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Syphilis in Pregnancy Jillian E Peterson.

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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


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

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. UpToDate


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