIV and syphilis screening for pregnant women at their first antenatal visit, using an opt-out approach. However, screening uptake is low and the guidelines do not include hepatitis B screening. It is essential to understand the factors influencing the implementation of integrated screening for HIV, syphilis, and hepatitis B, as recommended by WHO, to improve uptake and prevent vertical transmission. This study explored the knowledge, attitudes, and perceptions of pregnant women, their families, healthcare providers and policymakers on integrated prenatal screening. We conducted 12 in-depth interviews with pregnant women, 10 with their husbands and 4 with mothers-in-law in Kapilvastu and Kathmandu. In addition, we interviewed 7 health workers and 4 decision-makers. These interviews were sufficient to reach saturation. Data were analysed using a thematic content analysis. A combination of the social-ecological model and the WHO building blocks provided a theoretical framework for interpreting data. The analysis showed that antenatal screening in Nepal involved many stakeholders and was influenced by various factors. Implementation issues were found in the building blocks service delivery, health workforce and medical products. Husbands and in-laws play an important role in the acceptance of screening by pregnant women, especially in rural areas. High levels of stigma and discrimination against people with sexually transmitted diseases were reported, and knowledge of hepatitis B and syphilis was low. Access and uptake of screening could be improved through rapid testing, by strengthening the health system and by integrating hepatitis B screening through an opt-out approach like that for HIV and syphilis. Effective community involvement through awareness campaigns and investment in lower-level health facilities is essential to improve screening rates. This study provides information for decision-makers about challenges in implementing integrated screening to guide the design of targeted interventions to reduce vertical transmission.

[Translated article] AEDV Expert Consensus for the Management of Syphilis

Syphilis -the "great simulator" for classical venereologists-is re-emerging in Western countries despite adequate treatment; several contributing factors have been identified, including changes in sexual behaviour, which won't be the topic of this article though. In 2021, a total of 6613 new cases of syphilis were reported in Spain, representing an incidence of 13.9×100 000 inhabitants (90.5%, men). Rates have increased progressively since 2000. The clinical presentation of syphilis is heterogeneous. Although chancroid, syphilitic roseola and syphilitic nails are typical lesions, other forms of the disease can be present such as non-ulcerative primary lesions like Follmann balanitis, chancres in the oral cavity, patchy secondary lingual lesions, or enanthema on the palate and uvula, among many others. Regarding diagnosis, molecular assays such as PCR have been replacing dark-field microscopy in ulcerative lesions while automated treponemal tests (EIA, CLIA) are being used in serological tests, along with classical tests (such as RPR and HAART) for confirmation and follow-up purposes. The interpretation of these tests should be assessed in the epidemiological and clinical context of the patient. HIV serology and STI screening should be requested for anyone with syphilis. Follow-up of patients under treatment is important to ensure healing and detect reinfection. Serological response to treatment should be assessed with the same non-treponemal test (RPR/VDRL); 3-, 6-, 12-, and 24-month follow-up is a common practice in people living with HIV (PLHIV). Sexual contacts should be assessed and treated as appropriate. Screening is advised for pregnant women within the first trimester of pregnancy. Pregnant women with an abortion after week 20 should all be tested for syphilis. The treatment of choice for all forms of syphilis, including pregnant women and PLHIV, is penicillin. Macrolides are ill-advised because of potential resistance.

AEDV Expert Consensus for the Management of Syphilis

Syphilis -the "great simulator" for classical venereologists-is re-emerging in Western countries despite adequate treatment; several contributing factors have been identified, including changes in sexual behaviour, which won't be the topic of this article though. In 2021, a total of 6613 new cases of syphilis were reported in Spain, representing an incidence of 13.9×100 000 inhabitants (90.5%, men). Rates have increased progressively since 2000. The clinical presentation of syphilis is heterogeneous. Although chancroid, syphilitic roseola and syphilitic nails are typical lesions, other forms of the disease can be present such as non-ulcerative primary lesions like Follmann balanitis, chancres in the oral cavity, patchy secondary lingual lesions, or enanthema on the palate and uvula, among many others. Regarding diagnosis, molecular assays such as PCR have been replacing dark-field microscopy in ulcerative lesions while automated treponemal tests (EIA, CLIA) are being used in serological tests, along with classical tests (such as RPR and HAART) for confirmation and follow-up purposes. The interpretation of these tests should be assessed in the epidemiological and clinical context of the patient. HIV serology and STI screening should be requested for anyone with syphilis. Follow-up of patients under treatment is important to ensure healing and detect reinfection. Serological response to treatment should be assessed with the same non-treponemal test (RPR/VDRL); 3-, 6-, 12-, and 24-month follow-up is a common practice in people living with HIV (PLHIV). Sexual contacts should be assessed and treated as appropriate. Screening is advised for pregnant women within the first trimester of pregnancy. Pregnant women with an abortion after week 20 should all be tested for syphilis. The treatment of choice for all forms of syphilis, including pregnant women and PLHIV, is penicillin. Macrolides are ill-advised because of potential resistance.

Clinical Updates in Sexually Transmitted Infections, 2024

Sexually transmitted infections (STIs) continue to increase in the United States with more than 2.5 million cases of gonorrhea, chlamydia, and syphilis reported to the Centers for Disease Control and Prevention in 2022. Untreated STIs in women can lead to adverse outcomes, including pelvic inflammatory disease, infertility, chronic pelvic pain, and pregnancy complications such as ectopic pregnancy, early pregnancy loss, stillbirth, and neonatal transmission. STI-related guidelines can be complex and are frequently updated, making it challenging to stay informed on current guidance. This article provides high-yield updates to support clinicians managing STIs by highlighting changes in screening, diagnosis, and treatment. One important topic includes new guidance on syphilis screening, including a clarified description of high community rates of syphilis based on Healthy People 2030 goals, defined as a case rate of primary or secondary syphilis > 4.6 per 100,000. Reproductive aged persons living in counties above this threshold should be offered syphilis screening. Additionally, American College of Obstetricians & Gynecologists now recommends syphilis screening three times during pregnancy regardless of risk-at the first prenatal visit, during the third trimester, and at delivery. In addition, new guidance to support consideration for extragenital screening for gonorrhea and chlamydia in women at sites such as the anus and pharynx is discussed. Other topics include the most recent chlamydia, gonorrhea, trichomoniasis, and pelvic inflammatory disease treatment recommendations; screening and treatment guidance for Mycoplasma genitalium; genital herpes screening indications and current diagnostic challenges; and the diagnosis and management of mpox in women and during pregnancy.

Syphilis for dermatologists: Current concepts

Dermatologists are familiar with the classic aspects of syphilis. Our objective in this update is to display novel features of sexually acquired syphilis, its pathophysiology, natural history, atypical clinical variants, skin of color, clinical pearls, and prospects. Textbook knowledge, congenital syphilis, epidemiology, and historical data are excluded.

The incidence of Jarisch-Herxheimer reactions and associated risk factors in pregnant women and nonpregnant women: A retrospective chart review at a university hospital in Japan

AIMS

Jarisch-Herxheimer reactions (JHR) is a transient adverse event that occurs during initial antimicrobial treatment for syphilis patients, and is known to develop uterine contractions and fetal distress in pregnant women complicated with syphilis. The aim of this study is to identify risk factors for JHR in patients with syphilis, and to clarify whether pregnancy status is a risk factor for JHR, and to describe the characteristics of pregnant women who develop JHR.

