MANAGEMENT OF SYPHILIS IN PREGNANCY CLINICAL GUIDELINES

Register No: 10083

Status: Public

Developed in response to: Intrapartum NICE Guidelines

RCOG guideline
Contributes to CQC Regulation 9,12

Consulted With Post/Committee/Group Date

Anita Rao/ Clinical Director for Women’s, Children’s Division February 2018
Alison Cuthbertson
Vidya Thakur Consultant for Obstetrics and Gynaecology
Dr Hassan Consultant Paediatrician
Alison Cuthbertson Associate Director of Midwifery/Nursing
Paula Hollis Lead Midwife Acute Inpatient Services
Chris Berner Lead Midwife Clinical Governance
Ros Bullen-Bell Lead Midwife Community Services
Sarah Iskander Antenatal Clinic Midwife
Sarah Moon Specialist Midwife Guidelines and Audit
Dr Price Consultant GUM
Deborah Lepley Warner Library
Professionally Approved By
Miss Rao Lead Consultant for Obstetrics and Gynaecology February 2018

Version Number 4.0

Issuing Directorate Women’s and Children’s
Ratified By DRAG Chairmans Action
Ratified On 10th April 2018
Implementation Date 17th April 2018
EMG Sign off Date April/May 2018
Next Review Date March 2021
Author/Contact for Information Emma Neate, Antenatal Newborn Screening Co-ordinator
Policy to be followed by Midwives, Obstetricians, Paediatricians
Distribution Method Intranet & Website. Notified on Staff Focus
Related Trust Policies (to be 04071 Policy for Standard Infection Prevention Precautions
read in conjunction with) 04072 Hand Hygiene Policy
06036 Maternity Record Keeping including Documentation in Handheld
Records
06031 Receiving and Acting on Test Results in Maternity by both Hospital
and Community
09062 Maternity Care
08056 Guideline for the Management of HIV in Pregnancy
07011 Confidentiality and Data Protection Policy
Document History Review:
Review No: Reviewed by: Issue Date:
1.0 Nicky Leslie October 2009
2.0 Nicky Leslie February 2012
2.1 Nicky Leslie – clarification to point 11.0 September 2012
3.0 Nicky Leslie, Antenatal Newborn Screening Co-ordinator March 2015
3.1 Nicky Leslie – clarification to 8.4 and Appendix C June 2016
4.0 Emma Neate – Full review 17 April 2018

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INDEX

1. Purpose

2. Equality and Diversity

3. Background

4. Aetiology

5. Classification

6. Routine Screening in Antenatal Clinic

7. Declined Screening

8. Failsafe of Screening Results

9. Women presenting in Labour without an Antenatal Booking

10. Antenatal Management of Syphilis Positive Mothers

11. Complications of Pregnancy

12. Neonatologist Review

13. Intrapartum Management

14. Postpartum Management

15. Staff and Training

16. Infection Prevention

17. Audit and Monitoring

18. Guideline Management

19. Communication

20. References

Appendix A – Neonatal Alert Form

Appendix B – Receiving Syphilis Blood Results
Appendix C – Syphilis positive Proforma

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1.0 Purpose

1.1 To provide a guideline on the management of syphilis in pregnancy and to prevent

mother-to-child transmission of infection.

1.2 Untreated syphilis has serious maternal, fetal and neonatal consequences.

2.0 Equality and Diversity

2.1 Mid Essex Hospital Services NHS Trust is committed to the provision of a service that is
fair, accessible and meets the needs of all individuals.

3.0 Background

3.1 This guideline is written with reference to the UK National Guidelines on the
Management of Syphilis 2015, the Infectious Diseases in Pregnancy Screening
Standards 2016 and the British Association for Sexual Health and HIV (BASHH).

3.2 To identify and treat maternal syphilis as early as possible in the pregnancy.

3.3 To reduce the spread of syphilis infection to the fetus.

3.4 Congenital syphilis occurs when syphilis is transmitted from a woman to her unborn
baby during pregnancy. This can lead to miscarriage, stillbirth, neonatal death, or
disorders such as deafness and bone deformities. Antenatal screening and appropriate
treatment can reduce the risk of mother to baby transmission. Transmission can occur
via the placenta at any stage of the pregnancy. In England the uptake of antenatal
screening for infectious syphilis has been >95% (2005 to 2012) of those screened,
0.15% had an initial positive result but less than a third of these had an active infection
that required treatment.

