Congenital Syphilis continued... (from page 18)
Prevention The most significant and effective action to combat congenital syphilis is prevention of syphilis infection in the fetus. Prevention is composed of two steps: 1) maternal screening for syphilis infection and 2) effective treatment of maternal infection when discovered. In California, it is required by law that all pregnant women undergo screening for syphilis during the first prenatal visit, as recommended by the Centers for Disease Control (CDC). Pregnant women who may be at higher risk for syphilis infection should undergo additional screening for syphilis infection in the third trimester, at birth, and after exposure to an infected partner. Pregnant women who are at higher risk include those who have a history of substance abuse, incarceration, STI diagnosis, and those who did not get tested for syphilis in the 1st or 2nd trimesters of pregnancy. If screening suggests the presence of infection, followup tests can confirm the stage of infection in the mother. Once maternal syphilis infection is confirmed, the mother must receive antibiotic treatment appropriate for stage of infection. In general, timely, appropriate treatment of syphilis in the mother serves as adequate treatment of the fetus. However, treatment of the fetus is NOT considered adequate if maternal treatment begins less than 30 days prior to delivery.
Assessment of Infection in the Infant Congenital syphilis screening4 of the mother and infant must take place at birth if: 1) the mother has a history of STI, 2) was diagnosed with syphilis during pregnancy, or 3) is considered at high risk for syphilis infection at delivery. Both mother and infant should have serum RPR or VRDL titer drawn at delivery, and a neonatal physical examination must be performed to look for signs of congenital syphilis (e.g. hepatomegaly, jaundice, non-immune hydrops). PCR testing of any suspicious lesion or bodily fluid in the neonate must also be performed. If no abnormalities are found in the initial neonatal screening, then further congenital syphilis classification
References 1.
Firth J. (2012) Syphilis – Its early history and Treatment until Penicillin and the Debate on its Origins. Journal of Military and Veterans’ Health, 20(4), 49-58.
2.
Concerning Increases in Syphilis in Women and Congenital Syphilis – An Update for California Health Care Physicians, CDPH, 2018.
3.
Sharp, N. (2015) The Return of Syphilis, The Atlantic, December Issue.
4.
Congenital Syphilis: Evaluation & Treatment of Infants Born to Women with Syphilis during Pregnancy, CDPH, 2018.
depends upon the mother’s syphilis status. The neonate may be classified as low risk for congenital syphilis if the mother received adequate, documented treatment for syphilis more than four weeks prior to delivery AND there was no concern for reinfection during pregnancy. If the mother received no treatment or inadequate treatment for syphilis, or received treatment for syphilis less than four weeks prior to delivery, then the neonate must undergo supplemental evaluation with CSF analysis, CBC and long-bone radiographs. The neonate is classified as having possible congenital syphilis if no abnormalities are found in the supplemental evaluation. The neonate is classified as having probable congenital syphilis if abnormalities are identified in the supplemental examination. If any abnormality is found in the initial neonatal screening, the neonate is classified as having proven or highly probable congenital syphilis. In this scenario, a complete evaluation of the neonate includes CSF analysis, CBC, long-bone radiographs and other tests as necessary based on the physical exam (e.g. abdominal ultrasound for suspected hepatomegaly).
Treatment of Infection in the Infant Unlike cases of syphilis in an adult in which treatment choice depends upon stage of infection, treatment selection for congenital syphilis in newborns depends upon the likelihood of syphilis infection. When newborn screening and evaluation indicates proven or probable congenital syphilis, then penicillin G is administered intravenously twice daily for seven days and then three times a day for 10 days thereafter. If congenital infection is classified as possible but all elements of the neonate’s workup are otherwise negative or if there is a low risk classification for congenital syphilis but clinical follow up is uncertain, then a single dose of penicillin G administered intramuscularly is recommended. Finally, if congenital syphilis is considered unlikely, then no treatment is necessary; however, follow up lab tests confirming lack of infection is recommended. Congenital syphilis can only be defeated with a concerted effort amongst the health care system, public health, social services, and community outreach. When evaluating a pregnant woman in the office, think syphilis. While we might not be able to stop syphilis from hindering King Charles’ army, we must make every effort to prevent syphilis from affecting our most vulnerable populations, the fetus and neonate.