METHODS

This was a retrospective chart review in a singleton university hospital in Japan. We collected data of syphilis patients who were diagnosed and treated at department of obstetrics and gynecology, dermatology between January 2010 and May 2022. There were no validated diagnostic criteria for JHR, we defined JHR as one or more of the following in addition to raised body temperature (≧38.0°C) within 24 h of initial antibiotic treatment: headache, chills, myalgias, tachycardia (≧110 bpm), new rash.

RESULTS

There were 30 syphilis patients. Of whom nine (30%) were pregnant women and all their neonates were not diagnosed with congenital syphilis. Five patients (17%) developed JHR at the time of initial treatment (JHR group, n = 5). There was no difference between JHR group and non-JHR group (n = 25) in pregnancy status. Secondary syphilis was an only significant risk factor for JHR. Two pregnant women with JHR were both treated for secondary syphilis in the third trimester of pregnancy.

CONCLUSION

Pregnancy status was not a risk factor for JHR in syphilis patients. Further research is needed.

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.

Outcomes After Positive Syphilis Screening

BACKGROUND

Syphilis screening during pregnancy helps prevent congenital syphilis. The harms associated with false positive (FP) screens and whether screening leads to correct treatments has not been well determined.

METHODS

The population included mothers and infants from 75 056 pregnancies. Using laboratory-based criteria we classified initial positive syphilis screens as FP or true positive (TP) and calculated false discovery rates. For mothers and infants we determined treatments, clinical characteristics, and syphilis classifications.

RESULTS

There were 221 positive screens: 183 FP and 38 TP. The false discovery rate was 0.83 (95% confidence interval [CI], 0.78-0.88). False discovery rates were similar for traditional 0.83 [95% CI, 0.72-0.94] and reverse algorithms 0.83 (95% CI, 0.77-0.88), and for syphilis Immunoglobin (Ig) G 0.79 (95% CI, 0.71-0.86) and total 0.90 (95% CI, 0.82-0.97) assays. FP screens led to treatment in 2 women and 1 infant. Two high-risk women were not rescreened at delivery and were diagnosed after hospital discharge; 1 infant developed congenital syphilis. Among 15 TP women with new syphilis, the diagnosis was before the late third trimester in 14 (93%). In one-half of these women, there was concern for reinfection, treatment failure, inadequate treatment or follow-up care, or late treatment, and their infants did not achieve an optimal syphilis classification.

CONCLUSIONS

Syphilis screening identifies maternal syphilis, but limitations include FP screens, which occasionally lead to unnecessary treatment, inconsistent risk-based rescreening, and among TP mothers failure to optimize care to prevent birth of infants at higher risk for congenital syphilis.

Sexually transmitted infections and female reproductive health

Women are disproportionately affected by sexually transmitted infections (STIs) throughout life. In addition to their high prevalence in women, STIs have debilitating effects on female reproductive health due to female urogenital anatomy, socio-cultural and economic factors. In this Review, we discuss the prevalence and impact of non-HIV bacterial, viral and parasitic STIs on the reproductive and sexual health of cisgender women worldwide. We analyse factors affecting STI prevalence among transgender women and women in low-income settings, and describe the specific challenges and barriers to improved sexual health faced by these population groups. We also synthesize the latest advances in diagnosis, treatment and prevention of STIs.

Women are more affected by sexually transmitted infections than men. This Review examines the impact of non-HIV STIs on women’s health, and discusses recent advances and current challenges in the treatment and prevention of STIs.

Congenital Syphilis Presenting with Brain Abnormalities at Neuroscan: A Case Report and a Brief Literature Review

A case of vertical transmission in a 35-year-old pregnant woman, gravida 4, para 2 with an unknown medical history of carrying primary syphilis is described. A routine 3rd trimester scan was performed at 30 + 5 weeks of pregnancy, which revealed fetal growth restriction (FGR) associated with absent fetal movement, a pathologic neuroscan characterized by cortical calcifications and ominous Doppler waveform analysis of the umbilical artery and ductus venosus. Computerized electronic fetal monitoring (EFM) showed a Class III tracing, according to the American College of Obstetricians and Gynecologists (ACOG) guidelines. An emergency C-section was performed and a female newborn weighing 1470 g was delivered. The Apgar scores were 5 and 8 at the first and fifth min, respectively. Besides the prompted obstetrical and neonatal interventions, the neonate died after 7 days. A histologic examination of the placenta revealed a chorioamnionitis at stage 1/2 and grade 2/3. The parenchyma showed diffuse delayed villous maturation, focal infarcts, and intraparenchymal hemorrhages. The decidua presented with chronic deciduitis with plasma cells. The parents declined the autopsy. Congenital syphilis is an emerging worldwide phenomenon and the multidisciplinary management of the mother and the fetus should be mandatory.

Examination of Care Milestones for Preventing Congenital Syphilis Transmission Among Syphilis-Infected Pregnant Women in Alberta, Canada: 2017-2019

BACKGROUND

An infectious syphilis outbreak in Alberta has resulted in increased congenital syphilis (CS) cases. To shed light on potential risk factors, we used administrative data sets to examine care milestones for the prevention of CS among pregnant women diagnosed with syphilis, as well as correlates of women giving birth to infants with CS.

METHODS

Provincial administrative databases were used to identify and describe pregnant women diagnosed with any stage of infectious or noninfectious syphilis who gave birth in Alberta between January 1, 2017, and December 31, 2019. Data on prenatal care, syphilis screening, and syphilis medication dispensation were used to evaluate the care milestones. Clinical care and maternal demographics were assessed using logistic and linear regression analyses to determine correlates for missed care milestones or a newborn outcome of CS.

RESULTS

Of 182 syphilis-infected pregnant women, 63 (34.6%) delivered a newborn with CS. Overall, in the first trimester, 136 (75.1%) women had a health care visit, 72 (39.6%) had a prenatal care visit, 71 (39.0%) were screened for syphilis, and 44 (24.2%) were treated. Gestational time to treatment initiation (adjusted odds ratio, 1.04; 95% confidence interval, 1.02-1.06) and older maternal age at diagnosis (adjusted odds ratio: 1.28, 95% confidence interval, 1.08-1.50) were independently associated with CS outcomes. No variables were found to be independently associated with a health care visit, prenatal screening, or initiation of treatment.

CONCLUSIONS

Although nearly two-thirds of CS cases were prevented, there remained missed opportunities in the prevention of CS. Early treatment, which relies on timely access to prenatal care and screening, was the most important for the prevention of CS.

Ineffective penicillin treatment and absence of partner treatment may drive the congenital syphilis epidemic in Brazil

BACKGROUND

Reducing congenital syphilis has been the focus of Brazilian health programs for decades, yet the cases continue to increase. Although health interventions have targeted HIV screening and treatment, syphilis management continues to be challenging. Syphilis during pregnancy may enhance the HIV maternal seroconversion risk. The potential factors fueling the syphilis epidemic were evaluated in south Brazil, an area of high HIV or syphilis endemicity.