3.5 Management should be in collaboration between the Obstetric Consultant, the

Consultant in Genitourinary medicine and the Paediatric Consultant.

4.0 Aetiology

4.1 Syphilis is caused by a bacteria-like spirochete Treponema Pallidum. Transmission

occurs during sexual intercourse, via infected blood products, mother-to-child
transmission via the placenta or with direct contact with a syphilis chancre.

5.0 Classification

5.1 Syphilis is classified as acquired or congenital.

5.2 Acquired syphilis is divided into early (primary, secondary and early latent < 2 years of
infection) or late (late latent > 2 years of infection) as follows:

• Primary syphilis is characterised with a lesion (chancre) and regional

lymphadenopathy

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 • Secondary syphilis occurs if primary syphilis remains untreated. Multisystem
involvement, with a rash, general malaise and pyrexia characterise secondary
syphilis
• Tertiary syphilis is a further progression if syphilis remains untreated. Gummatous,
cardiovascular and neurological disease occurs in the tertiary stage.

5.3 Congenital syphilis is divided into early (less than 2 years) or late (more than 2 years).

6.0 Routine Screening in Antenatal Clinic

6.1 All pregnant women are offered a screening at their booking for infectious diseases:
• Human immunodeficiency virus (HIV)
• Syphilis
• Hepatitis B

6.2 Informed consent must be obtained prior to the specimen being taken

6.3 All pregnant women should be provided with written information ‘Screening tests for you
and your baby’ prior to their booking appointment. This is available in English and 12
other languages, via www.gov.uk/government/publications/screening-tests-for-you-and-
your-baby-description-in-brief. For women who do not have English as a first language,
they must be offered interpreting services to help them make an informed choice about
screening. It is not acceptable to use friends or family to translate.

6.4 When the midwife completes the woman’s booking and discusses the various blood
tests; bloods must be taken at booking or within 5 days for the booking (where not
possible at booking). The booking midwife should review the blood results within 10
days of the sample being taken and for them to follow up with women for samples to be
taken or repeated where required.

6.5 The midwife should clearly document whether the screening has been accepted or
declined and whether a blood sample has been obtained in the handheld notes.

6.6 All women with a positive result require a second confirmatory blood sample and will be
contacted by the Screening Team and urgently referred to an appropriate specialist
(Sexual Health Department).

6.7 Offer of bloods to late bookers

Women who book after 24 weeks of pregnancy should have blood samples marked as
urgent. Test results should be available after 24 hours of receipt of sample at
laboratory.

7.0 Declined Screening

7.1 Where women decline screening tests the midwife who offered the initial screening
should inform them they will be contacted by the Screening Team to discuss their
choices.

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 • Women should be contacted by the Screening team as soon as possible and ideally
before 20 weeks to discuss their decision to decline screening and ensure that they
are fully aware of the benefits of screening for infectious diseases for them and their
baby.

• Reoffer the screening test and arrange testing and follow up of results.

• The onus of the reoffer is to facilitate an informed choice and not to coerce women to
accept screening.

8.0 Failsafe of Screening Results

8.1 Maternity Phlebotomist will review all women on the daily scan list for 1st trimester
scans, they review all the screening results and check for completion of screening –
these results are checked by a Antenatal Clinic or Screening Midwife, if any results are
missing; these bloods will be taken with consent after the scan.

8.2 The Failsafe Officer will carry out a failsafe check following the woman’s 1st trimester
scan to ensure all screening results are available and to highlight any that are abnormal
to the screening midwives; this acts as a failsafe for abnormal results also. If any
results are found to be missing, the following steps are followed.

• Screening team will send one letter to the woman regarding the need to have
bloods taken.
• Screening team will develop a missing bloods list – send to ANC, WJC, St Peter’s,
Chelmsford community team each month and for the teams to contact and
arranging screening for the women within the following 2 weeks.

9.0 Women Presenting in Labour without an Antenatal Screening Blood Result

9.1 Women presenting in labour, who have not been previously for antenatal care, at the
Trust are recommended to be offered testing for HIV, Hep B, and Syphilis on first
contact. The sample should be marked as urgent. Results should be available within
24hrs.

