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Syphilis in pregnancy-final_version
The document discusses three case scenarios involving pregnant women with reactive syphilis serology. It provides details on interpreting syphilis serology, the stages of syphilis infection, and recommendations for treatment and follow up after treatment. The key points are: syphilis should be suspected in pregnant women who are sexually active or have partners with risk factors; reactive nontreponemal and treponemal tests indicate current or past untreated syphilis; and pregnant women with reactive tests should be treated with penicillin to prevent transmission to the fetus.
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Syphilis in pregnancy-final_version
- 1. Syphilis in pregnancySyphilisin pregnancy Dr. Areej MuftiDr. Areej Mufti MD,FRCPC,ABMM, FCCMMD,FRCPC,ABMM, FCCM Assistant professor, KSAUAssistant professor, KSAU Medical MicrobiologistMedical Microbiologist
- 2. Case scenario 1Casescenario 1 L.B. is a 26 y/o G3P2 at 18 weeks gestation whoL.B. is a 26 y/o G3P2 at 18 weeks gestation who has H/O"venereal disease " four years ago. Shehas H/O"venereal disease " four years ago. She was treated with 3 shots at that time. Currentwas treated with 3 shots at that time. Current new prenatal labs reveal anew prenatal labs reveal a reactivereactive RPR with aRPR with a titer oftiter of 1:41:4 and aand a reactivereactive FTA.FTA. How should she be managed nowHow should she be managed now?? a. repeat serology at 28 weeks/deliverya. repeat serology at 28 weeks/delivery.. b. She is reinfected, treat her with penicillinb. She is reinfected, treat her with penicillin nownow.. c. reassure her, no further work upc. reassure her, no further work up.. e. none of the abovee. none of the above.. e. I do not know, I will ask for helpe. I do not know, I will ask for help..
- 3. Case scenario 2Casescenario 2 ..R.H. is an 18 y/o G1P0 at 10 weeks gestationR.H. is an 18 y/o G1P0 at 10 weeks gestation whose new prenatal labs reveal awhose new prenatal labs reveal a reactivereactive RPR atRPR at a titer of 1:2 and aa titer of 1:2 and a reactivereactive FTA. She has noFTA. She has no history of STD but her husband has justhistory of STD but her husband has just diagnosed recently with HIV/syphilis coinfectiondiagnosed recently with HIV/syphilis coinfection.... How should she be managed?How should she be managed? a. repeat serology at 28 weeks/deliverya. repeat serology at 28 weeks/delivery b. repeat serology at 4-6 w .b. repeat serology at 4-6 w . d. reassure her, no further work up.d. reassure her, no further work up. e. I do not know, I will ask for help.e. I do not know, I will ask for help.
- 4. Case scenario 3Casescenario 3 D. F. is a 21 y/o G4P1 at 14 weeks gestation whoD. F. is a 21 y/o G4P1 at 14 weeks gestation who has ANC labs that reveal ahas ANC labs that reveal a nonreactivenonreactive RPR andRPR and aa reactivereactive FTA. She has no history of treatmentFTA. She has no history of treatment and her physical exam is normaland her physical exam is normal.. How should you manageHow should you manage?? a. no action, pregnancy can cause aa. no action, pregnancy can cause a biological false positive FTA.biological false positive FTA. b. repeat RPR test in 4-6 weeks.b. repeat RPR test in 4-6 weeks. c. treat her with Penicillin, 3 shots, each is ac. treat her with Penicillin, 3 shots, each is a week apart.week apart. e. none of the above.e. none of the above.
- 5. My talk willanswer the followingMy talk will answer the following.... WHEN SHOULD SYPHILIS BEWHEN SHOULD SYPHILIS BE SUSPECTED IN A PREGNANT WOMAN?SUSPECTED IN A PREGNANT WOMAN? HOW SHOULD SYPHILIS SEROLOGYHOW SHOULD SYPHILIS SEROLOGY BE INTERPRETED?BE INTERPRETED? WHICH WOMEN WITH REACTIVEWHICH WOMEN WITH REACTIVE TREPONEMAL TESTS HAVE BEENTREPONEMAL TESTS HAVE BEEN ADEQUATELY TREATED BEFOREADEQUATELY TREATED BEFORE PREGNANCY?PREGNANCY?