OBJECTIVE

We hypothesized that ineffective treatment because of a lack of partner treatment, late presentation to care, and reinfection of previously treated mothers were potential drivers of syphilis mother-to-child transmission.

STUDY DESIGN

Data on women diagnosed with syphilis during pregnancy between January 1, 2008 and December 31, 2018 were obtained from a large urban hospital in Porto Alegre, Brazil. The patients were stratified into effective vs ineffective treatment groups according to the World Health Organization guidelines. Crude and adjusted risk ratios for the prediction of congenital syphilis and adverse fetal or neonatal outcomes were computed using Poisson regression.

RESULTS

Nearly 56,000 pregnant women delivered over the 11-year period; 1541 (2.8%) had confirmed syphilis during pregnancy, with 934 (61%) receiving ineffective syphilis treatment because of late presentation and diagnosis, delayed treatment initiation, and loss to follow-up with no treatment recorded. Ineffective treatment was associated with maternal education, prenatal care, timing of syphilis diagnosis, venereal diseases research laboratory titers, and maternal HIV coinfection. On multivariate regression analysis, ineffective treatment (adjusted risk ratio, 4.52; 95% confidence interval, 2.35-8.69), absence of prenatal care (adjusted risk ratio, 9.31; 95% confidence interval, 3.77-23.0), syphilis diagnosis at delivery (adjusted risk ratio, 3.08; 95% confidence interval, 2.07-4.58), and maternal nontreponemal titers ≥1:64 (1.09-1.93) were associated with an increased risk of fetal loss. Ineffective treatment (adjusted risk ratio, 1.71; 95% confidence interval, 1.59-1.84), year of diagnosis 2014 to 2016 (adjusted risk ratio, 1.07; 95% confidence interval, 1.02-1.13), absence of prenatal care (adjusted risk ratio, 1.44; 95% confidence interval, 1.17-1.76), and maternal nontreponemal titers >1:4 were associated with an increased risk of congenital syphilis. Although partner treatment reduced the congenital syphilis risk (adjusted risk ratio, 0.60; 95% confidence interval, 0.55-0.66), only 31.8% of partners received treatment. Maternal HIV coinfection was not associated with an increased risk of fetal loss, low birthweight, preterm birth, congenital syphilis, or symptomatic neonatal infection.

CONCLUSION

Public health initiatives promoting effective syphilis treatment in pregnancy, increased access to high-quality prenatal care, and partner treatment should be considered to reduce congenital syphilis.

Congenital syphilis re-emergence in Winnipeg, Manitoba

Background

Infectious syphilis rates have been increasing in Winnipeg, Manitoba among individuals during their childbearing years. Untreated or inadequately treated prenatal infection often results in congenital syphilis, with devastating consequences to fetal health and survival. The objective of this study was to review public health surveillance data regarding congenital syphilis incidence and birthing parent risk factors in Winnipeg from 2018 to 2020.

Methods

Data extracted from a population-based surveillance database maintained by the Winnipeg Regional Health Authority Public Health investigations for all 2018-2020 probable or confirmed cases of early congenital syphilis or syphilitic stillbirth were reviewed. Rates of congenital syphilis were calculated per 1,000 live births. Descriptive analyses were performed to describe birthing parent age, neighbourhood of residence, intravenous substance use, Child and Family Services involvement, access to prenatal care and obtainment of adequate prenatal treatment.

Results

There were eight cases of confirmed/probable congenital syphilis in 2018, 22 cases in 2019 and 30 cases in 2020. Average birthing parent age was 26.5-27.0 years. The majority (66.7%) of birthing parents lived in inner city neighbourhoods with known infectious syphilis outbreaks. Over 50% of birthing parents did not receive any prenatal care, or the care received consisted of inadequate treatment or follow-up. Reinfection among birthing parents who did receive prenatal care was suspected in an additional 23.3% of cases.

Conclusion

Congenital syphilis rates in Winnipeg have increased dramatically. Public health and healthcare provider efforts to address the needs of the community are vital for promoting access to safe and effective prenatal care.

Addressing the crisis of congenital syphilis: Key findings from an evaluation of the management of syphilis in pregnancy and the newborn in South-East Queensland

BACKGROUND

Syphilis in pregnancy and congenital syphilis (CS) are increasing in Australia. Prevention of adverse outcomes requires adherence to management guidelines.

AIMS

The aim is to evaluate the management of syphilis in pregnant women and their newborns.

MATERIALS AND METHODS

A retrospective study of public health notifications, clinical records and testing results of women with positive syphilis serology in pregnancy requiring treatment from 2016 to 2018 inclusive across South-East Queensland was conducted. Management was described and compared with contemporary guidelines from the Australasian Society of Infectious Diseases, the Communicable Diseases Network Australia and the United States Centers for Disease Control and Prevention.

RESULTS

Of 30 women identified, 22 (73%) had management consistent with the guidelines (stage-appropriate penicillin regimen, appropriate dosing interval and treatment completed greater than 30 days before delivery). Only 14 (47%) women had documentation of partner testing and/or treatment. Of 26 mother-infant pairs with complete data, 16 (62%) had investigations at delivery consistent with recommendations (parallel maternal-infant rapid plasma reagin, infant syphilis immunoglobulin M, placental histopathology +/- syphilis polymerase chain reaction and infant clinical examination). One infant met the criteria for confirmed CS. Five infants received penicillin therapy. Only seven (27%) infants had serological monitoring after discharge.

CONCLUSIONS

Management can be optimised with timely maternal testing and treatment, comprehensive partner screening and treatment, strict adherence to seven-day penicillin dosing for late latent syphilis and thorough maternal and infant testing after treatment and delivery. If maternal treatment was inadequate in pregnancy, consideration needs to be given to close evaluation and empiric treatment of the infant.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11-14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

Syphilis in Neonates and Infants

Syphilis in neonates and infants remains a significant public health problem because it is a major cause of fetal and neonatal morbidity and mortality globally. Despite decades of experience with syphilis in adults and infants, maternal and congenital syphilis are increasing substantially in the United States. The vertical transmission, clinical manifestations, diagnosis, evaluation, treatment, and follow-up are reviewed to guide the health care professional in understanding the optimal management of this preventable disease.

Ceftriaxone treatment of syphilis

The article presents literature data on the use of antibacterial drugs for the treatment of patients with syphilis, where the main focus is on ceftriaxone. Based on the materials of national and foreign studies, data on the effectiveness of ceftriaxone in the treatment of patients with various forms of syphilis have been analyzed, and information characterizing the pharmacological and pharmacokinetic features of ceftriaxone has been presented. Based on the scientific and clinical experience accumulated over previous years, both in Russia and abroad, some results of the use of ceftriaxone in the treatment of syphilis have been summed up. To search for the necessary literature, the PubMed, MedLine, Web of Science and RSCI databases were used.

Failure to recognize Low non-treponemal titer syphilis infections in pregnancy May lead to widespread under-treatment

OBJECTIVES

Rates of maternal syphilis have increased five-fold in Brazil in the past decade. While penicillin remains the only appropriate treatment for maternal syphilis, we hypothesized that low non-treponemal titers (<1:16) may lead to reduced penicillin treatment in Brazil.

