2. Risk of Transmission : The likely hood of MTCT is
directly related to the
– Stage of maternal syphilis during pregnancy
– Primary
– Secondary
– Tertiary
– Stage of pregnancy at which infection is acquired
– In early maternal syphilis the maternal foetal transmission
rate is as much as 80%
– The concentration of spirochetes in the blood is highest
during the first two years after acquiring the infection
– It decreases slowly as a result of acquired immunity
EMTCT of Syphilis:
3. Stage Characterization
Primary
syphilis
Localized infection at site of inoculation (Chancre-
painless ulcer)
Secondary
syphilis
Disseminated infection-one area to other area/organ of
the body (Exanthem, Maculopapules, Condylomata lata )
Latent
syphilis
No clinical signs or symptoms of infection (Seropositive)
Early <1-year duration; any period between primary and
secondary stage
Late >1 year since patient became infected
Syphilis of unknown duration
Late (tertiary)
syphilis
Cutaneous, vascular, neurologic findings
Congenital
syphilis
Acquired perinatally; Early and Late clinical findings
4.
5. Epidemiology and Etiology
Etiology
• Treponema pallidum is a thin delicate spirochete with 6 to 14
spirals. Only natural host for T. pallidum is the Human.
Age of Onset
• In decreasing order:
– 20 - 39 years
– 15 - 19 years
– 40 - 49 years
• Sex
• Males outnumber females 2:1 to 4:1.(different studies: serological
marker)
•
6. Epidemiology and Etiology
Transmission
• Sexual contact: Contact with infectious lesion
(chancre, mucous patch, condyloma latum,
cutaneous lesions of secondary syphilis). 60% of
contacts of persons with primary and secondary
syphilis become infected.
• Congenital infection: In utero or Perinatal
transmission.
• Blood products: One-half of cases named as
contacts of infectious syphilis become infected.
7. 7
Pathology
• Penetration:
– T. pallidum enters the body via Skin and Mucous
membranes through abrasions during Sexual contact
– Transmitted transplacentally from mother to fetus
during pregnancy
Pathogenesis
8. 8
• Dissemination:
– Travels via the Circulatory system (including the
lymphatic system and regional lymph nodes) throughout
the body
– Invasion of the Central Nervous Cystem (CNS) can occur
during any stage of syphilis.
Pathogenesis
9. Course and Prognosis
• Even without treatment, chancre heals
completely in 4 to 6 weeks, the infection either
becoming latent or clinical manifestations of
secondary syphilis appearing.
• Secondary syphilis usually manifests as macular
exanthem initially; after weeks, lesions resolve
spontaneously and recur as maculopapular or
papular eruptions.
• In 20% of untreated cases, up to three to four
such recurrences followed by periods of clinical
remission may occur over a period of 1 year.
10. • Thereafter, infection enters a Latent stage, in
which there are no clinical signs or symptoms of
the disease.
• After untreated syphilis has persisted for >4
years, it is rarely communicable, except in the
case of pregnant women, who, if untreated, may
transmit syphilis to their foetuses, regardless of
the duration of their disease.
• One-third of patients with untreated latent
syphilis developed clinically apparent Tertiary
disease.
11. Type of Test
Serological Diagnosis of Maternal Syphillis.
• Non Treponema Test ( NTT) Non treponemal tests are
screening tests, very rapid and relatively simple, but need to be
confirmed by treponemal tests. Nontreponemal tests are an
indirect method in that they detect biomarkers that are
released during cellular damage that occurs from the syphilis
spirochete. (VDRL/RPR are NTT.
• Treponoma Test: This test detect antibody to T pallidum It can
be used to find syphilis except during the first 3 to 4 weeks
after exposure.
• Both tests are used to confirm the infection and determine
whether the disease is active.
12.
