What is the treatment of syphilis during pregnancy?

Syphilis is an infection that is completely preventable.
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If you’re pregnant and have syphilis, get treatment right away. Getting early treatment can help protect you and your baby.
Syphilis during pregnancy can cause problems for your baby, like miscarriage, premature birth, stillbirth and death after birth.
Ask your partner to get tested and treated for syphilis. Even if you get treatment, he can reinfect you if he doesn’t get treatment.

Syphilis is a sexually transmitted infection (also called STI, sexually transmitted disease or STD). An STI is an infection you can get from having unprotected sex or intimate physical contact with someone who is infected. You can get an STI from unprotected vaginal, anal or oral sex. You also can get syphilis by having direct contact with (touching or kissing) an infected person’s syphilis sore. Sores usually are found on the external genitals (also called sex organs) or in the vagina, anus or rectum. They also can be on a person’s lips and in the mouth.

If you have syphilis and don’t get treated right away, you can pass the infection to your baby. Up to 2 in 5 babies (40 percent) born to women with untreated syphilis die from the infection. Most of the time, syphilis is passed from mom to baby during pregnancy, but it can happen during vaginal birth if a baby has direct contact with a syphilis sore. Vaginal birth is when contractions in your uterus (womb) help push your baby out through the vagina. When your baby is born with syphilis, it’s called congenital syphilis.

At your first prenatal care visit, your health care provider does a blood test to check for STIs like syphilis. Your provider also asks about your sexual history to see if you may be at risk for having syphilis. A sexual history is a set of questions your provider asks about your sex life. For example, your provider asks about your sex partners, what kinds of sex you have, if you use birth control, if you’ve had an STI in the past and how you protect yourself from STIs. If your provider thinks you may have syphilis or another STI based on your sexual history, she may test your blood again in your third trimester and after you give birth.

Can syphilis during pregnancy cause problems for your baby?

Yes. Having syphilis can cause problems during pregnancy, including:

Miscarriage. Miscarriage is when a baby dies in the womb before 20 weeks of pregnancy.
Premature birth. This is birth that happens too soon, before 37 weeks of pregnancy.
Fetal growth restriction (also called growth-restricted, small for gestational age or small for date) and low birthweight. Fetal growth restriction is when a baby doesn’t gain the weight she should before birth. Low birthweight is when a baby is born weighing less than 5 pounds, 8 ounces.
Problems with the placenta and the umbilical cord. The placenta grows in your uterus (womb) and supplies your baby with food and oxygen through the umbilical cord. Congenital syphilis may cause the placenta to grow large and the umbilical cord to be swollen, which can cause problems with how they work to support your baby in the womb.
Stillbirth. This is when a baby dies in the womb after 20 weeks of pregnancy.

Having syphilis during pregnancy can cause problems for your baby after birth, too, including neonatal death and serious lifelong health conditions for your baby. Neonatal death is when a baby dies in the first 28 days of life.

Stillbirth and neonatal death are more likely to happen to your baby if you have syphilis and don’t get treated.

What are the signs and symptoms of syphilis and how is syphilis treated?

Signs and symptoms of syphilis depend on how long you’ve been infected and when you get treatment. Even if your signs and symptoms go away without treatment, the infection can get worse. If you think you have syphilis, tell your provider. If you’re pregnant, have syphilis and get treated for syphilis before 26 weeks of pregnancy, your baby is probably safe from the infection.

Signs and symptoms of syphilis happen over time in stages. The stage you’re in depends on whether or not you get treatment. Treatment usually is with an antibiotic called penicillin. Antibiotics are medicines that kill infections caused by bacteria. Treatment can prevent you from moving to the next stage, so it’s important to get treated as soon as you know you’re infected.

Stages of syphilis include:

Primary syphilis. The first sign of syphilis is a small, hard, painless sore called a chancre that usually develops in the genital or vaginal area. You may have one or a few sores. They last for about 6 weeks, even if you get treatment.

Secondary syphilis. In the second stage, you have sores and a rash on the palms of your hands and on the bottoms of your feet. You also may have:

Fever
Swollen lymph nodes. Lymph nodes are glands throughout the body that help fight infection. You usually can’t feel lymph nodes unless they’re swollen.
Sore throat
Hair loss
Headaches
Weight loss
Muscle aches and fatigue. Fatigue is being really tired and having little energy.

Latent syphilis. In this stage, your signs and symptoms go away, but you’re still infected. The infection can stay in your body for years without having any signs or symptoms.

Late syphilis. If you don’t get treatment for syphilis, you can have signs and symptoms later in life, including:

Vision problems, like blindness
Damage to internal organs, including the heart
Neurological problems. These affect the brain, spinal cord and nerves throughout the body. You may have problems with coordination and may have numbness or paralysis. Paralysis is when you can’t feel or move one or more parts of your body. You also may develop dementia. This is when you have problems thinking, remembering, communicating and doing daily activities.