METHODS

Using Brazilian Ministry of Health data on women diagnosed with maternal syphilis between January 1, 2010, and December 31, 2018, we conducted a random-effects logistic regression model with a cluster correction at the state level to evaluate predictive factors of penicillin treatment.

RESULTS

We observed yearly increases in cases of pregnant women with syphilis from 2010 to 2018. There was significant variation by state: 52,451 cases were reported in São Paulo, followed by 26,838 in Rio de Janeiro. Among 215,937 cases of maternal syphilis, 91·3% received penicillin. In the random-effects model, a non-treponemal titer ≥1:16 was associated with 1·44 higher odds of receiving penicillin (95% confidence interval [CI]: 1·391·48), and prenatal care was associated with a 2·12 increased odds of receiving penicillin (95% CI: 2·022·21). Although there is an association between the absence of prenatal care and inadequate treatment for syphilis, 83·2% of women in this cohort who did not receive penicillin were engaged in prenatal care.

CONCLUSIONS

Providers may inappropriately exclude low non-treponemal titers and thereby fail to use penicillin treatment in maternal syphilis. While the cause of the maternal syphilis epidemic in Brazil is multifactorial, we believe our findings can be used to develop targeted interventions throughout Brazil as well as shape public health initiatives globally.

Assessment of syndromic management of curable sexually transmitted and reproductive tract infections among pregnant women: an observational cross-sectional study

Background

This study estimated the prevalence of curable sexually transmitted and reproductive tract infections (STIs/RTIs) among pregnant women attending antenatal care (ANC) in rural Zambia, evaluated the effectiveness of syndromic management of STIs/RTIs versus reference-standard laboratory diagnoses, and identified determinants of curable STIs/RTIs during pregnancy.

Methods

A total of 1086 pregnant women were enrolled at ANC booking, socio-demographic information and biological samples were collected, and the provision of syndromic management based care was documented. The Piot-Fransen model was used to evaluate the effectiveness of syndromic management versus etiological testing, and univariate and multivariate logistic regression analyses were used to identify determinants of STIs/RTIs.

Results

Participants had a mean age of 25.6 years and a mean gestational age of 22.0 weeks. Of 1084 women, 700 had at least one STI/RTI (64.6%; 95% confidence interval [CI], 61.7, 67.4). Only 10.2% of infected women received any treatment for a curable STI/RTI (excluding syphilis). Treatment was given to 0 of 56 women with chlamydia (prevalence 5.2%; 95% CI, 4.0, 6.6), 14.7% of participants with gonorrhoea (prevalence 3.1%; 95% CI, 2.2, 4.4), 7.8% of trichomoniasis positives (prevalence 24.8%; 95% CI, 22.3, 27.5) and 7.5% of women with bacterial vaginosis (prevalence 48.7%; 95% CI, 45.2, 51.2). An estimated 7.1% (95% CI, 5.6, 8.7) of participants had syphilis and received treatment. Women < 20 years old were more likely (adjusted odds ratio [aOR] = 5.01; 95% CI: 1.23, 19.44) to have gonorrhoea compared to women ≥30. The odds of trichomoniasis infection were highest among primigravidae (aOR = 2.40; 95% CI: 1.69, 3.40), decreasing with each subsequent pregnancy. Women 20 to 29 years old were more likely to be diagnosed with bacterial vaginosis compared to women ≥30 (aOR = 1.58; 95% CI: 1.19, 2.10). Women aged 20 to 29 and ≥ 30 years had higher odds of infection with syphilis, aOR = 3.96; 95% CI: 1.40, 11.20 and aOR = 3.29; 95% CI: 1.11, 9.74 respectively, compared to women under 20.

Conclusions

Curable STIs/RTIs were common and the majority of cases were undetected and untreated. Alternative approaches are urgently needed in the ANC setting in rural Zambia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03573-3.

Syphilis in Pregnancy

Despite a national plan to eliminate syphilis by 2005, recent trends have reversed previously achieved progress in the United States. After a nadir between 2000 and 2013, rates of primary and secondary syphilis among women and congenital syphilis rose by 172% and 185% between 2014 and 2018, respectively. Screening early in pregnancy, repeat screening in the third trimester and at delivery among women at high risk, adherence to recommended treatment regimens, and prompt reporting of newly diagnosed syphilis cases to local public health authorities are strategies that obstetrician-gynecologists can employ to fight the current epidemic. In this report, clinical manifestations and management of syphilis in pregnancy are reviewed, and both traditional and reverse sequence screening algorithms are reviewed in detail in the context of clinical obstetrics.

Congenital syphilis: A contemporary update on an ancient disease

Congenital syphilis (CS) rates reached a 20-year high in the United States in 2018. Unlike previous years, most babies diagnosed with CS were born to mothers who received prenatal care, indicative of the need for better provider education and guideline adherence. Current rates suggest that screening for syphilis should be performed at the first prenatal care visit and twice during the third trimester. There are two diagnostic algorithms available for use in the United States (traditional and reverse) and providers must understand how to perform each algorithm. Treatment should be administered according to stage of syphilis per Centers for Disease Control recommendations with best neonatal outcomes seen when treatment is initiated >30 days before delivery. Benzathine Penicillin G remains the only recommended treatment of syphilis during pregnancy. In viable pregnancies, a pretreatment ultrasound is recommended to identify sonographic evidence of fetal infection and treatment should be initiated with continuous fetal monitoring to evaluate for the Jarisch-Herxheimer reaction which can cause preterm labor and fetal distress. After adequate syphilotherapy, a fourfold decline in maternal nontreponemal titers may not be observed by delivery and does not correlate with rates of CS.

Phase II trial evaluating the clinical efficacy of cefixime for treatment of active syphilis in non-pregnant women in Brazil (CeBra)

BACKGROUND

Syphilis is a sexually and vertically transmitted infection caused by the bacteria Treponema pallidum for which there are few proven alternatives to penicillin for treatment. For pregnant women infected with syphilis, penicillin is the only WHO-recommended treatment that will treat the mother and cross the placenta to treat the unborn infant and prevent congenital syphilis. Recent shortages, national level stockouts as well as other barriers to penicillin use call for the urgent identification of alternative therapies to treat pregnant women infected with syphilis.

METHODS

This prospective, randomized, non-comparative trial will enroll non-pregnant women aged 18 years and older with active syphilis, defined as a positive rapid treponemal and a positive non-treponemal RPR test with titer ≥1:16. Women will be a, domized in a 2:1 ratio to receive the oral third generation cephalosporin cefixime at a dose of 400 mg two times per day for 10 days (n = 140) or benzathine penicillin G 2.4 million units intramuscularly based on the stage of syphilis infection (n = 70). RPR titers will be collected at enrolment, and at three, six, and nine months following treatment. Participants experiencing a 4-fold (2 titer) decline by 6 months will be considered as having an adequate or curative treatment response.

DISCUSSION

Demonstration of efficacy of cefixime in the treatment of active syphilis in this Phase 2 trial among non-pregnant women will inform a proposed randomized controlled trial to evaluate cefixime as an alternative treatment for pregnant women with active syphilis to evaluate prevention of congenital syphilis.

TRIAL REGISTRATION

Trial identifier: www.Clinicaltrials.gov, NCT03752112. Registration Date: November 22, 2018.

