Syphilis in pregnancy

What is syphilis?
• Sexually transmitted infection
• Cause by a gram negative organism ; Treponema Pallidum
• Incubation period – 10 – 90 days contact
• Classification:
• Acquired ( STI / Direct Contact / Blood transfusion)
• Congenital ( Transplacental transmission)
Clinical stages of syphilis

Secondar
Primary Latent Tertiary
y
Primary syphilis
• Presence of “chancre”
• Inoculation site
• Solitary and painless ulcer
• Deep ulcer with rolled edge
• Hard and indurated base
• Lasted for 2 to 6 weeks
• Healed after 4 – 6 weeks
• Infectious state
• Localised disease
• Presence of enlarged lymph nodes
• Fetal infection – 60%
• Confirm with Dark field microscope
Secondary syphilis
• Occurs 4 to 10 weeks after the chancre
• Lasted for 2 to 6 weeks
• Highly infectious
• Extent of disease is disseminated
• Fetal infection rate – 60%
• Confirmed with dark field microscope
Latent syphilis
• If the primary and secondary syphilis left untreated
• No clinical manifestation
• But seropositive
• Can divided into 2:
• Early – within 1 year of infection
• Late – more than 1 year of infection
Tertiary syphilis
• Occurs several years / decades after infection
• Neurosyphilis
• Cardiovascular syphilis
• Late benign syphilis
 Congenital syphilis
• Occurs via mother child transmission
• transplacental transmission
• vertical transmission
• Divided into 2:
• Early – occurs within first 2 years old
• Late – occurs after 2 years + stigmata
of congenital syphilis
Cont…
• How to diagnose? • When to treat?
• Clinical signs • Symptomatic
• Titre comparison with mother; if 4 • VDRL titre > 4 fold of mother’s titre
fold > mother’s titre • Mother received inadequate
• IgM antibody positive treatment
• Mother treated with non penicillin
regime
Treatment regime :
• Persistent > high titre in other
- aqueous Penicillin G 50,000 despite adequate treatment
unit/kg for 10 days
• Maternal diagnosis and treatment
commenced < 1/12 before delivery
Follow up?
• Follow up at the age of 3, 6, and 12 months old
• Repeat VDRL
• Should reduced > 4 fold
• If persist at 1 year / increased  repeat CSF VDRL
• If CSF VDRL positive  treat with 10 days course of penicillin G
• Follow up for 1 to 2 years to ensure VDRL negative
Syphilis in pregnancy
• Manifestation is the same as non pregnant state
• Occurs via transplacental transmission
• Usually occurs as early as 16 – 28 weeks; can also happen as early as 9
weeks of gestation
• Likelihood of transmission is directly related to the stage of syphilis in
the infected pregnant woman
• Highest in primary and secondary stage;
• 100% in primary stage
• 40% early latent
• 10% late latent
Adverse pregnancy outcomes
• Miscarriage
• Intrauterine death / stillbirth
• Preterm labour
• Fetal growth restriction
• Ascites
• Hepatosplenomegaly
• Non immune hydrops
• Hydropic enlarged placenta
• Neonatal death
Screening
• All pregnant women  screen for syphilis at booking
• VDRL / RPR
• Non specific test
• Testing against cardiolipin antibodies (a lipid antigen that presence within
spirochete as well as on other cell in our body)
• For those who are high risk :
• Repeat test at 28w
• Before delivery
• For those who first test is negative but suspicious of syphilis remain:
• Repeat test 6 and 12weeks after of last contact
• Antibodies appear after 4 to 8 weeks after infection
Diagnostic tools

Serology Microscopy
• Non treponemal Assay • Dark field miscroscopy
• VDRL
• RPR
• Automated regain test
• Treponema specific Assays
• Fluorescent T. Pallidum Antibody
Absorbed (FTA –ABS)
• T. Pallidum Passive Particle Agglutination
(TP-PA)
• T. Pallidum Haemagglutination Assay
(TPHA)
VDRL
• Venereal disease research
labarotory
• Microfloculation semi
quantitative screening test
• Detect IgG, IgM heterophil
cardiolipin antibodies
• Detect thru serum / CSF
• If titre 1:8
• False positive
• Residual infection
• Past infection
• If titre > 1:8
• Current active infection
• Use for monitoring ; response to
treatment
• Repeat titre in 4 weeks
• If reduced > 4 folds  respond towards
treatment
• If initial titre is low  within 1 year  NR
• If initial titre is high  within 2 years  NR
Treatment Non penicillin allergy Penicillin allergy
Malaysia National Antibiotic 1st & 2nd trimester (up to 27/52) IM Ceftriaxone 500mg OD x 10 days
Guideline • IM Benzathine Penicillin G
2.4MU (single dose) T.Azithromycin 500mg OD x 10 days

3rd trimester (28/52 to term) T.EES 800mg QID x 14 days

• IM Benzathine Penicillin G
2.4MU weekly for 2/52

Or

IM Procaine Penicillin G 600,000

unit OD for 10/7

WHO IM Benzathine Penicillin G 2.4MU IM Ceftriaxone 1g OD x 10 -14 days

(single dose)
T.Azithromycin 2g OD x 10 days

T.EES 500mg QID x 14 days