10.0 Antenatal Management of Syphilis Positive Mothers

10.1 High risk blood results are referred to the Antenatal and Screening Team by virology
team in the laboratory; this is communicated via telephone and email to screening
generic email address

10.2 A second blood sample is required to confirm a positive syphilis. Confirmation testing is
carried out at the Sexually Transmitted Bacterial Reference Laboratory. Results should
be available after 5 working days, as extra time is required transporting specimens and
receiving results.

10.3 The Antenatal Screening Team will contact the patient. A referral to the Consultant in
the Genitourinary medicine (GUM) will be booked, along with an appointment in
Antenatal clinic with the Obstetric Consultant Lead for Infectious Diseases, after the
GUM appointment.

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10.4 The Antenatal Screening Team will commence a syphilis positive profoma and secure in
the patient’s hospital records.
(Refer to Appendix C)

10.5 All syphilis positive patients presenting in the Genitourinary Medicine Clinic will be
assessed for the following:

• Management of maternal treatment requirements

• Screening for HIV, Hepatitis B and C
(Refer to HIV ‘Management of Human Immunodeficiency Virus (HIV) in pregnancy’;
register number 08056)
• Women with a history of a treated infection should still be referred to the Consultant
in Genitourinary medicine clinic though further treatment might not be required
• Treatment with antibiotics is individualised depending on the stage of infection
• Follow up bloods, to check the efficiency of the treatment will be arranged by the
Genitourinary Medicine Clinic.

10.6 All pregnant women are treated according to National guidelines and are assessed
individually by the Consultant in Genitourinary medicine.

10.7 Data is collected quarterly for positive results and the information is shared with the
Antenatal Syphilis Screening (SASS) in association with the RCOG and National
screening Committee (NSC). This study is linked to a surveillance system for
congenital syphilis.

10.8 In line with MEHT guidance, patient confidentiality must be adhered to. Documentation
in the handheld records, including printed blood results must be with patient consent.
All other documentation must be placed in the hospital records.
(Refer to ‘Confidentiality and Data Protection Policy’; register number 07011)

11.0 Complications of Pregnancy

11.1 Vertical transmission may result in polyhydramnios, pre-term labour, hydrops,

intrauterine growth retardation (IUGR), hepatosplenomegaly or congenital syphilis.

11.2 Referral to a Fetal Medicine Unit may be required to evaluate fetal wellbeing.

11.3 Monitoring for fetal distress is recommended after 26 weeks gestation.

12.0 Neonatologist Review

12.1 A neonatal alert form should be completed and sent to the Antenatal Screening Team,
located in the screening office, Antenatal Clinic. A copy of the alert form is kept in the
screening office and a copy is forwarded to the named Paediatric Consultant for a plan
of care post-delivery to be developed. (Refer to the ‘Calling paediatric staff and for
obtaining paediatric referral’; register number 09113) (Refer to Appendix A)

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12.2 The paediatrician will prescribe any medication required, in the antenatal period. The
medication will be available prior to the delivery of the baby.

13.0 Intrapartum Management

13.1 Vaginal delivery is the planned mode of delivery; unless the patient has an active genital
lesion (chancre).

13.2 The mode of delivery must be discussed with the patient and her wishes respected.

13.3 The paediatrician should examine the baby at delivery for signs / symptoms of
congenital syphilis.

14.0 Postpartum Management

14.1 Breast feeding is not contraindicated unless there is an active lesion on the breast.

14.2 All babies require serial serological tests for syphilis and a thorough physical
examination for signs / symptoms of congenital syphilis. Neonatal antibiotics may be
prescribed.

15.0 Staffing and Training

15.1 All midwifery and obstetric staff must attend yearly mandatory training which includes
skills and drills training.

15.2 All midwifery and obstetric staff are to ensure that their knowledge and skills are up-to-
date in order to complete their portfolio for appraisal.

16.0 Infection Prevention

16.1 All staff should follow Trust guidelines on infection prevention by ensuring that they
effectively ‘decontaminate their hands’ before and after each procedure.

16.2 All staff should ensure that they follow Trust guidelines on infection prevention. All
invasive devices must be inserted and cared for using High Impact Intervention
guidelines to reduce the risk of infection and deliver safe care. This care should be
recorded in the Saving Lives High Impact Intervention Monitoring Tool Paperwork
(Medical Devices).