The Effect of Different Treatment Regimens and Multiple Risk Factors on Adverse Pregnancy Outcomes among Syphilis-Seropositive Women in Guangzhou: A Retrospective Cohort Study

BACKGROUND

To eliminate mother-to-child transmission of syphilis, the Chinese government recommends a treatment regimen that slightly differs from the World Health Organization- (WHO-) recommended treatment. However, little is known about their difference in efficacy. This study is aimed at comparing the effect of China-recommended and WHO-recommend treatment regimens on adverse pregnancy outcomes (APOs) and at examining associated risk factors of APOs among syphilis-seropositive women.

METHODS

Using the syphilis registry data, we retrospectively collected data from 4488 syphilis-infected pregnant women in Guangzhou during 2011-2018. Multivariate analyses were used to investigate the association between treatment regimens and APOs (ectopic pregnancy, spontaneous abortion, stillbirth, preterm birth or low birth weight, newborn smaller than gestational age, congenital syphilis, and infant death) and the association between risk factors and APOs.

RESULTS

Of 3474 participants, 27.3% had at least one APO. Compared to those receiving WHO-recommended treatment, women who received China-recommended treatment were less likely to have APOs (odds ratio (OR) 0.47, 95% confidence interval (CI) 0.38-0.57), whereas those who received no treatment had 1.6 times higher odds of experiencing APOs. One common risk factor across different APOs was high levels of log2-transformed toluidine red unheated serum test (TRUST) titers before treatment (OR 1.14, 95% CI 1.10-1.19). China-recommended treatment was effective in reducing APOs for those with TRUST ≥ 1 : 8 (OR 0.21, 95% CI 0.14-0.29) and those with TRUST < 1 : 8 (OR 0.62, 95% CI 0.50-0.77).

CONCLUSIONS

Syphilis-seropositive women receiving China-recommended treatment had lower odds of APOs, especially when TRUST titers before treatment were high. Findings can be used to guide health professionals to reduce APOs among syphilis-infected mothers and promote nationwide use of China-recommended treatment.

Adequacy of prenatal care, diagnosis and treatment of syphilis in pregnancy: a study with open data from Brazilian state capitals

To assess the adequacy of prenatal care offered in the Brazilian capital cities and the diagnosis of gestational syphilis through public data from health information systems. The modified Kotelchuck index for adequacy of prenatal care was built using Brazilian Information System on Live Births (SINASC) data. Data on gestational syphilis, congenital syphilis, estimated population coverage by the Family Health Strategy (FHS), the Municipal Human Development Index (MHDI) and data from National Program for Access and Quality Improvement in Primary Care (PMAQ-AB) were accessed in public sites. The profile of pregnant women associated with inadequate care was assessed by logistic regression. In total, 685,286 births were analyzed. Only 2.3% of women did not attend prenatal appointments. The mean adequacy was 79.7%. No correlation was found between adequacy of prenatal care and FHS coverage (p = 0.172), but a positive correlation was found with the MHDI (p < 0.001). Inadequacy of prenatal care was associated with age below 20 years old, schooling less than 4 years, non-white skin color and not having a partner. Among the congenital syphilis cases, 17.2% of mothers did not attend prenatal care. Gestational syphilis more often affected vulnerable women, including a higher proportion of adolescents, women with low schooling, and women of non-white color. The PMAQ-AB showed a median availability of 27.3% for syphilis rapid tests, 67.7% for benzathine penicillin, and 86.7% for benzathine penicillin administration by health teams. The use of public data showed a low adequacy of prenatal care in Brazilian capitals, denoting insufficient quality for the diagnosis and treatment of gestational syphilis, despite the availability of supplies. Continuous monitoring can be carried out using public data, indicating to local strategies to eliminate congenital syphilis.

Use of National Syphilis Surveillance Data to Develop a Congenital Syphilis Prevention Cascade and Estimate the Number of Potential Congenital Syphilis Cases Averted

BACKGROUND

Recent increases in reported congenital syphilis have led to an urgent need to identify interventions that will have the greatest impact on congenital syphilis prevention. We sought to create a congenital syphilis prevention cascade using national syphilis surveillance data to (1) estimate the proportion of potential congenital syphilis cases averted with current prevention efforts and (2) develop a classification framework to better describe why reported cases were not averted.

METHODS

We reviewed national syphilis and congenital syphilis case report data from 2016, including pregnancy status of all reported female syphilis cases and data on prenatal care, testing, and treatment status of mothers of reported congenital syphilis cases to derive estimates of the proportion of pregnant women with syphilis who received prenatal care, syphilis testing, and adequate syphilis treatment at least 30 days before delivery, as well as the proportion of potential congenital syphilis cases averted.

RESULTS

Among the 2508 pregnant women who were reported to have syphilis, an estimated 88.0% received prenatal care at least 30 days before delivery, 89.4% were tested for syphilis at least 30 days before delivery, and 76.9% received an adequate treatment regimen that began at least 30 days before delivery. Overall, an estimated 1928 (75.0%) potential congenital syphilis cases in the United States were successfully averted. Among states that reported at least 10 syphilis cases among pregnant women, the estimated proportion of potential congenital syphilis cases averted ranged from 55.0% to 92.3%.

CONCLUSIONS

Although the majority of potential congenital syphilis cases in the United States were averted in 2016, there was substantial geographic variation, and significant gaps in delivering timely prenatal care, syphilis testing, and adequate treatment to pregnant women with syphilis were identified. The congenital syphilis prevention cascade is a useful tool to quantify programmatic successes and identify where improvements are needed.

Availability of benzathine penicillin G for syphilis treatment in Shandong Province, Eastern China

Background

The shortage of benzathine penicillin G (BPG) worldwide presents a major challenge in the treatment of syphilis. Its availability for syphilis treatment has not been adequately evaluated in China.

Methods

Two surveys were conducted among hospitals providing sexually transmitted infection clinical services in Shandong Province in 2012 and 2018. Data on the basic information and BPG availability of the surveyed hospitals and related factors were collected and analyzed using SPSS 17.0.

Results

A total of 433 and 515 hospitals were surveyed in 2012 and 2018, respectively. A significant difference in BPG availability was observed among different levels and types of hospitals both in 2012 (X² = 9.747, p = 0.008; X² = 37.167, p = 0.000) and 2018 (X² = 11.775, p = 0.003; X² = 28.331, p = 0.000). The BPG availability among surveyed hospitals increased from 45.0% in 2012 to 56.4% in 2018 (X² = 11.131, p = 0.001). The BPG availability was higher in 2018 than in 2012 among county-level hospitals (52.0% vs. 40.8%, X² = 7.783, p = 0.005), general western medicine hospitals (62.1% vs. 50.0%, X² = 6.742, p = 0.009), maternal and child health hospitals (57.1% vs. 26.9%, X² = 13.906, p = 0.000), and public hospitals (56.8% vs. 45.0%, X² = 11.361, p = 0.001). However, the county-level availability of BPG (at least one hospital has BPG in a county-level unit) has not improved between 2012 and 2018 (65.93% vs. 70.34%; X² = 0.563, p = 0.453). The absences of clinical needs, restriction of clinical antibacterial drugs, and lack of qualifications for providing syphilis treatment were the major reasons for the low BPG availability of hospitals.

