1. Syphilis in Pregnancy
Jillian E Peterson

2. Syphilis Infection caused by spirochete Treponema pallidum
Sexual transmission
Spirochetes pass from open lesion across mucosal membrane
4 stages of adult acquired infection
Primary
Secondary
Latent
Tertiary

3. Primary Syphilis
Occurs an average of 21 days after point of contact
Classical chancre
Single painless ulceration
Multiple ulcerations can occur
if coexisting HIV infection
Can persist 3-6wks without treatment

4. Secondary Syphilis
25% of untreated patients will develop secondary syphilis
Rash
Most characteristic finding
Diffuse symmetric maculopapular rash
Includes trunk, extremities, palms and soles
Lesions all have bacteria and are infectious
Condyloma lata
Occur in mucosal membranes

5. Secondary Syphilis LAD “Moth eaten” alopecia Hepatitis Uveitis
Synovitis
Nephritis
Systemic symptoms
Fever, malaise, weight loss

6. Latent Syphilis Positive serology without symptoms
Categorized as early or late
Early latent
<1 yr after secondary syphilis
Late latent
> 1 yr after secondary syphilis

7. Tertiary Syphilis Occurs 1-30 yrs after primary infection Symptoms:
Neurosyphilis
Tabes dorsales
Cardiovascular syphilis
Gummatous syphilis

8. Epidemiology
Syphilis occurs worldwide but most prevalent in developing countries
Incidence has greatly declined after introduction of penicillin

9. CONGENITAL SYPHILIS

10. Congenital syphilis Methods of transmission
Transplacental transmission of spirochetes
Direct contact w/ infectious time of birth
NOT transferred via breast milk
Transfer can occur if infectious lesion on breast

11. Congenital Syphilis Transmission can occur any time in gestation
Frequency of transmission increases as gestation advances
Higher rate of transmission w/ primary & secondary infection

12. Congenital Syphilis Epidemiology
Affects an estimated 1 million pregnancies per year worldwide
Most mothers received no prenatal care or insufficient treatment for syphilis
US Incidence peaked at 100 cases for 100,000 in 1991 and has steadily declined

13. Congenital Syphilis
Women with untreated primary syphilis apprx 40% of pregnancies result in spontaneous abortions
Those born w/ syphilis categorized
Early congenital syphilis
Clinical manifestations prior to 2 yrs of age
Late congenital syphilis
Clinical manifestations after 2 yrs of age

14. Early Congenital Syphilis
Systemic Symptoms
Fever
HSM
General LAD
FTT
Edema
Hematologic
Coombs + hemolytic anemia
Thrombocytopenia
Leukopenia/leukocytosis

15. Early Congenital Syphilis
Mucocutaneous
Syphilitic Rhinitis
Maculopapular rash
Oval red/brown lesions
Can have superficial desquamation/scaling
Involves palms/soles
Condyloma lata
Mucosal surfaces
*ALL contain spirochetes = INFECTIOUS*

16. Early Congenital Syphilis

17. Early Congenital Syphilis
Snuffles

18. Early Congenital Syphilis
MSK
Radiographic bone abnormalities
Periostitis
Wegners sign = “sawtooth metaphysis”
Wimberger sign = demineralization of upper tibia
Pseudoparalysis of Parrot
Later finding
Lack of extremity movement due to bone pain

19. Early Congenital Syphilis
Neurological
Acute syphilitic leptomeningitis
Similar presentation to bacterial meningitis
CSF findings more c/w aseptic meningitis (mononuclear predominance)
Chronic meningovascular syphilis
Onset ~1yr
Hydrocephalus
CN palsy
Intellectual/neurodevelopmental deterioration

20. Early Congenital Syphilis
Misc.
PNA
Nephrotic syndrome
Jaundice

21. Late Congenital Syphilis

22. Late Congenital Syphilis

23. Late Congenital Syphilis
Hutchinson Teeth
Mulberry Molar

24. Late Congenital Syphilis
Saber Shin
Rhagades

25. Testing Maternal Testing Non-treponemal testing Treponemal testing
Screening test
VDRL, RPR
Treponemal testing
Confirmatory testing
Fluorescent treponemal antibody absorption (FTA-ABS)
Microhemagglutination test for antibodies to Treponema pallidum (MHA-TP)
Treponema pallidum particle assay (TP-PA)
Treponema pallidum enzyme immunoassay (TP-EIA)

27. Maternal Treatment Primary/Secondary/Early latent
Benzathine Penicillin G, 2.4 million units IM
One dose
Late latent/Tertiary/Unknown duration
Benzathine Penicillin G, 7.2 million units IM
3 doses of 2.4 million units x 1/week x 3 wks
Penicillin allergy in pregnant female w/ syphilis
Skin testing & desensitization

28. Newborn Treatment Benzathine Penicillin G Aqueous Penicillin G
50,000 units/kg IM x 1
Only used if infant asymptomatic and no signs of CNS syphilis after lab/radiology evaluation
Aqueous Penicillin G
50,000 units/kg IV
Q12 hrs for infants <7days old or q8 hrs >7days old
10 days total
Procaine Penicillin G
50,000 units/kg IM
Single daily dose x 10 days

29. Follow Up
Newborns should be closely screened at follow up visits for signs of late syphilis
Follow up VDRL/RPR titers
Repeated every 2-3 months until test non-reactive or titer decreased four-fold
Titers should decline by 3mo and be non-reactive by 6 months

30. References
American Academy of Pediatrics. Syphilis. In: Red Book: 2012 Report of the Committee on Infectious Diseases, 29th ed, Pickering LK (Ed), American Academy of Pediatrics, Elk Grove Village, IL Copyright 2012 American Academy of Pediatrics.
Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010http:// mmwrhtml/rr5912a1.htm?s_cid=rr5912a.
Genc M, Ledger W. Syphilis in Pregnancy Review Sex Trans Inf, 2000; 76:
Nelsons Textbook of Pediatrics
Sanchez P, Wendel G. Syphilis in pregnancy. Clin Perinat, 1997;24:71–90.
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