17.0 Audit and Monitoring

17.1 Audit of compliance with this guideline will be considered on an annual audit basis in
accordance with the Clinical Audit Strategy and Policy (register number 08076), the
Corporate Clinical Audit and Quality Improvement Project Plan and the Maternity annual
audit work plan; to encompass national and local audit and clinical governance
identifying key harm themes. The Women’s and Children’s Clinical Audit Group will
identify a lead for the audit.

17.2 As a minimum the following specific requirements will be monitored:

• Designated lead for antenatal screening in the maternity service

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 • Antenatal screening tests, which follow the UK National Screening Committee
guidance
• System for ensuring that appropriate tests are undertaken within appropriate
timescales
• System for ensuring that appropriate tests are undertaken when patients book late
• Process for the review of the results
• Process for reporting all results to patients
• Process for reporting results to other relevant healthcare professionals
• Process for ensuring that women with screen positive test results are referred and
managed within appropriate timescales
• Maternity service’s expectations for staff training, as identified in the training needs
analysis
• Process for audit, multidisciplinary review of results and subsequent monitoring of
action plans

17.3 1% or 10 sets, whichever is the greater, of all health records of patients who have
delivered process for the review of the results to evidence the process for ensuring that
patients with screen positive test results are referred and managed within appropriate
timescales.

17.4 1% or 10 sets, whichever is the greater, of all health records of patients with screen
positive test results. A minimum compliance 75% is required for each requirement.
Where concerns are identified more frequent audit will be undertaken.

17.5 The findings of the audit will be reported to and approved by the Multi-disciplinary Risk
Management Group (MRMG) and an action plan with named leads and timescales will
be developed to address any identified deficiencies. Performance against the action
plan will be monitored by this group at subsequent meetings.

17.6 The audit report will be reported to the monthly Directorate Governance Meeting (DGM)
and significant concerns relating to compliance will be entered on the local Risk
Assurance Framework.

17.7 Key findings and learning points from the audit will be submitted to the Clinical
Governance Group within the integrated learning report.

17.8 Key findings and learning points will be disseminated to relevant staff.

18.0 Guideline Management

18.1 As an integral part of the knowledge, skills framework, staff are appraised annually to
ensure competency in computer skills and the ability to access the current approved
guidelines via the Trust’s intranet site.

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18.2 Quarterly memos are sent to line managers to disseminate to their staff the most
currently approved guidelines available via the intranet and clinical guideline folders,
located in each designated clinical area.

18.3 Guideline monitors have been nominated to each clinical area to ensure a system
whereby obsolete guidelines are archived and newly approved guidelines are now
downloaded from the intranet and filed appropriately in the guideline folders. ‘Spot
checks’ are performed on all clinical guidelines quarterly.

18.4 Quarterly Clinical Practices group meetings are held to discuss ‘guidelines’. During this
meeting the practice development midwife can highlight any areas for future training
needs will be met using methods such as ‘workshops’ or to be included in future ‘skills
and drills’ mandatory training sessions.

19.0 Communication

19.1 A quarterly ‘maternity newsletter’ is issued to all staff with embedded icons to highlight
key changes in clinical practice to include a list of newly approved guidelines for staff to
acknowledge and familiarise themselves with and practice accordingly. Midwives that
are on maternity leave or ‘bank’ staff have letters sent to their home address to update
them on current clinical changes.

19.2 Approved guidelines are published monthly in the Trust’s Staff Focus that is sent via
email to all staff.

19.3 Approved guidelines will be disseminated to appropriate staff quarterly via email.

19.4 Regular memos are posted on the guideline and audit notice boards in each clinical
area to notify staff of the latest revised guidelines and how to access guidelines via the
intranet or clinical guideline folders.