If you have primary or secondary syphilis, one shot of penicillin usually can cure the infection. If you have latent or late syphilis, you may need more than one shot.

How can you protect yourself from syphilis?

Here’s what you can do:

Don’t have sex. This is the best way to protect yourself from STIs, including syphilis.
If you do have sex, have safe sex. Have sex with only one person who doesn’t have other sex partners. If you’re not sure if your partner has an STI, use a barrier method of birth control. Barrier methods include male and female condoms and dental dams. A dental dam is a square piece of rubber that can help protect you from STIs during oral sex.
Go to all your prenatal care checkups, even if you’re feeling fine. Many cases of syphilis happen in women who don’t get regular prenatal care. At your prenatal care checkups, your provider asks you questions to see if you may be at risk for syphilis and other infections that can affect your pregnancy. If you’re at risk for syphilis, your provider gives you a blood test to see if you have the infection.
Get tested and treated. If you think you may have syphilis, tell your provider right away. He can test you for syphilis and begin treatment if you’re infected. The sooner you’re treated, the less likely you and your baby are to have complications from your infection.
Ask your partner to get tested and treated for syphilis. If you get treated for syphilis, you’re no longer infected. But if your partner is infected, you can get infected again. This is called reinfection. Ask your partner to get tested and treated to protect you from infection and reinfection.

If congenital syphilis is suspected a specialist should be consulted.

Antenatal syphilis screening is recommended in the first trimester.

Patients at increased risk, for example, Aboriginal women, should have a further test in the third trimester.

Additional antenatal screening is required in high-risk communities during syphilis outbreaks:

first antenatal visit (routine)
28 weeks
36 weeks
at birth
6-week post-natal check

The Communicable Disease Control Branch, SA Health issues public health alerts when a syphilis outbreak occurs.

Positive tests during pregnancy should be evaluated rapidly on history and examination, with testing of contacts and, if unresolved a further RPR (two weeks after the first test).

Syphilis in pregnancy should be treated with the standard regimen used for the same clinical stage of syphilis in non-pregnant people.

The only exception is early syphilis diagnosed in the third trimester of pregnancy, which should be treated with:

Benzathine penicillin G 1.8 gm (2.4 million units) im weekly for two weeks.

Coordination of pre-natal and post-natal care is vital. When syphilis is diagnosed in the second half of pregnancy an ultrasound evaluation for congenital syphilis should be done, but should not delay treatment.

If active syphilis cannot be reasonably excluded by this process the patient should be treated for early syphilis, as a safeguard against foetal infection.

Pregnant patients with a history of penicillin allergy should be desensitised and treated with penicillin. No proven alternatives for maternal or foetal infection exist.

Treatment for syphilis in pregnancy should have follow-up RPR at 28 to 32 weeks gestation and at delivery, and beyond for their clinical stage of syphilis.

Treatment during the second half of pregnancy involves a risk of premature labour and foetal distress, due to a Jarisch-Herxheimer reaction. Patients over 20 weeks of pregnancy requiring treatment for syphilis should be discussed with the attending Obstetrician prior to treatment, but treatment should not be delayed.

HIV testing should be offered to all patients with syphilis, including pregnant patients.

If the patient completes treatment with penicillin more than four weeks before delivery, risk to the infant is minimal, and follow up of the infant involves clinical examination at birth, serology at birth and thereafter three monthly until RPR is negative.

If maternal treatment was:

inadequate
unknown
with a non-penicillin regimen
completed less than four weeks prior to delivery
or if adequate follow-up of the infant cannot be assured.

The infant should be treated at birth and have repeat serology three-monthly until the RPR becomes negative. The CSF should be examined before treatment if there is a substantial risk of congenital syphilis.

Aqueous crystalline penicillin G 50,000 units/kg i.v. 12 hourly for the first seven days of life and every eight hours thereafter for a total of ten days OR

Aqueous procaine penicillin G 50,000 units/kg im in a single daily dose for ten days.

For asymptomatic infants with normal CSF and for whom follow up cannot be guaranteed:

Benzathine penicillin G 50,000 units/kg im as one dose.

Further information

For further information on the management of syphilis during pregnancy contact Adelaide Sexual Health Centre.

Disclaimer

These guidelines are based on a review of current literature, current recommendations of the United States Centers for Disease Control and Prevention, World Health Organization, the British Association for Sexual Health and HIV and local expert opinion.

They are written primarily for use by Adelaide Sexual Health Centre staff and some flexibility is required in applying them to certain private practice situations.

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