Conclusions

BPG availability for syphilis treatment in Shandong Province remains low and presents disparities among different levels and types of hospitals, although it has been improved in recent years. The low availability of BPG for syphilis treatment in China is related to its clinical use by doctors rather than the market supply. Health care reforms should further improve the availability and accessibility of health services.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4006-4) contains supplementary material, which is available to authorized users.

Antibiotic treatment for newborns with congenital syphilis

BACKGROUND

Congenital syphilis continues to be a substantial public health problem in many parts of the world. Since the first use of penicillin for the treatment of syphilis in 1943, which was a notable early success, it has remained the preferred and standard treatment including for congenital syphilis. However, the treatment of congenital syphilis is largely based on clinical experience and there is extremely limited evidence on the optimal dose or duration of administration of penicillin or the use of other antibiotics.

OBJECTIVES

To assess the effectiveness and safety of antibiotic treatment for newborns with confirmed, highly probable and possible congenital syphilis.

SEARCH METHODS

We searched the Cochrane STI Group Specialized Register, CENTRAL, MEDLINE, Embase, LILACS, WHO ICTRP, ClinicalTrials.gov and Web of Science to 23 May 2018. We also handsearched conference proceedings, contacted trial authors and reviewed the reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing antibiotic treatment (any concentration, frequency, duration and route) with no intervention or any other antibiotic treatment for neonates with confirmed, highly probable or possible congenital syphilis.

DATA COLLECTION AND ANALYSIS

All review authors independently assessed trials for inclusion, extracted data and assessed the risk of bias in the included studies. We resolved any disagreements through consensus. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

Two RCTs (191 participants) met our inclusion criteria and none of these trials was funded by the industry. One trial (22 participants) compared benzathine penicillin with no intervention for infants with possible congenital syphilis. Low-quality evidence suggested that benzathine penicillin administration may not have decreased the rate of neonatal death due to any cause (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.06 to 11.70), and showed a possible reduction into the proportion of neonates with clinical manifestations of congenital syphilis (RR 0.12, 95% CI 0.01 to 2.09). Penicillin administration increased the serological cure at the third month (RR 2.13, 95% CI 1.06 to 4.27). These results should be taken with caution, because the trial was stopped early because there were four cases with clinical congenital syphilis in the no treatment group and none in the treatment group. Interim analysis suggested this difference was significant. This study did not report neonatal death due to congenital syphilis or the frequency of serious or minor adverse events after therapy. We downgraded the quality of evidence because of imprecision and risk of bias.One trial (169 participants) compared benzathine penicillin versus procaine benzylpenicillin. High- and moderate-quality evidence suggested that there were probably no differences between benzathine penicillin and procaine benzylpenicillin for the outcomes: absence of clinical manifestations of congenital syphilis (RR 1.00, 95% CI 0.97 to 1.03) and serological cure (RR 1.00, 95% CI 0.97 to 1.03). There were no cases of neonatal death due congenital syphilis; all 152 babies who followed up survived. This study did not report on the frequency of serious or minor adverse events after therapy. We downgraded the quality of evidence because of serious risk of bias.

AUTHORS' CONCLUSIONS

At present, the evidence on the effectiveness and safety of antibiotic treatment for newborns with confirmed, highly probable or possible congenital syphilis is sparse, implying that we are uncertain about the estimated effect. One trial compared benzathine penicillin with no intervention for infants with possible congenital syphilis. Low-quality evidence suggested penicillin administration possibly reduce the proportion of neonates with clinical manifestations of congenital syphilis, penicillin administration increased the serological cure at the third month. These findings support the clinical use of penicillin in neonates with confirmed, highly probable or possible congenital syphilis. High- and moderate-quality evidence suggests that there are probably no differences between benzathine penicillin and procaine benzylpenicillin administration for the outcomes of absence of clinical manifestations of syphilis or serological cure.

Challenges in the Contemporary Management of Syphilis among Pregnant Women in New Orleans, LA

Objective

The aim of this retrospective review is to evaluate trends in the management of maternal and congenital syphilis (CS) in a tertiary care center in New Orleans, LA.

Study Design

All cases of maternal and neonatal syphilis over a five year period at Touro Infirmary, New Orleans, LA, were identified using ICD-9/10 codes. Charts were reviewed for demographic and obstetrical variables, stage of syphilis at diagnosis, lab values, and treatment regimen. Newborn treatment and other outcomes were recorded.

Results

During the study period 106 infected mother-baby pairs were identified. Of these, 73 charts are available for review. 41% (n = 30) of women received inadequate therapy according to their stage of disease. 9% of newborns (n = 6) were found to be symptomatic for CS; however, only 83.3% of these were admitted to the neonatal intensive care unit. Only 20% (n = 6) of infants were adequately treated with an extended penicillin regimen if the mother was not adequately treated. Furthermore, only 63.0% of newborns had a nontreponemal titer performed.

Conclusion

With rising rates of CS, strict adherence to the 2015 CDC guidelines for treatment of syphilis must be maintained.

Ultrasound Findings Associated With Antepartum Viral Infection

This article reviews the sonographic manifestations of fetal infection and the role of ultrasound in the evaluation of the fetus at risk for congenital infection. Several ultrasound findings have been associated with in utero fetal infections. For the patient with a known or suspected fetal infection, sonographic identification of characteristic abnormalities can provide useful information for counseling and perinatal management. Demonstration of such findings in the low-risk patient may serve to identify the fetus with a previously unsuspected infection. The clinician should understand the limitations of ultrasound in the prenatal diagnosis of congenital infection and discuss them with the patient.

Common Bacterial and Viral Infections: Review of Management in the Pregnant Patient

OBJECTIVE

To review the treatment of common bacterial and viral infections occurring in the pregnant patient.

DATA SOURCES

A literature search of MEDLINE was performed (inception to October 2018). The Centers for Disease Control and Prevention website was utilized for additional information.

STUDY SELECTION AND DATA EXTRACTION

Relevant English-language studies and those conducted in humans were considered.

DATA SYNTHESIS

β-Lactams alone or in combination are the preferred treatment for many common infections in pregnancy, such as urinary tract infections, pelvic inflammatory disease (PID), gonococcal infections, syphilis, chancroid, upper- and lower-respiratory-tract infections, certain gastrointestinal infections, Group B Streptococcus, listeriosis, and intrauterine inflammation or infection. Macrolides, particularly azithromycin, are also utilized for the treatment of PID, chlamydia, gonococcal infections, chancroid, community-acquired pneumonia, and certain gastrointestinal infections. Other antibiotics or antivirals such as vancomycin, aminoglycosides, metronidazole, nitrofurantoin, fosfomycin, acyclovir, valacyclovir, and oseltamivir are included in the preferred therapy for some common bacterial and viral infections in pregnant patients as well. Relevance to Patient Care and Clinical Practice: This review synthesizes available evidence of treatments of common infections in pregnancy and provides a concise summary to guide clinicians on empirical treatment during pregnancy.

CONCLUSIONS

There are limited data on clinical outcomes in pregnant patients with common bacterial and viral infections. Empirical management decisions require balance of benefit and risk to both mother and infant. Although few clinical practice guidelines have quality evidence for strong recommendations in this population, clinicians should weigh antimicrobial dosing, pharmacokinetics, safety, and established effectiveness to optimize antimicrobial therapy in pregnancy.

