Syphilis in pregnancy-final_version

Syphilis in pregnancy-final_version

1. Syphilis in pregnancySyphilis in pregnancy
Dr. Areej MuftiDr. Areej Mufti
MD,FRCPC,ABMM, FCCMMD,FRCPC,ABMM, FCCM
Assistant professor, KSAUAssistant professor, KSAU
Medical MicrobiologistMedical Microbiologist

2. Case scenario 1Case scenario 1
L.B. is a 26 y/o G3P2 at 18 weeks gestation who L.B. is a 26 y/o G3P2 at 18 weeks gestation who
has H/O"venereal disease " four years ago. She has H/O"venereal disease " four years ago. She
was treated with 3 shots at that time. Current was treated with 3 shots at that time. Current
new prenatal labs reveal a new prenatal labs reveal a reactive reactive RPR with a RPR with a
titer of titer of 1:41:4 and a and a reactive reactive FTA.FTA.
How should she be managed nowHow should she be managed now ? ?
a. repeat serology at 28 weeks/deliverya. repeat serology at 28 weeks/delivery..
b. She is reinfected, treat her with penicillin b. She is reinfected, treat her with penicillin
nownow..
c. reassure her, no further work upc. reassure her, no further work up..
e. none of the abovee. none of the above..
e. I do not know, I will ask for helpe. I do not know, I will ask for help..

3. Case scenario 2Case scenario 2
..R.H. is an 18 y/o G1P0 at 10 weeks gestation R.H. is an 18 y/o G1P0 at 10 weeks gestation
whose new prenatal labs reveal a whose new prenatal labs reveal a reactivereactive RPR at RPR at
a titer of 1:2 and a a titer of 1:2 and a reactive reactive FTA. She has no FTA. She has no
history of STD but her husband has just history of STD but her husband has just
diagnosed recently with HIV/syphilis coinfectiondiagnosed recently with HIV/syphilis coinfection.. ..
How should she be managed? How should she be managed?
a. repeat serology at 28 weeks/deliverya. repeat serology at 28 weeks/delivery
b. repeat serology at 4-6 w .b. repeat serology at 4-6 w .
d. reassure her, no further work up.d. reassure her, no further work up.
e. I do not know, I will ask for help.e. I do not know, I will ask for help.

4. Case scenario 3Case scenario 3
D. F. is a 21 y/o G4P1 at 14 weeks gestation who D. F. is a 21 y/o G4P1 at 14 weeks gestation who
has ANC labs that reveal a has ANC labs that reveal a nonreactivenonreactive RPR and RPR and
a a reactivereactive FTA. She has no history of treatment FTA. She has no history of treatment
and her physical exam is normaland her physical exam is normal..
How should you manageHow should you manage??
a. no action, pregnancy can cause a a. no action, pregnancy can cause a
biological false positive FTA.biological false positive FTA.
b. repeat RPR test in 4-6 weeks.b. repeat RPR test in 4-6 weeks.
c. treat her with Penicillin, 3 shots, each is a c. treat her with Penicillin, 3 shots, each is a
week apart. week apart.
e. none of the above.e. none of the above.

5. My talk will answer the followingMy talk will answer the following....
WHEN SHOULD SYPHILIS BE WHEN SHOULD SYPHILIS BE
SUSPECTED IN A PREGNANT WOMAN?SUSPECTED IN A PREGNANT WOMAN?
HOW SHOULD SYPHILIS SEROLOGY HOW SHOULD SYPHILIS SEROLOGY
BE INTERPRETED?BE INTERPRETED?
WHICH WOMEN WITH REACTIVE WHICH WOMEN WITH REACTIVE
TREPONEMAL TESTS HAVE BEEN TREPONEMAL TESTS HAVE BEEN
ADEQUATELY TREATED BEFORE ADEQUATELY TREATED BEFORE
PREGNANCY?PREGNANCY?