13. National Algorithm for Screening and Management of
Syphillis in PW
• PW Arrives at PHC with Laboratory/CHC/SDH/DHH
• PW Arrives at VHSND/SC/PHC having to laboratory
• PW Arrives Directly in Labour
14. Situation 1:PW Arrives at PHC with Laboratory/CHC/SDH/DHH
– Register for ANC
– Test for Qualitative & Quantitative RPR/VDRL
– If test result is non reactive , Retest high risk mother at third trimester
or at labour
– High Risk Mother for Syphillis: ( History of STI in past, more than
one sexual patner, sex workers and IDUs)
– History of repeated abortion , still birth, Premature baby and
neonatal death etc
– Whose partners are not treated for Syphillis
– If the test Result is Reactive:
– Conduct TPHA Test if available to confirm Syphillis
– Immediately treat PW and her spouse with BPG
– Ensure Institutional Delivery for mother especially at FRUs
where paediatrician is there
– Repeat titre test after delivery to PW and new born baby and
– Assess infant for treatment.
15. Situation 2: PW Arrives at VHSND/SC/PHC having to
laboratory
– Register ANC
– Perform test using POC/Dual RDT (Combo Kits)
– If test result is non reactive , Retest high risk mother at third
trimester or at labour
– High Risk Mother for Syphillis: ( History of STI in past, more than one sexual patner,
sex workers and IDUs)
– History of repeated abortion , still birth, Premature baby and neonatal death etc
– Whose partners are not treated for Syphillis
– If test Result is Reactive-Refer PW to nearest DSRC/DHH
• Test PW with Quatitative & Qualitative RPR/VDRL
• If test is non reactive , retest high risk mother at 3rd trimester or at
labour
• If test is reactive
– Conduct TPHA Test if available to confirm Syphillis
– Immediately treat PW and her spouse with BPG
– Ensure Institutional Delivery for mother
– Repeat titre test after delivery to PW and new born baby and
– Assess infant for treatment
16. Situation 3: PW Arrives Directly in Labour
– Test PW with RPR/POC
– If non reactive no issue
– If Reactive
– Conduct TPHA Test if available to confirm Syphillis
– Immediately treat PW and her spouse with BPG
– Ensure Institutional Delivery for mother
– Repeat titre test after delivery to PW and new born baby
and
– Assess infant for treatment
17. Key Points:
• While testing, partners of syphilis reactive PW can
be conducted and they have to be treated promptly
irrespective of test results.
• Treatment using non penicillin regimen is considered
inadequate for the prevention of mother to child
transmission of Syphillis
• BPG administered less than 4 weeks before delivery
is also considered inadequate for prevention of
congenital Syphillis
• Syphillis reactive mothers delivery to be conducted
at FRUs where Paediatrician is there to draw the
Venus blood of newborn for titre test
• Syphillis reactive mother to be tested again at 6
months after initiation of treatment.
18. • To ensure that results are comparable , follow
up tests should be performed by using the
same RPR/VDRL test that was used initially
• The RPR/VDRL titre is expected to decrease
four fold by the six months
• The rate of sero reversion depends on the pre
treatment titre & Stage of disease
19. Treatment for Maternal Syphillis
NHM/NACO/WHO strongly recommends: IM injection of BPG as the
most effective treatment for maternal Syphillis ( except for those who
are allergic to Penicillin)
Four Steps prior to BPG
• Step1: Assess patient Eligibility
• Step2: Determine BPG Dosage
• Step3: Administer IM BPG Injection
• Step4: Observe patient for signs of Anaphylactic Shock
Step1:
– Assess test Results: Must be reactive in ( RPR/VDRL/TPHA/POC/combo
Kit)
– Identify the stages of Client
• Early : Mouth sore/rash/Asymptomatic: Infected for < 2 yrs( titre is <1.8)
• Latent : Asymptomatic: Infected for > 2 yrs( titre is >1.8)
• Ensure the client is not allergic to penicillin ( no history of anaphylaxis)
After assessing the eligibility follow the step 2 for dosages……………….