- 6. WHEN SHOULD SYPHILISBEWHEN SHOULD SYPHILIS BE SUSPECTED IN A PREGNANT WOMANSUSPECTED IN A PREGNANT WOMAN?? sexual/direct contact (infected lesions)sexual/direct contact (infected lesions) with a person who was infected withwith a person who was infected with syphilis within thesyphilis within the preceding year.preceding year. If the cause is not known for a hydropic orIf the cause is not known for a hydropic or still birth newborn;do pstpartum screen.still birth newborn;do pstpartum screen. Remember:Remember: allall pregnant women must bepregnant women must be assumed to be at risk.assumed to be at risk.
- 7. Doctor: why Ihave to be screenedDoctor: why I have to be screened for Syphilis?for Syphilis? I never had any STD in the pastI never had any STD in the past ……I have no complain at theI have no complain at the present!!present!! WHEN SHOULD SYPHILIS BE SUSPECTED INWHEN SHOULD SYPHILIS BE SUSPECTED IN A PREGNANT WOMANA PREGNANT WOMAN??
- 8. Why universal earlyantepartamWhy universal early antepartam screen is importantscreen is important?? Epidemiological factors.Epidemiological factors. Clinical factors.Clinical factors. Outcome factors.Outcome factors.
- 9. Syphilis stagesSyphilis stages Incubation periodIncubation period:: 10-90 days, average 3 weeks10-90 days, average 3 weeks.. Primary SPrimary S :: - starts 3 w post infection- starts 3 w post infection -lasts 3-6w-lasts 3-6w.. Secondary S:: - 6w-6m post infection.- 6w-6m post infection. -25% of untreated primary progress to-25% of untreated primary progress to this stage;this stage; -resolve in 2-6 w.-resolve in 2-6 w. latent S:latent S: --developed when primary or secondary S isdeveloped when primary or secondary S is not treated. Reactivity of NTT decrease with increasednot treated. Reactivity of NTT decrease with increased latency>1 ylatency>1 y.. Tertiary S:Tertiary S: -10-30y after initial infection.-10-30y after initial infection. -30 % of untreated 2° syphilis.-30 % of untreated 2° syphilis.
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- 14. HOW SHOULD SYPHILISSEROLOGY BEHOW SHOULD SYPHILIS SEROLOGY BE INTERPRETEDINTERPRETED?? Nontreponemal testNontreponemal test Treponemal testTreponemal test interpretationinterpretation NonreactiveNonreactive Reactive/IndeterminateReactive/Indeterminate • Early 1Early 1ْْsyphilis.syphilis. • Late latent/ 3Late latent/ 3 ْْsyphilis.(3)syphilis.(3) • Previously treatedPreviously treated syphilis.syphilis. • Endemic syphilisEndemic syphilis ReactiveReactive NonreactiveNonreactive False positiveFalse positive ReactiveReactive ReactiveReactive • Syphilis at any stage.Syphilis at any stage. • Old treated syphilisOld treated syphilis (serofast).(1)(serofast).(1) • Follow up of treatmentFollow up of treatment • Endemic syphilis.Endemic syphilis. ReactiveReactive IndeterminateIndeterminate • Early 1Early 1ْْsyphilis.syphilis. • Late latent/ 3Late latent/ 3 ْْsyphilis.syphilis. • Previously treatedPreviously treated syphilis.syphilis. • Endemic syphilisEndemic syphilis Public Health Agency of CanadaPublic Health Agency of Canada.. Canadian Guidelines on Sexually Transmitted Infections,2008Canadian Guidelines on Sexually Transmitted Infections,2008
- 16. Treponematoses in SaudiArabiaTreponematoses in Saudi Arabia the overall incidence of treponemal seropositivity:the overall incidence of treponemal seropositivity: 2.7%-2.7%-16.6%16.6% withwith 0.85%0.85% positivity among the pregnant womenpositivity among the pregnant women
- 17. Syphilis serologySyphilis serology Capture IgM EIA test:Capture IgM EIA test: its value is:its value is: - untreated syphilis :+ even in earlyuntreated syphilis :+ even in early primary cases were RPR/TPHA mayprimary cases were RPR/TPHA may be -be - - F/U treatment success:F/U treatment success: –– - Bejel: RPR/TPHA:+/- (usually ≤1:8)- Bejel: RPR/TPHA:+/- (usually ≤1:8) EIA IgM: -EIA IgM: -