6. WHEN SHOULD SYPHILIS BE WHEN SHOULD SYPHILIS BE
SUSPECTED IN A PREGNANT WOMANSUSPECTED IN A PREGNANT WOMAN??
 sexual/direct contact (infected lesions) sexual/direct contact (infected lesions)
with a person who was infected with with a person who was infected with
syphilis within the syphilis within the preceding year.preceding year.
If the cause is not known for a hydropic or If the cause is not known for a hydropic or
still birth newborn;do pstpartum screen.still birth newborn;do pstpartum screen.
Remember:Remember: allall pregnant women must be pregnant women must be
assumed to be at risk. assumed to be at risk.

7. Doctor: why I have to be screened Doctor: why I have to be screened
for Syphilis?for Syphilis?
I never had any STD in the past I never had any STD in the past
……I have no complain at the I have no complain at the
present!!present!!
WHEN SHOULD SYPHILIS BE SUSPECTED IN WHEN SHOULD SYPHILIS BE SUSPECTED IN
A PREGNANT WOMAN A PREGNANT WOMAN??

8. Why universal early antepartam Why universal early antepartam
screen is importantscreen is important? ?
Epidemiological factors. Epidemiological factors.
Clinical factors. Clinical factors.
Outcome factors.Outcome factors.

9. Syphilis stagesSyphilis stages
Incubation periodIncubation period: : 10-90 days, average 3 weeks10-90 days, average 3 weeks..
Primary SPrimary S : : - starts 3 w post infection- starts 3 w post infection
-lasts 3-6w-lasts 3-6w. .

Secondary S: : - 6w-6m post infection. - 6w-6m post infection.
-25% of untreated primary progress to -25% of untreated primary progress to
this stage; this stage;
-resolve in 2-6 w.-resolve in 2-6 w.

latent S:latent S: - -developed when primary or secondary S is developed when primary or secondary S is
not treated. Reactivity of NTT decrease with increasednot treated. Reactivity of NTT decrease with increased
latency>1 ylatency>1 y..
Tertiary S:Tertiary S: -10-30y after initial infection. -10-30y after initial infection.
-30 % of untreated 2° syphilis. -30 % of untreated 2° syphilis.

11. corkscrew-
shaped thin
(0.1-0.18(
10%-20%

75%-100%
5%

12. Syphilis serologySyphilis serology

13. Syphilis serologySyphilis serology

14. HOW SHOULD SYPHILIS SEROLOGY BE HOW SHOULD SYPHILIS SEROLOGY BE
INTERPRETEDINTERPRETED??
Nontreponemal testNontreponemal test Treponemal testTreponemal test interpretationinterpretation
NonreactiveNonreactive Reactive/IndeterminateReactive/Indeterminate ·Early 1Early 1ْْ syphilis.syphilis.
·Late latent/ 3Late latent/ 3 ْ ْ syphilis.(3)syphilis.(3)
·Previously treated Previously treated
syphilis.syphilis.
·Endemic syphilisEndemic syphilis
ReactiveReactive NonreactiveNonreactive False positiveFalse positive
ReactiveReactive ReactiveReactive ·Syphilis at any stage.Syphilis at any stage.
·Old treated syphilis Old treated syphilis
(serofast).(1)(serofast).(1)
·Follow up of treatmentFollow up of treatment
·Endemic syphilis. Endemic syphilis.
ReactiveReactive IndeterminateIndeterminate ·Early 1Early 1ْْ syphilis.syphilis.
·Late latent/ 3Late latent/ 3 ْ ْ syphilis.syphilis.
·Previously treated Previously treated
syphilis.syphilis.
·Endemic syphilisEndemic syphilis
Public Health Agency of CanadaPublic Health Agency of Canada. .
Canadian Guidelines on Sexually Transmitted Infections,2008Canadian Guidelines on Sexually Transmitted Infections,2008

16. Treponematoses in Saudi ArabiaTreponematoses in Saudi Arabia
the overall incidence of treponemal seropositivity: the overall incidence of treponemal seropositivity: 2.7%-2.7%-16.6%16.6%
with with 0.85%0.85% positivity among the pregnant women positivity among the pregnant women

