Syphilis in Pregnancy

If you have syphilis in pregnancy and don’t receive treatment right away, your baby could be affected.
Up to 40% of children born to untreated women with syphilis die from it.
Untreated active syphilis in pregnant women increases the risk of poor pregnancy outcomes almost fivefold.

Potential Complications:

Risk Factors:

The stage of syphilis in the mother and the stage of pregnancy when the infection was acquired determine the risk of vertical transmission.
Vertical transmission rates are higher (60% to 90%) with untreated primary or secondary syphilis compared to latent syphilis (40%) or late latent syphilis (less than 10%).

Management:

Close collaboration between healthcare providers treating pregnant women and children is essential.

General Management

Checklist: A syphilis management checklist ensures all necessary steps are taken and that women are informed about their baby’s follow-up care. It should be completed as soon as treatment ends, but no later than 28 weeks into pregnancy.
Post-28 Weeks: If identified after 28 weeks, complete the checklist as soon as treatment concludes.
Explanation: Provide a full explanation of the diagnosis, long-term health effects, and clear written information.
Baseline Testing: Conduct quantitative VDRL/RPR testing (±EIA IgM) on the first day of treatment to establish a baseline for tracking treatment efficacy.

Treatment

Antimicrobial Goal: Achieve a treponemicidal level of penicillin in the blood (and cerebrospinal fluid if neurosyphilis is present).
Penicillin: The preferred treatment, effective at levels above 0.018 mg/L.
Duration: 7–10 days for early syphilis and 14–21 days for late syphilis.
Administration: Parenteral treatment ensures bioavailability. Benzathine benzylpenicillin injections should be reconstituted with 1% lidocaine hydrochloride, split, and administered deeply in two areas (e.g., upper outer quadrants of each buttock).
Penicillin Allergy: Consider desensitization for those allergic to penicillin. Many who have previously reacted to penicillin may not react upon re-exposure.
Expertise Required: Skin tests and desensitization require expertise.

Treatment Complications

Jarisch-Herxheimer Reaction:

Description: A severe feverish illness occurring upon initial antibiotic administration, especially in newly infected individuals.
Symptoms: Headaches, muscle pain, and stiffness within 8 hours, resolving in 24 hours unless there are neurological or ophthalmological complications, or if the patient is pregnant.
Management: Inform patients, recommend bed rest, and administer antipyretics. Severe reactions may require corticosteroids.

Procaine Reaction (Hoigne’s Syndrome):

Description: A non-allergic response to intravenous procaine penicillin.
Symptoms: Immediate onset of impending doom, hallucinations, or seizures lasting less than 20 minutes.
Management: Verbal reassurance and, if necessary, 10 mg rectal diazepam for seizures. Use aspiration method for injections to reduce risk.

Anaphylaxis:

Penicillin: A common cause of anaphylaxis, necessitating preparedness for CPR.

Partner Notification

Healthcare Provider: Individuals diagnosed with syphilis should consult with a healthcare provider, such as a sexual health adviser, for partner notification.
Sexual Contact: Avoid until sores heal and initial follow-up test results are reviewed.
Look-Back Period: For primary syphilis, 3 months; for secondary or early latent syphilis, 2 years.
Late Syphilis: Not contagious when first detected but notify contacts from the past two years. Previous negative serology aids in estimating the infection timeline.
Screening: Close contacts of early-stage syphilis patients should be screened and treated epidemiologically if full follow-up isn’t feasible.

Follow-Up

Testing Schedule: Conduct tests at the end of treatment and at 1, 2, 3, 6, and 12 months to detect early syphilis.
Continued Monitoring: Test every six months until the serofast or VDRL/RPR test returns negative.
Titer Reduction: Expect a fourfold drop in VDRL titer within 6 to 12 months (e.g., from 1:32 to 1:8).
Treatment Failure/Relapse: Indicated by a fourfold rise in VDRL titer at any time.
Discharge: If VDRL/RPR is negative or serofast after 12 months and the patient is symptom-free, they can be discharged.
Summary: Provide an overview of treatment and discharge serology to the patient and their doctor to avoid unnecessary future treatments.

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