A favorable pregnancy outcome in women with secondary syphilis

A clinical case of secondary fresh syphilis in a pregnant woman at 36 weeks is presented. A ttention deserves infection of a woman in the second half of pregnancy, which was resolved by the birth of a healthy child.

Update on syphilis and pregnancy

While the origins of syphilis remain unknown, it has long been recognized as an infectious entity with complex pathophysiology. In this review, we highlighted the epidemiology and risk factors associated with syphilis. The incidence of syphilis in most populations showed a consistent upward trend until the 1940s with the introduction of penicillin as the preferred treatment. The emergence of congenital syphilis and vertical transmission has been a direct result of heterosexual syphilis transmission. We also explore the microbiology and pathogenesis of Treponema pallidum as it directly correlates with its route of transmission and infectivity. The clinical features are best categorized into stages (primary, secondary, early, and late latent and tertiary). The primary stage presents as a characteristic chancre and inguinal adenopathy, while the secondary "bacteremia" stage has a predilection to dermatologic manifestations and constitutional symptoms. The latent phase of syphilis witnesses a quiescent period with variable relapse of symptoms and finally, one-third of untreated patients undergo tertiary syphilis years after the initial infection characterized by severe neurologic or cardiovascular symptomatology. We will also review the data collected for congenital syphilis from the CDC as this can manifest with stillbirth, neonatal death, and nonimmune hydrops. The diagnosis of syphilis focuses on a combination of nontreponemal and treponemal antibody tests with the CDC recommending a traditional algorithm from screening to confirmation. However, other agencies have recently adopted the reverse testing algorithm which has outperformed the traditional algorithm in certain populations. We finally focus on syphilotherapy and monitoring response to treatment with a specific emphasis on pregnancy. Birth Defects Research 109:347-352, 2017. © 2017 Wiley Periodicals, Inc.

Effectiveness of Prenatal Screening and Treatment to Prevent Congenital Syphilis, Louisiana and Florida, 2013-2014

BACKGROUND

From 2012 to 2014, rates of congenital syphilis increased in Louisiana and Florida. We evaluated the effectiveness of early (first or second) and third trimester syphilis screening for the prevention of congenital syphilis in these high-morbidity states.

METHODS

Reported syphilis cases among pregnant women in Louisiana and Florida during January 1, 2013, to December 31, 2014, were reviewed for documented screening for syphilis in the first 2 trimesters and third trimester. Pregnant women with syphilis were linked to congenital syphilis records and stratified by whether the pregnancy led to a reported congenital syphilis case.

RESULTS

Seven hundred ten pregnant women with syphilis in Louisiana and Florida were linked to 155 congenital syphilis cases. Three hundred seventy (52%) pregnant women with syphilis were staged as early syphilis (n = 270) or high-titer late or unknown duration-latent syphilis (n = 100), and 109 (70% of the total) were linked to congenital syphilis cases. Screening in the first 2 trimesters identified 513 pregnant women who tested positive for syphilis, and 470 (92%) potential congenital syphilis were averted. One hundred nine pregnant women tested positive for syphilis in the third trimester, and 85 (78%) had babies without congenital syphilis. During their pregnancy, 85 (12%) women tested negative at least once, and 55 (65%) had babies with congenital syphilis. Thirty-nine women had no reported syphilis screening 30 days or longer before delivery.

CONCLUSIONS

Screening for syphilis both early and in the third trimester prevented many pregnant women with syphilis from having a baby with congenital syphilis. Preventing all congenital syphilis would likely require preventing all syphilis among women.

Oral Desensitization to Penicillin for the Treatment of Pregnant Women with Syphilis: A Successful Program

Gestational syphilis is a prevalent disease in Brazil and other low and medium income countries. Desensitization to penicillin is recommended for pregnant women with syphilis who are allergic to β-lactams. This is a descriptive study utilizing outpatient medical records from 2011 to 2015 from a mother and child hospital that is part of the national healthcare system in the South of Brazil, which performs an average of 3,600 birth assistances per year. All cases of pregnant women with syphilis and presumptive diagnosis of β-lactam allergy during the study period were included. The patients referred for desensitization originated from the hospital prenatal care service, as well as from municipal/state antenatal care services. Oral desensitization was performed in the obstetric emergency room, and adult and pediatric intensive care units were available at all times. Ten patients underwent desensitization during the period of study. Personal history of urticaria was the most common reaction that demanded desensitization. All patients tolerated the procedure well, and showed no adverse reactions. We report a successful program of oral desensitization. None of the patients presented adverse reactions or complications, a fact that corroborates the feasibility and safety of the desensitization protocol. Oral administration of penicillin comes at a low cost, and optimizes the use of time and resources.

Syphilis during pregnancy: a preventable threat to maternal-fetal health

Syphilis remains the most common congenital infection worldwide and has tremendous consequences for the mother and her developing fetus if left untreated. Recently, there has been an increase in the number of congenital syphilis cases in the United States. Thus, recognition and appropriate treatment of reproductive-age women must be a priority. Testing should be performed at initiation of prenatal care and twice during the third trimester in high-risk patients. There are 2 diagnostic algorithms available and physicians should be aware of which algorithm is utilized by their testing laboratory. Women testing positive for syphilis should undergo a history and physical exam as well as testing for other sexually transmitted infections, including HIV. Serofast syphilis can occur in patients with previous adequate treatment but persistent low nontreponemal titers (<1:8). Syphilis can infect the fetus in all stages of the disease regardless of trimester and can sometimes be detected with ultrasound >20 weeks. The most common findings include hepatomegaly and placentomegaly, but also elevated peak systolic velocity in the middle cerebral artery (indicative of fetal anemia), ascites, and hydrops fetalis. Pregnancies with ultrasound abnormalities are at higher risk of compromise during syphilotherapy as well as fetal treatment failure. Thus, we recommend a pretreatment ultrasound in viable pregnancies when feasible. The only recommended treatment during pregnancy is benzathine penicillin G and it should be administered according to maternal stage of infection per Centers for Disease Control and Prevention guidelines. Women with a penicillin allergy should be desensitized and then treated with penicillin appropriate for their stage of syphilis. The Jarisch-Herxheimer reaction occurs in up to 44% of gravidas and can cause contractions, fetal heart rate abnormalities, and even stillbirth in the most severely affected pregnancies. We recommend all viable pregnancies receive the first dose of benzathine penicillin G in a labor and delivery department under continuous fetal monitoring for at least 24 hours. Thereafter, the remaining benzathine penicillin G doses can be given in an outpatient setting. The rate of maternal titer decline is not tied to pregnancy outcomes. Therefore, after adequate syphilotherapy, maternal titers should be checked monthly to ensure they are not increasing four-fold, as this may indicate reinfection or treatment failure.

Estimating Benzathine Penicillin Need for the Treatment of Pregnant Women Diagnosed with Syphilis during Antenatal Care in High-Morbidity Countries

BACKGROUND

Congenital syphilis continues to be a preventable cause of global stillbirth and neonatal morbidity and mortality. Shortages of injectable penicillin, the only recommended treatment for pregnant women and infants with syphilis, have been reported by high-morbidity countries. We sought to estimate current and projected annual needs for benzathine penicillin in antenatal care settings for 30 high morbidity countries that account for approximately 33% of the global burden of congenital syphilis.