17. Syphilis serologySyphilis serology
Capture IgM EIA test:Capture IgM EIA test:
its value is:its value is:
-untreated syphilis :+ even in early untreated syphilis :+ even in early
primary cases were RPR/TPHA may primary cases were RPR/TPHA may
be -be -
-F/U treatment success: F/U treatment success: ––
- Bejel: RPR/TPHA:+/- (usually ≤1:8)- Bejel: RPR/TPHA:+/- (usually ≤1:8)
EIA IgM: -EIA IgM: -

18. TREATMENTTREATMENT
Primary, secondary, and early latent syphilis:Primary, secondary, and early latent syphilis:
Benzathine penicillin GBenzathine penicillin G, , IM, 2.4 million units in a single IM, 2.4 million units in a single
dose.dose.
* additional therapy* additional therapy a second dosea second dose of benzathine penicillin of benzathine penicillin
2.4 million units IM administered 1 week after the initial 2.4 million units IM administered 1 week after the initial
dose to improve the likelyhood of serologic response in dose to improve the likelyhood of serologic response in
early disease..early disease..
        Late latent or latent syphilis of unknown duration; Late latent or latent syphilis of unknown duration;
Benzathine penicillin administered as three doses of 2.4 Benzathine penicillin administered as three doses of 2.4
million units IM each at 1-week intervals.million units IM each at 1-week intervals.

Tertiary (late) syphilis without neurologic involvementTertiary (late) syphilis without neurologic involvement : :
Benzathine penicillin administered as three doses of Benzathine penicillin administered as three doses of
2.4 million units IM each at 1-week intervals.2.4 million units IM each at 1-week intervals.
NeurosyphilisNeurosyphilis::
AqueousAqueous crystalline penicillin crystalline penicillin GG 18-24 18-24 million units per day, million units per day,
administered as 3-4 million units IV every 4 hours or administered as 3-4 million units IV every 4 hours or
continuous infusion for 10-14 days IVcontinuous infusion for 10-14 days IV

19. Issues related to treatmentIssues related to treatment
Penicillin Allergy: 5-10 %.... verify, desensitize.Penicillin Allergy: 5-10 %.... verify, desensitize.
Jarisch - Herxheimer reaction.Jarisch - Herxheimer reaction.
In pregnant women , missed doses are not In pregnant women , missed doses are not
considered acceptable, and the full course of considered acceptable, and the full course of
therapy must be repeated.therapy must be repeated.
Long-term sex partners of patients who have
latent syphilis should be evaluated clinically and
serologically for syphilis and treated on the basis
of the evaluation findings.

20. Evaluation after treatmentEvaluation after treatment**
primary syphilis:
* should be re-examined clinically and serologically 1, 3, 6, 12, 24 M. * should be re-examined clinically and serologically 1, 3, 6, 12, 24 M.
by 6th m: at least X4 decline in titer.by 6th m: at least X4 decline in titer.
by 8by 8
thth
m: X8 decline in titer m: X8 decline in titer..
by 24by 24
thth
m : x16 decline in titer m : x16 decline in titer..

Secondary syphilis:
by 6by 6
thth
m:x8 m:x8
by 12by 12
thth
m: x16 m: x16
latent syphilis
* * should be followed up clinically and serologically at 6, 12, and 24 monthsshould be followed up clinically and serologically at 6, 12, and 24 months
early latent: 12early latent: 12
thth
m: x4 m: x4

Note: Latent/late: more gradual decline, persistent low titer in 50% of patients after 2 Note: Latent/late: more gradual decline, persistent low titer in 50% of patients after 2
yearsyears..
**Public Health Agency of CanadaPublic Health Agency of Canada..
Canadian Guidelines on Sexually Transmitted Infections,2008Canadian Guidelines on Sexually Transmitted Infections,2008

22. Causes of treatment failureCauses of treatment failure
High RPR titer at time of Dx/ delivery.High RPR titer at time of Dx/ delivery.
Delivery ≤ 36 w.Delivery ≤ 36 w.
Short interval between treatment and Short interval between treatment and
delivery(≤ 30 d).delivery(≤ 30 d).
Non penicillin regimen.Non penicillin regimen.