20.0 References

Public Health England (2016) NHS Infectious Diseases in Pregnancy Screening

Programme. Standards 2016-2017. London: Public Health England
Available at:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/529070/I
DPS_Programme_Standards_2016_to_2017.pdf

Kingston, M et al (2015) UK National Guidelines on the Management of Syphilis 2015

International Journal of STD and AIDS 0(0): 1-26
Available at: https://www.bashhguidelines.org/media/1148/uk-syphilis-guidelines-
2015.pdf

National Institute for Health and Care Excellence (2014) Antenatal and Postnatal Mental
Health: clinical management and service guidance. Clinical Guideline (CG192) London:
NICE

The Northern Ireland Antenatal Syphilis Screening Programme (2016) Syphilis infection
detection and management in pregnancy and management of the newborn:
Professional Guidance and Responsibilities.
Available at:

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http://www.southernguidelines.hscni.net/?wpfb_dl=517

Public Health England (2017) Sexually transmitted infections and chlamydia screening
in England 2016. Health Protection Report Volume 11 Number 20. London: Public
Health England
Available at:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/617025/H
ealth_Protection_Report_STIs_NCSP_2017.pdf

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 Appendix A
Jason Dover

Neonatal Alert Form

First Name Surname

NHS No Hospital No Referral Date

EDD Gestation Consultant

Background history & problem summary

Delivery Plans
Broomfield Hospital Not Decided
Other Hospital _____________________________________
Neonatal Alert Form Criteria
Please use the neonatal alert form for the following conditions:

• Multiple pregnancy (higher order > 2 fetus) • Severe oligohydramnios / IUGR

• Hepatitis B positive mother • Abnormal dopplers
• HIV positive mother • Genetic / hereditary conditions in the
immediate family that may affect the fetus
• Previous baby with GBBS sepsis /
meningitis • Social e.g. drug abuse, alcohol abuse in this
pregnancy
• Significant structural abnormalities
diagnosedon ultrasound scan • Any other condition that will require
paediatric input at birth
• All cases that require referral to specialist
units for treatment or advice
• Mothers with high antibody titres e.g. Anti-
D, C and Kell

Postnatal Plan (paediatric)

Designation __________________________ Date _________________________

Print Name __________________________ Signature _________________________

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 Receiving Syphilis Blood Results Appendix B

Negative Results Equivocal Results Positive Results

Signed by a midwife in Results sent to the Results sent to Results sent to the Results sent to
Antenatal Clinic GP/Midwifery Led Units Screening Team G.P/Midwifery Led Units Screening Team

This blood test should be repeated by Antenatal

Screening Team/GP. Two blood samples are
The blood test should be repeated by the Antenatal
Filed in notes required before a confirmed Syphilis Positive result is
Screening Team/GP. Two blood samples are required
given to the patient
before a confirmed Positive/Negative Syphilis status is
given to the patient

Confirmed negative Confirmed positive

status status

Confirmed negative Confirmed positive

Syphilis status syphilis status Sign result and file in
Sign result and file in
maternity records
Inform Antenatal
Screening Team of
positive result
Reassure patient Mon – Fri 9-5
maternity notes
Reassure patient
Inform antenatal
Screening Team of
positive result
Mon-Fri 9-5
Antenatal Screening
Team will arrange

Antenatal screening Team will arrange Obstetrician’s Referral to consultant in

antenatal genitourinary medicine.in
appointment Sexual Health

Obstetrician’s antenatal Referral to consultant in

appointment genitourinary medicine in Follow syphilis guideline
Sexual Health
 Appendix C

Proforma for Management of Syphilis positive Women in Pregnancy

First name: EDD

Surname:

DOB:
Date of Diagnosis
Hospital no:

NHS no:

Antenatal Screening Team:

(please circle)

Contacted/seen by Antenatal Screening Team Yes / No

Second confirmatory blood sample required Yes / No.

Date taken…………………………..

Previous Diagnosis Yes / No

Referral to GUM Yes / No

Consultants name and contact details

…………………………………………………………………………………………………………………

Date

Signature

Print name
Antenatal Care Plan:

(please circle)

Antenatal Clinic Appointment 16-18 weeks gestation Yes / No

Neonatal Unit Alert form completed and sent Yes / No

Date:

Signature:

Print name:

Antenatal discussion of the benefits and risks of :

(please circle)

• Antibiotic Therapy Yes / No

Date:

Signature:

Print name:

Management plan for delivery :

(please circle)

Elective caesarean section Yes / No

Vaginal delivery Yes / No

Date:

Signature:

Print name:

Management of the Newborn: (please circle)

Discussion of plan from the NNU Alert form Yes / No

Neonatal bloods obtained Yes / No

Date:

Signature:

Print name:

Revised March 2018