- 18. TREATMENTTREATMENT Primary, secondary, andearly latent syphilis:Primary, secondary, and early latent syphilis: Benzathine penicillin GBenzathine penicillin G,, IM, 2.4 million units in a singleIM, 2.4 million units in a single dose.dose. * additional therapy* additional therapy a second dosea second dose of benzathine penicillinof benzathine penicillin 2.4 million units IM administered 1 week after the initial2.4 million units IM administered 1 week after the initial dose to improve the likelyhood of serologic response indose to improve the likelyhood of serologic response in early disease..early disease.. Late latent or latent syphilis of unknown duration;Late latent or latent syphilis of unknown duration; Benzathine penicillin administered as three doses of 2.4Benzathine penicillin administered as three doses of 2.4 million units IM each at 1-week intervals.million units IM each at 1-week intervals. Tertiary (late) syphilis without neurologic involvementTertiary (late) syphilis without neurologic involvement:: Benzathine penicillin administered as three doses ofBenzathine penicillin administered as three doses of 2.4 million units IM each at 1-week intervals.2.4 million units IM each at 1-week intervals. NeurosyphilisNeurosyphilis:: AqueousAqueous crystalline penicillincrystalline penicillin GG 18-2418-24 million units per day,million units per day, administered as 3-4 million units IV every 4 hours oradministered as 3-4 million units IV every 4 hours or continuous infusion for 10-14 days IVcontinuous infusion for 10-14 days IV
- 19. Issues related totreatmentIssues related to treatment Penicillin Allergy: 5-10 %.... verify, desensitize.Penicillin Allergy: 5-10 %.... verify, desensitize. Jarisch - Herxheimer reaction.Jarisch - Herxheimer reaction. In pregnant women , missed doses are notIn pregnant women , missed doses are not considered acceptable, and the full course ofconsidered acceptable, and the full course of therapy must be repeated.therapy must be repeated. Long-term sex partners of patients who have latent syphilis should be evaluated clinically and serologically for syphilis and treated on the basis of the evaluation findings.
- 20. Evaluation after treatmentEvaluationafter treatment** primary syphilis: * should be re-examined clinically and serologically 1, 3, 6, 12, 24 M.* should be re-examined clinically and serologically 1, 3, 6, 12, 24 M. by 6th m: at least X4 decline in titer.by 6th m: at least X4 decline in titer. by 8by 8thth m: X8 decline in titerm: X8 decline in titer.. by 24by 24thth m : x16 decline in titerm : x16 decline in titer.. Secondary syphilis: by 6by 6thth m:x8m:x8 by 12by 12thth m: x16m: x16 latent syphilis **should be followed up clinically and serologically at 6, 12, and 24 monthsshould be followed up clinically and serologically at 6, 12, and 24 months early latent: 12early latent: 12thth m: x4m: x4 Note: Latent/late: more gradual decline, persistent low titer in 50% of patients after 2Note: Latent/late: more gradual decline, persistent low titer in 50% of patients after 2 yearsyears.. **Public Health Agency of CanadaPublic Health Agency of Canada.. Canadian Guidelines on Sexually Transmitted Infections,2008Canadian Guidelines on Sexually Transmitted Infections,2008
- 22. Causes of treatmentfailureCauses of treatment failure High RPR titer at time of Dx/ delivery.High RPR titer at time of Dx/ delivery. Delivery ≤ 36 w.Delivery ≤ 36 w. Short interval between treatment andShort interval between treatment and delivery(≤ 30 d).delivery(≤ 30 d). Non penicillin regimen.Non penicillin regimen.