23. Indications of probable treatment Indications of probable treatment 
failure / reinfection includefailure / reinfection include::
–Persistent or recurring signs or symptoms .Persistent or recurring signs or symptoms .
–Sustained fourfold Sustained fourfold increaseincrease in nontreponemal titer OR in nontreponemal titer OR
Failure of nontreponemal titers to decline X4 within 6M Failure of nontreponemal titers to decline X4 within 6M
POST Rx for primary or secondary syphilis: POST Rx for primary or secondary syphilis:
* re-treat* re-treat
*R/O HIV infection.*R/O HIV infection.
* CSF examination * CSF examination
Note:Note:
retreatment regimen:retreatment regimen:
weekly injections of benzathine penicillin G 2.4 million weekly injections of benzathine penicillin G 2.4 million
units IM for 3 weeks are recommended, unless CSF units IM for 3 weeks are recommended, unless CSF
examination indicates that neurosyphilis is present.examination indicates that neurosyphilis is present.

24. Congenital syphilisCongenital syphilis
The risk of vertical transmission (in utero/during delivery) The risk of vertical transmission (in utero/during delivery)
depends primarily on the stage of maternal syphilisdepends primarily on the stage of maternal syphilis: :
 untreated primary or secondary syphilis: 70% to 100%untreated primary or secondary syphilis: 70% to 100%
 early latent syphilis: 40% (as she remains at risk of early latent syphilis: 40% (as she remains at risk of
reactivation).reactivation).
late latent syphilis/tertiary: less than 10%. late latent syphilis/tertiary: less than 10%.
Note: the risk is extremely high for the Note: the risk is extremely high for the first four yearsfirst four years
after maternal acquisition of infection (untreated) where after maternal acquisition of infection (untreated) where
spirochetemia in pregnancy is common.spirochetemia in pregnancy is common.
Remember: 50% born Remember: 50% born asymptomatic,asymptomatic, manifestations can manifestations can
be shown up to 2 years of age (late congenital syphilis): be shown up to 2 years of age (late congenital syphilis):
usually 2w-3m post delivery: skin rash ulcers, fever, weak usually 2w-3m post delivery: skin rash ulcers, fever, weak
cry, hepatosplenomegaly, jaundice, anaemia, bone cry, hepatosplenomegaly, jaundice, anaemia, bone
deformities.deformities.

26. Postpartum management issuesPostpartum management issues
RememberRemember: : Even with appropriate penicillin therapy, up to 10 per Even with appropriate penicillin therapy, up to 10 per
cent of infants will be found to have active disease after birth.cent of infants will be found to have active disease after birth.
Serologic testing of maternal blood at the time of delivery is Serologic testing of maternal blood at the time of delivery is
superior to infant testing( FP/FN). superior to infant testing( FP/FN).
Umbilical cord blood testing is not recommended.Umbilical cord blood testing is not recommended.
 Treatment decisions need to be made on the basis of maternal Treatment decisions need to be made on the basis of maternal
history and treatment:history and treatment:
Was the mother treated? Was she treated adequately? Was the mother treated? Was she treated adequately?
Was she treated with a non-penicillin regimen?Was she treated with a non-penicillin regimen?
Was she treated <4 weeks before delivery? Was she treated <4 weeks before delivery?
Has she had a fourfold decrease in titer after treatment? Has she had a fourfold decrease in titer after treatment?
Does the infant have clinical signs ? Does the infant have clinical signs ?
A comparisonA comparison of maternal and infant non-treponemal test titers is of maternal and infant non-treponemal test titers is
very helpful for guiding therapyvery helpful for guiding therapy. .
Infectious Diseases and Immunization CommitteeInfectious Diseases and Immunization Committee , Canadian Paediatric Society (CPS) , Canadian Paediatric Society (CPS)
Paediatr Child Health 2009;14(5):337 Paediatr Child Health 2009;14(5):337

27. Case scenario 1Case scenario 1
LL.B. is a 26 y/o G3P2 at 18 weeks gestation who has a history of "venereal .B. is a 26 y/o G3P2 at 18 weeks gestation who has a history of "venereal
disease " four years ago. She was treated with 3 shots" at that time. disease " four years ago. She was treated with 3 shots" at that time.
Current new prenatal labs reveal a reactive RPR with a titer of Current new prenatal labs reveal a reactive RPR with a titer of 1:41:4 and a and a
reactive FTA.reactive FTA.
How should she be managed nowHow should she be managed now ? ?
a. repeat serology at 28 weeks/deliverya. repeat serology at 28 weeks/delivery
b. treat her right away with penicillinb. treat her right away with penicillin..
c. reassure her, no further work upc. reassure her, no further work up..
d. none of the aboved. none of the above
e. I do not know, I will ask for helpe. I do not know, I will ask for help..



