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Syphilis during pregnancy: a preventable threat to maternal-fetal health.
Am J Obstet Gynecol. 2017 04; 216(4):352-363.AJ

Abstract

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.

Authors+Show Affiliations

Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX. Electronic address: Martha.Rac@bcm.edu.Department of Pathology and Pediatrics, Baylor College of Medicine, Houston, TX.Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX.

Pub Type(s)

Journal Article
Review

Language

eng

PubMed ID

27956203

Citation

Rac, Martha W F., et al. "Syphilis During Pregnancy: a Preventable Threat to Maternal-fetal Health." American Journal of Obstetrics and Gynecology, vol. 216, no. 4, 2017, pp. 352-363.
Rac MW, Revell PA, Eppes CS. Syphilis during pregnancy: a preventable threat to maternal-fetal health. Am J Obstet Gynecol. 2017;216(4):352-363.
Rac, M. W., Revell, P. A., & Eppes, C. S. (2017). Syphilis during pregnancy: a preventable threat to maternal-fetal health. American Journal of Obstetrics and Gynecology, 216(4), 352-363. https://doi.org/10.1016/j.ajog.2016.11.1052
Rac MW, Revell PA, Eppes CS. Syphilis During Pregnancy: a Preventable Threat to Maternal-fetal Health. Am J Obstet Gynecol. 2017;216(4):352-363. PubMed PMID: 27956203.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Syphilis during pregnancy: a preventable threat to maternal-fetal health. AU - Rac,Martha W F, AU - Revell,Paula A, AU - Eppes,Catherine S, Y1 - 2016/12/09/ PY - 2016/09/08/received PY - 2016/11/17/revised PY - 2016/11/30/accepted PY - 2016/12/14/pubmed PY - 2017/6/1/medline PY - 2016/12/14/entrez KW - congenital syphilis KW - fetal syphilis KW - syphilis during pregnancy SP - 352 EP - 363 JF - American journal of obstetrics and gynecology JO - Am. J. Obstet. Gynecol. VL - 216 IS - 4 N2 - 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. SN - 1097-6868 UR - https://www.unboundmedicine.com/medline/citation/27956203/Syphilis_during_pregnancy:_a_preventable_threat_to_maternal_fetal_health_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0002-9378(16)32167-6 DB - PRIME DP - Unbound Medicine ER -