Syphilis in Pregnancy Jillian E Peterson

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

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

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

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

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

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

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

CONGENITAL SYPHILIS

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

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

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

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

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

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*

Early Congenital Syphilis

Early Congenital Syphilis Snuffles

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

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

Early Congenital Syphilis Misc. PNA Nephrotic syndrome Jaundice

Late Congenital Syphilis

Late Congenital Syphilis

Late Congenital Syphilis Hutchinson Teeth Mulberry Molar

Late Congenital Syphilis Saber Shin Rhagades

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)

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

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

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

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 2012. Copyright 2012 American Academy of Pediatrics. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010http://www.cdc.gov/mmwr/preview/ mmwrhtml/rr5912a1.htm?s_cid=rr5912a. Genc M, Ledger W. Syphilis in Pregnancy Review Sex Trans Inf, 2000; 76: 73-79. Nelsons Textbook of Pediatrics Sanchez P, Wendel G. Syphilis in pregnancy. Clin Perinat, 1997;24:71–90. UpToDate