20. Step2: BPG Dosage
RPT Titre Value /
Stage of Infection
Recommended
Regimen
Alternative Regimens( only if allergic to
penicillin)
Titre <1.8
Early Stage
2.4 IU BPG IM
Injection single
dose
-Erythromycin 500mg/orally, 4
dosages/day for 15 days
-Azithromycin 2 g orally in 1 dose
Titre >1.8
Late Stage
2.4 IU BPG IM
Injection Weekly
for 3 Weeks
-Erythromycin 500mg/orally, 4
dosages/day for 30 days
-Azithromycin 2 g orally in 1 dose
21. Step3: Administer BPG Injection
• Penicillin sensitive test to be done, in case of adverse
signs consider alternative treatment regimen
• Administer in to ventrogluteal or dorsogluteal area of
buttock/Vastus laterals of thighs, alternating on each
administration
• BPG Should not be given in to the Deltoid muscle of the
upper arm
• Deliver medication in slow steady rate ( 2 to 3 min
preferably)
• Never administer BPG on intravenous administration
• Avoid IM inj of these suspensions near major nerves or
blood vessels ( as it may lead to neurovascular damage)
22. Step 4: Observe patient for sign of Anaphylactic Shock
• In extremely rare cases BPG may cause anaphylaxis ( 0.01% chances)
• Observe patient for minimum 10 minutes for the following signs and symptoms
• Discomfort in breathing
• Shock
• Itchy rashes or hives
• Call for Help-Preferably a Doctor
• Check: Airways, Breathing-give mouth to mouth respiration, Circulation ( prefer
CPR if necessary)
• If Anaphylaxis :
– Give Adrenaline IM
– Give Hydrocortisone IM
– Give Chlorpheniramine IM
• Transfer patient to hospital
• Repeat adrenaline if necessary
• Record all Details of treatment
23. Congenital Syphillis (CS)
• Congenital Syphillis is easily preventable
• Its Curable
• Can be eliminated by effective screening of
PW for syphilis & providing adequate
treatment to those who are found to be
reactive
• Guideline of MoH & FW, India & WHO strongly
recommends for Penicillin as the most
effective treatment for syphilis
24. • After delivery of Live born infant from syphilis Reactive
Mother
– Conduct Physical examination of baby for sign of Syphillis . At
least any two of the following
• Swelling of joints
• Jaundice
• Hepatosplenomegaly ( enlarged Spleen & liver)
• Anaemia
• Bullious Skin Lesions. (large, fluid-filled blisters)
• Snuffles.( Running nose etc)
• Radiological Changes in long bones
– Extract 2ml of Venus blood from baby and also mother for
titre test
– Then follow the recommended treatment protocol of WHO
Management of Infant in Risk of Congenital Syphillis
25. Treatment Protocol for Baby
Prophylactic Treatment
-Regimen1
• IM Injection
• Inj. Benzathine
penicillin G
50,000
units/kg given
as a single
intramuscular
Curative Treatment
Regimen2
• I.V. Injection:
• Aqueous crystalline penicillin G 50,000
units/kg/dose IV every 12 hours during
the first 7 days, and thereafter 8 hrly. x
3 days
OR
• IM treatment regimen:
• Inj. Procaine penicillin 50,000 units/kg
bw IM single daily dose x 10 days
Infants are never Allergic to Penicillin
If more than one day of treatment is missed, the entire course of treatment
should be restarted.
26. Conditions for Prophylactic Treatment for baby
Conditions:
• If the baby is not
symptomatic
• If the mother is treated
adequately
• If the infants RPR titre is
four times lower than the
titre of the mother
Then.....
Inj. Benzedrine penicillin G
Mother treatment is adequate if :
• PW treated at least for 4
weeks prior to Delivery
AND
• PW treated with complete
recommended dosage
Conditions for Prophylactic Treatment for baby
27. Conditions:
• If the baby is symptomatic
( any two symptoms)
• If the mother is not
treated adequately.
• If the infants RPR titre is
four times higher than the
titre of the mother
Then.....
Refer the Regimen 2
Regimen-2
• Aqueous crystalline penicillin G
50,000 units/kg/dose IV every
12 hours during the first 7 days,
and thereafter 8 hrly. x 3 days
OR
• Inj. Procaine penicillin 50,000
units/kg bw IM single daily dose
x 10 days
Infant should be Retested at 6 months and followed up at least
24 months/2 years of age
Conditions for Curative Treatment for baby
28. Thank you
No Child should be born with Syphillis /HIV….
No Child should die because of Syphilis/HIV…
No Child become an orphan because of
Syphillis/HIV.....
11/13/2022 28