- 23. Indications of probable treatment Indications of probable treatment failure / reinfection includefailure / reinfection include:: – Persistent orrecurring signs or symptoms .Persistent or recurring signs or symptoms . – Sustained fourfoldSustained fourfold increaseincrease in nontreponemal titer ORin nontreponemal titer OR Failure of nontreponemal titers to decline X4 within 6MFailure of nontreponemal titers to decline X4 within 6M POST Rx for primary or secondary syphilis:POST Rx for primary or secondary syphilis: * re-treat* re-treat *R/O HIV infection.*R/O HIV infection. * CSF examination* CSF examination Note:Note: retreatment regimen:retreatment regimen: weekly injections of benzathine penicillin G 2.4 millionweekly injections of benzathine penicillin G 2.4 million units IM for 3 weeks are recommended, unless CSFunits IM for 3 weeks are recommended, unless CSF examination indicates that neurosyphilis is present.examination indicates that neurosyphilis is present.
- 24. Congenital syphilisCongenital syphilis Therisk of vertical transmission (in utero/during delivery)The risk of vertical transmission (in utero/during delivery) depends primarily on the stage of maternal syphilisdepends primarily on the stage of maternal syphilis:: untreated primary or secondary syphilis: 70% to 100%untreated primary or secondary syphilis: 70% to 100% early latent syphilis: 40% (as she remains at risk ofearly latent syphilis: 40% (as she remains at risk of reactivation).reactivation). late latent syphilis/tertiary: less than 10%.late latent syphilis/tertiary: less than 10%. Note: the risk is extremely high for theNote: the risk is extremely high for the first four yearsfirst four years after maternal acquisition of infection (untreated) whereafter maternal acquisition of infection (untreated) where spirochetemia in pregnancy is common.spirochetemia in pregnancy is common. Remember: 50% bornRemember: 50% born asymptomatic,asymptomatic, manifestations canmanifestations can be shown up to 2 years of age (late congenital syphilis):be shown up to 2 years of age (late congenital syphilis): usually 2w-3m post delivery: skin rash ulcers, fever, weakusually 2w-3m post delivery: skin rash ulcers, fever, weak cry, hepatosplenomegaly, jaundice, anaemia, bonecry, hepatosplenomegaly, jaundice, anaemia, bone deformities.deformities.
- 26. Postpartum management issuesPostpartummanagement issues RememberRemember:: Even with appropriate penicillin therapy, up to 10 perEven with appropriate penicillin therapy, up to 10 per cent of infants will be found to have active disease after birth.cent of infants will be found to have active disease after birth. Serologic testing of maternal blood at the time of delivery isSerologic testing of maternal blood at the time of delivery is superior to infant testing( FP/FN).superior to infant testing( FP/FN). Umbilical cord blood testing is not recommended.Umbilical cord blood testing is not recommended. Treatment decisions need to be made on the basis of maternalTreatment decisions need to be made on the basis of maternal history and treatment:history and treatment: Was the mother treated? Was she treated adequately?Was the mother treated? Was she treated adequately? Was she treated with a non-penicillin regimen?Was she treated with a non-penicillin regimen? Was she treated <4 weeks before delivery?Was she treated <4 weeks before delivery? Has she had a fourfold decrease in titer after treatment?Has she had a fourfold decrease in titer after treatment? Does the infant have clinical signs ?Does the infant have clinical signs ? A comparisonA comparison of maternal and infant non-treponemal test titers isof maternal and infant non-treponemal test titers is very helpful for guiding therapyvery helpful for guiding therapy.. Infectious Diseases and Immunization CommitteeInfectious Diseases and Immunization Committee, Canadian Paediatric Society (CPS), Canadian Paediatric Society (CPS) Paediatr Child Health 2009;14(5):337Paediatr Child Health 2009;14(5):337
