1. Maria Fernanda Ramirez Tovar, MD

2.  5 do Baby boy born FT C/S because of non reassuring FHT  AS 9/9  BW 3.465Kg  BT A+, RPR negative  Transferred Prenatal Care from DR  Mother 42yo, G6P3, BT O+, HIV neg, RPR Positive 1:2, MHA-TP Positive, treated with Bicillinx2  PE WNL  CSF and Long Bone Xrays WNL

3.  Congenital syphilis occurs when the spirochete Treponema pallidum is transmitted from a pregnant woman to her fetus. Infection can result in stillbirth, prematurity, or a wide spectrum of clinical manifestations; only severe cases are clinically apparent at birth

7. Facial FeaturesFrontal bossing, Saddle Nose, Short Maxilla, Protuberant Mandible OphthalmologicInterstitial Keratitis, Chorioretinitis, Secondary Glaucoma, Corneal Scarring, Optic Atrophy EarsSensorineural Hearing loss OropharynxHutchinson teeth, Mulberry molars, Perforation hard palate CutaneousRhagades, Gummas Central Nervous SystemIntellectual disability, arrested hydrocephalus, seizures, optic atrophy, juvenile general paresis SkeletalSaber shins (anterior bowing of the tibia), Higoumenakis sign (enlargement of the sternoclavicular portion of the clavicule), Clutton joints (painless arthritis), Scaphoid Scapula.

9. Evaluation < 1 mo Evaluation > 1 mo IV Penicillin 10 days  Mother with reactive Nontreponemal or Treponemal test  Nontreponemal test performed in the Newborn should be the same as the mother’s  Physical examination  Darkfield microscopic examination or DFA of body fluids  Pathologic examination of Placenta and Umbilical Cord, DFA staining  Child found to have a reactive test after 1 month of life  Congenital Vs. Acquired Syphilis (Maternal Hx, Clinical judgment)  CBC, CSF, HIV, LFT  Long bones XR’s, CXR, Abdominal US, Neuroimaging  Ophthalmological evaluation  Auditory brain stem response  Sexual Abuse?

10. Proven or Highly ProbableAt Risk Neonates  Abnormal PE/Positive Darkfield or DFA/VDRL or RPR fourfold or higher than mother’s titers  CBC, CSF, HIV, LFT  Long bones XR’s, CXR, Abdominal US, Neuroimaging  Ophthalmological evaluation,  Auditory brain stem response  Penicillin G for 10 days  Non reactive VDRL/RPR plus Normal PE: no further evaluation  Mother not treated or inadequately treated>Presumptive Syphilis  Mother NT or IT+ Reactive test (not fourfold)+ Normal PE: CBC, CSF, etc.  Mother adequately treated during pregnancy  Mother adequately treated before pregnancy

11. Treatment with a nonpenicillin antibiotic Treatment less than 4 weeks before delivery Inappropriate dose for stage of disease Inadequate Therapy Lack of performance of serial non-treponemal antibody titers after maternal treatment Maternal therapy was not documented Inadequate documentation of Maternal Treatment Maternal non-treponemal antibody titers did not decline at least fourfold after treatment Maternal non-treponemal antibody titers suggest reinfection or relapse (fourfold increase) Inadequate Response to Therapy

12. IV Aqueous Penicillin G 50,000U/Kg every 12hours for 10 days, every 8 hours if older than 1 week or IM Procaine Penicillin G 50,000U/Kg every 24hours for 10 days Option1 If 24 hours or more of therapy is missed the entire course must be restarted Benzathine penicillin G 50,000 U/Kg IM Single dose Option2

13. Reactive Maternal RPR/VDRL Nonreactive Maternal Treponemal test False Positive: No further evaluation Reactive Maternal Treponemal test No treatment/ Inadequate treatment Evaluation Adequate Treat. during Pregnancy Adequate Treat. Before Pregnancy VDRL/RPR lower than maternal and Normal PE No further Evaluation Abnormal PE Evaluation

14. PE is normal VDRL/RPR same or lower than maternal Evaluation Normal Treatment Option2 PE abnormal Evaluation abnormal or Incomplete RPR/VDRL fourfold greater than maternal Treatment Option1

15. Adequate Treatment during Pregnancy Infant RPR/VDRL fourfold greater than maternal titer Evaluation and Treatment Option1 RPR/VDRL same or lower than maternal titer Abnormal PE Evaluation and Treatment Option1 Normal PE No Evaluation and Treatment Option2

19.  Syphilis. Erica L. Hyman, MD. Pediatrics in Review Vol. 27 No. 1 January 1, 2006 pp. 37 -39(doi: 10.1542/pir.27-1-37)  Congenital Syphilis: Evaluation, management and prevention. Simon R Dobson. www.Uptodate.com  U.S. Preventive Services Task Force. Screening for syphilis infection in pregnancy: U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med 2009; 150:705.  Syphilis in Pregnancy. Errol R Norwitz. www.Uptodate.comwww.Uptodate.com  CDC. Sexually transmitted disease surveillance, 2008. Atlanta, GA: US Department of Health and Human Services, CDC; 2009. Available at http://www.cdc.gov/std/stats08/main.htm.http://www.cdc.gov/std/stats08/main.htm  CDC. Sexually transmitted diseases treatment guidelines, 2006. MMWR 2006;55(No. RR-11).  Hollier LM, Hill J, Sheffield JS, Wendel GD Jr. State laws regarding prenatal syphilis screening in the United States. Am J Obstet Gynecol 2003;198:1178--83.