Background to key points in diagnosis and management

• In pregnant women with untreated early syphilis 70-100% of infants will be infected, with still births occurring in up to one third of cases.
• Infection in pregnancy can cause intra uterine growth retardation, stillbirth, hydrops fetalis, or premature delivery.
• Babies born with congenital syphilis can have early manifestations of the disease (within the first 2 years of life) or late manifestations (after 2 years of life) including the stigmata of congenital syphilis.
• Although fetal infection usually occurs late in pregnancy it has been demonstrated as early as 8-9 weeks gestation.
• Prompt treatment reduces the risk of spread to the fetus.

• Serology can be negative in the early stage of syphilis and any concerns should be discussed with Sexual Health.
• Risk factors for syphilis in pregnant women include belonging to an ethnic minority group, having been born abroad and having a male sexual partner who has sex with men.
• In addition, asymptomatic patients with initial negative serology but who are either considered to have on going risk of syphilis or risk in the 3 months leading up to initial serology should be retested later in pregnancy.
• Prompt treatment reduces the risk of spread of the infection to the fetus and this should be taken into account when planning the timing of repeat tests.

It is the responsibility of the patient’s Obstetric team to directly inform by telephone a Sexual Health doctor  that a patient has positive syphilis serology.

NHS D&G screen with a combined IgM and IgG Enzyme Immunoassay (EIA). Since biological false positive results are common during pregnancy accounting for about ¼ of positive screening tests, ‘reactive results’ are not communicated to clinicians until reference laboratory confirmation is obtained.

Specimens reactive at NHS D&G using EIA screening test are forwarded to the Reference Laboratory in Edinburgh. The Reference Lab tests using different treponemal tests (TPPA) and a quantitative non treponemal test (RPR). A positive syphilis report is one which has been confirmed at the Reference Lab.

All syphilis serology results should be available within 2 weeks. A second sample should be sent to the microbiology laboratory for all patients with a positive result. Sexual Health may request this sample is taken by obstetric staff if there is expected to be a delay of more than 2 working days before the patient is seen (clinical details: urgent for reference lab, pregnant, previous positive serology).

On receipt of the referral the Sexual Health doctor will phone the patient to explain the purpose of the visit and answer any immediate questions.

Sexual Health will fully explore this with the pregnant woman, the Obstetric team and, where relevant and with her permission, other clinicians currently or previously involved in her care.

Treatment ideally should only take place once the first positive result has been confirmed on a second sample but may need to take place with second result pending depending on patient history and gestation.

Women with documented previous syphilis treatment (as recommended by current UK guidelines) with supporting serological evidence of response to treatment should have repeat serology sent to the reference laboratory in Edinburgh around 28 weeks gestation to exclude reinfection.

Syphilis staging takes into account the patients history, current (and if available previous serological results), and clinical examination with particular emphasis on the skin, genitals, lymph nodes and mucosa. Cardiovascular and neurological examination is required in late syphilis and those with relevant symptoms.

Treatment is individualised depending on the stage of infection and normally involves administration of parental drugs. Treatment will either be prescribed/administered by Sexual Health or the woman’s obstetric or primary care team based on Sexual Health recommendations.

Syphilis serology should always be repeated on the first day of treatment to allow serological response to treatment to be monitored.

Patients receiving syphilis treatment require follow up to detect reinfection or relapse by assessing clinical and serological response to treatment. Sexual Health will either arrange follow up visits within their service or liaise with the women’s obstetric team for the follow up serology to be taken during routine antenatal care visits.

When syphilis is diagnosed during the second half of pregnancy, management should include detailed US evaluation but this should not delay treatment. Ultrasound signs of fetal or placental syphilis indicate a greater risk for fetal treatment failure. There is a risk of a Jarisch-Herxheimer reaction to treatment at some stages of infection and this may lead to fetal distress and premature labour.

In some cases patients may require to be admitted to the antenatal unit for syphilis treatment. The need for admission will be based on the gestation of pregnancy, the stage of syphilis, the serology (in particular the RPR) and the travel time between home and Dumfries Royal Infirmary or the Galloway Community Hospital. All women need to be advised to seek obstetric attention after treatment if they notice fever, contractions, or decrease in fetal movements.

• Partner notification is a voluntary process.
• It would be anticipated that with appropriate counselling pregnant women would engage with this process to avoid re-infection of themselves (and their unborn child).
• Partner notification may include both current and previous partners, the ‘look back’ period depending on the stage of infection.
• Immediate epidemiological treatment for current sexual partner(s) may be appropriate.
• Partner notification will be explored by sexual health with the pregnant woman.

Babies should be fully assessed (both clinically and serologically) by a paediatrician and decisions made will include whether the baby requires further treatment and or follow up.

The details of the case holding obstetric consultant are available from the community midwifery team or the antenatal clinic reception 01387 241200.