METHODS

Proportions of antenatal care attendance, syphilis screening coverage in pregnancy, syphilis prevalence among pregnant women, and adverse pregnancy outcomes due to untreated maternal syphilis reported to WHO were applied to 2012 birth estimates for 30 high syphilis burden countries to estimate current and projected benzathine penicillin need for prevention of congenital syphilis.

RESULTS

Using current antenatal care syphilis screening coverage and seroprevalence, we estimated the total number of women requiring treatment with at least one injection of 2.4 MU of benzathine penicillin in these 30 countries to be 351,016. Syphilis screening coverage at or above 95% for all 30 countries would increase the number of women requiring treatment with benzathine penicillin to 712,030. Based on WHO management guidelines, 351,016 doses of weight-based benzathine penicillin would also be needed for the live-born infants of mothers who test positive and are treated for syphilis in pregnancy. Assuming availability of penicillin and provision of treatment for all mothers diagnosed with syphilis, an estimated 95,938 adverse birth outcomes overall would be prevented including 37,822 stillbirths, 15,814 neonatal deaths, and 34,088 other congenital syphilis cases.

CONCLUSION

Penicillin need for maternal and infant syphilis treatment is high among this group of syphilis burdened countries. Initiatives to ensure a stable and adequate supply of benzathine penicillin for treatment of maternal syphilis are important for congenital syphilis prevention, and will be increasingly critical in the future as more countries move toward elimination targets.

Current Perspectives on Prevention of Mother-to-Child Transmission of Syphilis

This article aims to provide an update on the prevention of mother-to-child transmission of syphilis by drawing upon some important basic concepts and reviewing the most recent literature on the diagnosis and treatment of syphilis in pregnancy. New technologies, such as automated and point-of-care immunologic tests, are shifting some paradigms, which will certainly be further investigated in the forthcoming years. This is the time to carefully evaluate traditional as well as new strategies to prevent congenital syphilis. Adverse outcomes of mother-to-child transmission of syphilis can be prevented with antenatal screening and penicillin therapy, which proved to have an excellent cost-benefit ratio even in populations with a low prevalence of syphilis. However, syphilis epidemiology is influenced by socioeconomic and cultural factors, and major challenges are faced by poor and developing countries in which the severity of the problem is extremely alarming. On the other hand, the emergence of new technologies has raised doubts about the best algorithm to be used when proper laboratory resources are available. Conditions are quite heterogeneous across populations, and some procedures should not be generalized while there is no evidence that supports some changes and while in-depth studies about local conditions are not conducted. Official organizations need to be alert in order to avoid isolated decisions and ensure that evidence-based guidelines be used in the management of syphilis in pregnancy.

Assessment of the impact of rapid syphilis tests on syphilis screening and treatment of pregnant women in Zambia

OBJECTIVE

To evaluate the impact of rapid syphilis tests (RSTs) on syphilis testing and treatment in pregnant women in Kalomo District, Zambia.

METHODS

In March 2012, health workers at all 35 health facilities in Kalomo Distract were trained in RST use and penicillin treatment. In March 2013, data were retrospectively abstracted from 18 randomly selected health facilities and stratified into three time intervals: baseline (6months prior to RST introduction), midline (0-6 months after RST introduction), and endline (7-12 months after RST introduction).

RESULTS

Data collected on 4154 pregnant women showed a syphilis-reactive seroprevalence of 2.7%. The proportion of women screened improved from baseline (140/1365, 10.6%) to midline (976/1446, 67.5%), finally decreasing at endline (752/1337, 56.3%) (P<0.001). There was no significant difference in the proportion of syphilis-seroreactive pregnant women who received 1 dose of penicillin before (1/2, 50%) or after (5/48, 10.4%; P=0.199) RST introduction with low treatment rates throughout.

CONCLUSION

With RST scale-up in Zambia and other resource-limited settings, same-day test and treatment with penicillin should be prioritized to achieve the goal of eliminating congenital syphilis.

Current standards for syphilis treatment: comparing the russian and foreign guidelines (part II)

The introduction of penicillin has been a breakthrough in the treatment of syphilis. For 70 years, penicillin remains the preferred drug for the treatment of all forms of the disease; its effectiveness has been proven by wide experience gained from clinical observations. However, a very limited number of published meta-analyzes, systematic reviews and data from randomized controlled trials on the comparative assessment of the effectiveness of various antibiotics and treatment regimens are currently available. Some aspects of syphilis treatment are insufficiently developed, particularly, the treatment schedules for neurosyphilis, syphilis in pregnancy, syphilis in HIV-infected individuals and persons allergic to penicillin. There are disagreements in the assessment of the clinical significance of serofast state after a course of antibiotic therapy. There is no uniform approach to the management of patients with treatment failures. This article compares the Russian standards for syphilis treatment set out in the «Federal guidelines for the management of patients with syphilis» with the current European recommendations of the International Union against Sexually Transmitted Infections (IUSTI) and the recommendations of the US Centers for Disease Control and Prevention (CDC). The peculiarities of these guidelines, their strengths and shortcomings, as well as controversial issues of syphilis therapy are discussed. The differences between the domestic and foreign recommendations are more significant in the section concerning the treatment of syphilis than in the section of diagnosis.

Progression of ultrasound findings of fetal syphilis after maternal treatment

OBJECTIVE

The purpose of this study was to evaluate ultrasound findings of fetal syphilis and to describe their progression after maternal treatment.

STUDY DESIGN

This was a retrospective cohort study from September 1981 to June 2011 of seropositive women after 18 weeks of gestation who had an ultrasound before treatment to evaluate for fetal syphilis. Only those women who received treatment after the initial ultrasound scan, but before delivery, were included. If the initial ultrasound scan was abnormal, serial sonography was performed until resolution of the abnormality or delivery. Patient demographics, ultrasound findings, stage of syphilis, delivery, and infant outcomes were recorded. Standard statistical analyses were performed. Kaplan-Meier estimates were constructed to estimate time to resolution.

RESULTS

Two hundred thirty-five women met the inclusion criteria; 73 of them (30%) had evidence of fetal syphilis on initial ultrasound scan. Abnormalities included hepatomegaly (79%), placentomegaly (27%), polyhydramnios (12%), ascites (10%) and abnormal middle cerebral arterial Doppler assessment (33%). After treatment, middle cerebral arterial Doppler assessment abnormalities, ascites, and polyhydramnios resolved first, followed by placentomegaly and finally hepatomegaly. Infant outcomes were available for 173 deliveries; of these, 32 infants (18%) were diagnosed with congenital syphilis. Congenital syphilis was more common when antenatal ultrasound abnormalities were present (39% vs 12%; P < .001). Infant examination findings at delivery were similar between women with and without an abnormal pretreatment ultrasound scan. However, in those infants with congenital syphilis, hepatomegaly was the most frequent abnormality found, regardless of antenatal ultrasound findings.

CONCLUSION

Sonographic signs of fetal syphilis confer a higher risk of congenital syphilis at delivery for all maternal stages. Hepatomegaly develops early and resolves last after antepartum treatment.