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 whoL.B. is a 26 y/o G3P2 at 18 weeks gestation who
has H/O"venereal disease " four years ago. Shehas H/O"venereal disease " four years ago. She
was treated with 3 shots at that time. Currentwas treated with 3 shots at that time. Current
new prenatal labs reveal anew prenatal labs reveal a reactivereactive RPR with aRPR with a
titer oftiter of 1:41:4 and aand a reactivereactive 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 penicillinb. 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 gestationR.H. is an 18 y/o G1P0 at 10 weeks gestation
whose new prenatal labs reveal awhose new prenatal labs reveal a reactivereactive RPR atRPR at
a titer of 1:2 and aa titer of 1:2 and a reactivereactive FTA. She has noFTA. She has no
history of STD but her husband has justhistory 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 whoD. F. is a 21 y/o G4P1 at 14 weeks gestation who
has ANC labs that reveal ahas ANC labs that reveal a nonreactivenonreactive RPR andRPR and
aa reactivereactive FTA. She has no history of treatmentFTA. 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 aa. 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 ac. 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 BEWHEN SHOULD SYPHILIS BE
SUSPECTED IN A PREGNANT WOMAN?SUSPECTED IN A PREGNANT WOMAN?
 HOW SHOULD SYPHILIS SEROLOGYHOW SHOULD SYPHILIS SEROLOGY
BE INTERPRETED?BE INTERPRETED?
 WHICH WOMEN WITH REACTIVEWHICH WOMEN WITH REACTIVE
TREPONEMAL TESTS HAVE BEENTREPONEMAL TESTS HAVE BEEN
ADEQUATELY TREATED BEFOREADEQUATELY TREATED BEFORE
PREGNANCY?PREGNANCY?

6. WHEN SHOULD SYPHILIS BEWHEN 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 withwith a person who was infected with
syphilis within thesyphilis within the preceding year.preceding year.
 If the cause is not known for a hydropic orIf 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 bepregnant women must be
assumed to be at risk.assumed to be at risk.

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

8. Why universal early antepartamWhy 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 isdeveloped 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 BEHOW SHOULD SYPHILIS SEROLOGY BE
INTERPRETEDINTERPRETED??
Nontreponemal testNontreponemal test Treponemal testTreponemal test interpretationinterpretation
NonreactiveNonreactive Reactive/IndeterminateReactive/Indeterminate • Early 1Early 1ْْsyphilis.syphilis.
• Late latent/ 3Late latent/ 3 ْْsyphilis.(3)syphilis.(3)
• Previously treatedPreviously treated
syphilis.syphilis.
• Endemic syphilisEndemic syphilis
ReactiveReactive NonreactiveNonreactive False positiveFalse positive
ReactiveReactive ReactiveReactive • Syphilis at any stage.Syphilis at any stage.
• Old treated syphilisOld treated syphilis
(serofast).(1)(serofast).(1)
• Follow up of treatmentFollow up of treatment
• Endemic syphilis.Endemic syphilis.
ReactiveReactive IndeterminateIndeterminate • Early 1Early 1ْْsyphilis.syphilis.
• Late latent/ 3Late latent/ 3 ْْsyphilis.syphilis.
• Previously treatedPreviously 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%
withwith 0.85%0.85% positivity among the pregnant womenpositivity 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 earlyuntreated syphilis :+ even in early
primary cases were RPR/TPHA mayprimary 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 singleIM, 2.4 million units in a single
dose.dose.
* additional therapy* additional therapy a second dosea second dose of benzathine penicillinof benzathine penicillin
2.4 million units IM administered 1 week after the initial2.4 million units IM administered 1 week after the initial
dose to improve the likelyhood of serologic response indose 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 2.4Benzathine 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 ofBenzathine 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 penicillincrystalline penicillin GG 18-2418-24 million units per day,million units per day,
administered as 3-4 million units IV every 4 hours oradministered 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 notIn pregnant women , missed doses are not
considered acceptable, and the full course ofconsidered 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 8thth
m: X8 decline in titerm: X8 decline in titer..
by 24by 24thth
m : x16 decline in titerm : x16 decline in titer..
Secondary syphilis:
by 6by 6thth
m:x8m:x8
by 12by 12thth
m: x16m: 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: 12thth
m: x4m: x4
Note: Latent/late: more gradual decline, persistent low titer in 50% of patients after 2Note: 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 andShort 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 fourfoldSustained fourfold increaseincrease in nontreponemal titer ORin nontreponemal titer OR
Failure of nontreponemal titers to decline X4 within 6MFailure 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 millionweekly injections of benzathine penicillin G 2.4 million
units IM for 3 weeks are recommended, unless CSFunits 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 ofearly 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 theNote: the risk is extremely high for the first four yearsfirst four years
after maternal acquisition of infection (untreated) whereafter maternal acquisition of infection (untreated) where
spirochetemia in pregnancy is common.spirochetemia in pregnancy is common.
 Remember: 50% bornRemember: 50% born asymptomatic,asymptomatic, manifestations canmanifestations 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, weakusually 2w-3m post delivery: skin rash ulcers, fever, weak
cry, hepatosplenomegaly, jaundice, anaemia, bonecry, hepatosplenomegaly, jaundice, anaemia, bone
deformities.deformities.

26. Postpartum management issuesPostpartum management issues
 RememberRemember:: Even with appropriate penicillin therapy, up to 10 perEven 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 isSerologic 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 maternalTreatment 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 isof 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):337Paediatr 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 ofCurrent new prenatal labs reveal a reactive RPR with a titer of 1:41:4 and aand 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 newR.H. is an 18 y/o G1P0 at 10 weeks gestation whose new
prenatal labs reveal aprenatal labs reveal a nonreactivenonreactive RPR/FTA . She has noRPR/FTA . She has no
history of sexually transmitted disease but herhistory of sexually transmitted disease but her husbandhusband
has just diagnosed recently withhas 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 areveal a nonreactivenonreactive RPR and aRPR and a reactivereactive FTA. She has no historyFTA. 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 falsea. 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 weekc. 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
 AllAll pregnant women should be screened for syphilis.pregnant women should be screened for syphilis.
 AbortionAbortion due to syphilis isdue to syphilis is uncommonuncommon during the early pregnancy:during the early pregnancy:
as in utero infection is usually acquired after 4as in utero infection is usually acquired after 4thth
month of gestationmonth of gestation
after the formation of placenta.after the formation of placenta.
 Sequential serologic tests should be performed bySequential serologic tests should be performed by using theusing 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% ofof PRIMARYPRIMARY S: Both treponemal and nontreponemal testsS: Both treponemal and nontreponemal tests
can producecan produce nonreactive.nonreactive.
 Nontreponemal test titers might decline more slowly for personsNontreponemal 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 carefullyThe results of serological test of syphilis should be carefully
interpreted in ainterpreted in a geographical areageographical area like Saudi Arabia where bothlike 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