- 27. Case scenario 1Casescenario 1 LL.B. is a 26 y/o G3P2 at 18 weeks gestation who has a history of "venereal.B. is a 26 y/o G3P2 at 18 weeks gestation who has a history of "venereal disease " four years ago. She was treated with 3 shots" at that time.disease " four years ago. She was treated with 3 shots" at that time. Current new prenatal labs reveal a reactive RPR with a titer ofCurrent new prenatal labs reveal a reactive RPR with a titer of 1:41:4 and aand a reactive FTA.reactive FTA. How should she be managed nowHow should she be managed now?? a. repeat serology at 28 weeks/deliverya. repeat serology at 28 weeks/delivery b. treat her right away with penicillinb. treat her right away with penicillin.. c. reassure her, no further work upc. reassure her, no further work up.. d. none of the aboved. none of the above e. I do not know, I will ask for helpe. I do not know, I will ask for help.. Serofast low antibody titers might not require treatment; however, persistent higher titer antibody tests might indicate reinfection and require treatment. CDS,MMWR, STD Rx guidelines, August 2006
- 28. Case scenario 2Casescenario 2 ..R.H. is an 18 y/o G1P0 at 10 weeks gestation whose newR.H. is an 18 y/o G1P0 at 10 weeks gestation whose new prenatal labs reveal aprenatal labs reveal a nonreactivenonreactive RPR/FTA . She has noRPR/FTA . She has no history of sexually transmitted disease but herhistory of sexually transmitted disease but her husbandhusband has just diagnosed recently withhas just diagnosed recently with HIV/Syphilis coinfectionHIV/Syphilis coinfection.... How should she be managedHow should she be managed?? a. repeat serology at 4-6wa. repeat serology at 4-6w.. b. repeat serology at 28w/delivaryb. repeat serology at 28w/delivary.. d. reassure her, no further work upd. reassure her, no further work up.. e. I do not know, I will ask for helpe. I do not know, I will ask for help.. for patients at high risk, serologic testing should be performed twice during the third trimester, at 28 to 32 weeks' gestation and at delivery.
- 29. Case scenario 3Casescenario 3 DD. F. is a 21 y/o G4P1 at 14 weeks gestation who has ANC labs that. F. is a 21 y/o G4P1 at 14 weeks gestation who has ANC labs that reveal areveal a nonreactivenonreactive RPR and aRPR and a reactivereactive FTA. She has no historyFTA. She has no history of treatment and her physical exam is normalof treatment and her physical exam is normal.. How should you manageHow should you manage?? a. no action, pregnancy can cause a biological falsea. no action, pregnancy can cause a biological false positive FTA.positive FTA. b. repeat RPR test in 4-6 weeks.b. repeat RPR test in 4-6 weeks. c. treat her with Penicillin, 3 shots, each is a weekc. treat her with Penicillin, 3 shots, each is a week apart.apart. e. none of the above.e. none of the above. she should be treated for late latent syphilis and it should be assumed that there is some risk of vertical transmission.
- 30. TAKE HOME MESSAGESTAKEHOME MESSAGES AllAll pregnant women should be screened for syphilis.pregnant women should be screened for syphilis. AbortionAbortion due to syphilis isdue to syphilis is uncommonuncommon during the early pregnancy:during the early pregnancy: as in utero infection is usually acquired after 4as in utero infection is usually acquired after 4thth month of gestationmonth of gestation after the formation of placenta.after the formation of placenta. Sequential serologic tests should be performed bySequential serologic tests should be performed by using theusing the samesame testing methodtesting method (e.g., VDRL or RPR:RPR titers frequently are(e.g., VDRL or RPR:RPR titers frequently are slightly higher than VDRL titers ).slightly higher than VDRL titers ). 20%20% ofof PRIMARYPRIMARY S: Both treponemal and nontreponemal testsS: Both treponemal and nontreponemal tests can producecan produce nonreactive.nonreactive. Nontreponemal test titers might decline more slowly for personsNontreponemal test titers might decline more slowly for persons who previously had syphilis (who previously had syphilis (serofast reactionserofast reaction).). The results of serological test of syphilis should be carefullyThe results of serological test of syphilis should be carefully interpreted in ainterpreted in a geographical areageographical area like Saudi Arabia where bothlike Saudi Arabia where both venereal syphilis and Bejel co-exist.venereal syphilis and Bejel co-exist.
- 31. Thank youThank you Havea wonderful dayHave a wonderful day