Serofast low antibody titers might not require treatment; however, persistent higher
titer antibody tests might indicate reinfection and require treatment.
CDS,MMWR, STD Rx guidelines, August 2006

28. Case scenario 2Case scenario 2
..R.H. is an 18 y/o G1P0 at 10 weeks gestation whose new R.H. is an 18 y/o G1P0 at 10 weeks gestation whose new
prenatal labs reveal a prenatal labs reveal a nonreactivenonreactive RPR/FTA . She has no RPR/FTA . She has no
history of sexually transmitted disease but her history of sexually transmitted disease but her husbandhusband
has just diagnosed recently with has just diagnosed recently with HIV/Syphilis coinfectionHIV/Syphilis coinfection.. ..
How should she be managedHow should she be managed? ?
a. repeat serology at 4-6wa. repeat serology at 4-6w. .
b. repeat serology at 28w/delivaryb. repeat serology at 28w/delivary..
d. reassure her, no further work upd. reassure her, no further work up..
e. I do not know, I will ask for helpe. I do not know, I will ask for help..

for patients at high risk, serologic testing should be performed
twice during the third trimester, at 28 to 32 weeks'
gestation and at delivery.

29. Case scenario 3Case scenario 3
DD. F. is a 21 y/o G4P1 at 14 weeks gestation who has ANC labs that . F. is a 21 y/o G4P1 at 14 weeks gestation who has ANC labs that
reveal a reveal a nonreactivenonreactive RPR and a RPR and a reactivereactive FTA. She has no history FTA. She has no history
of treatment and her physical exam is normalof treatment and her physical exam is normal..
How should you manageHow should you manage??
a. no action, pregnancy can cause a biological false a. no action, pregnancy can cause a biological false
positive FTA.positive FTA.
b. repeat RPR test in 4-6 weeks.b. repeat RPR test in 4-6 weeks.
c. treat her with Penicillin, 3 shots, each is a week c. treat her with Penicillin, 3 shots, each is a week
apart. apart.
e. none of the above.e. none of the above.

she should be treated for late latent syphilis and it
should be assumed that there is some risk of vertical
transmission.

30. TAKE HOME MESSAGESTAKE HOME MESSAGES
All All pregnant women should be screened for syphilis.pregnant women should be screened for syphilis.
AbortionAbortion due to syphilis is due to syphilis is uncommon uncommon during the early pregnancy: during the early pregnancy:
as in utero infection is usually acquired after 4as in utero infection is usually acquired after 4
thth
month of gestation month of gestation
after the formation of placenta.after the formation of placenta.
Sequential serologic tests should be performed by Sequential serologic tests should be performed by using the using the samesame
testing methodtesting method (e.g., VDRL or RPR:RPR titers frequently are (e.g., VDRL or RPR:RPR titers frequently are
slightly higher than VDRL titers ).slightly higher than VDRL titers ).
20%20% of of PRIMARYPRIMARY S: Both treponemal and nontreponemal tests S: Both treponemal and nontreponemal tests
can produce can produce nonreactive.nonreactive.
Nontreponemal test titers might decline more slowly for persons Nontreponemal test titers might decline more slowly for persons
who previously had syphilis (who previously had syphilis (serofast reactionserofast reaction).).
The results of serological test of syphilis should be carefully The results of serological test of syphilis should be carefully
interpreted in a interpreted in a geographical areageographical area like Saudi Arabia where both like Saudi Arabia where both
venereal syphilis and Bejel co-exist.venereal syphilis and Bejel co-exist.

31. Thank youThank you
Have a wonderful dayHave a wonderful day