1. General considerations
In general, GUM will manage the assessment, treatment and follow-up of women diagnosed with syphilis. Women with a history of previously treated syphilis should also be referred to GUM for monitoring, although further treatment may not be necessary.
Advice can always be sought from the on-call GUM doctor at Chalmers, available through switchboard.
2. Screening
All women should be offered a screening blood test for syphilis at booking, as per the UK national screening recommendations. The aim of screening is early maternal diagnosis in order to offer prompt treatment and minimise transmission risk. Women at high risk should be retested at 24 and 36 weeks.
• A 5ml clotted sample (brown tube) should be sent to microbiology for screening IgG at the booking appointment.
3. Diagnosis
When a presumptive positive result is received a second sample is required urgently to confirm the diagnosis.
• A 5ml brown tube should be sent as soon as possible either by the community midwife team or the antenatal clinic, and clearly documented on TRAK.
Full syphilis serology will be undertaken by the lab, but assessment of the result should only be undertaken by a GUM senior. Further interpretation of syphilis serology is complex and outwith the remit of this guideline.
For all patients, including those booked at St John’s:
• The laboratory will inform Dr Sarah Cooper/Sarah Stock and the specialist midwife of the result
• A joint appointment with GUM Consultant and Dr Sarah Cooper will be arranged asap at the Wednesday afternoon high risk antenatal clinic at RIE.
• Referral to Dr Laura Jones, Consultant Paediatrician at RHSC will be made antenatally to plan neonatal care. Older siblings may need to be screened for congenital syphilis.
• Discuss with fetal medicine team to evaluate fetal involvement. USS assessment for hydrops or hepatosplenomegaly may be required. Fetal monitoring may be needed if treatment is given after 26 weeks, due to the risk of Jarisch-Herxheimer reaction (see below).
Patients should be told of the need for further assessment with GUM to evaluate disease, offer partner notification, and further STI testing. They should be made aware of the significance of syphilis on their own health and on the pregnancy.
- Following this, an entry should be made in Obstetric and Neonatal special features on TRAK.
4. Treatment and follow-up
• A treatment plan will be decided by GUM depending on disease stage following assessment. Treatment should be started as soon as possible following diagnosis. The result of the confirmatory test is not required if there is clinical suspicion.
• Treatment is a single dose of benzathine penicillin 2.4 megaunits IM single dose (if non penicillin allergic). Alternative regimes or penicillin desensitization may be considered in those with penicillin allergy, under the management of GUM. Consideration should be given to treatment at initial review, only on the advice of GUM, if there is a high risk the patient may default further review.
• Further treatment may be necessary, for those in whom the efficacy of treatment is uncertain, depending on the results of monitoring. If treatment is given in the 3rd trimester, a second dose is usually required one week later.
• Women should be offered further STI testing, including HIV, chlamydia and gonorrhoea.
• Follow-up will also be by GUM to ensure adequate treatment. Full syphilis serology will be checked at 1,2,3,6 months post treatment. Some of these tests may be performed at routine antenatal visits by agreement with GUM. Monitoring is essential to ensure adequate treatment and detect potential re-infection.
Jarisch-Herxheimer reaction
Approximately 40% of patients will experience an acute febrile reaction following penicillin treatment. This is characterised by headache, myalagia, chills and rigors which will resolve after 24 hours. In pregnancy this reaction may also cause transient uterine activity and fetal distress. There is a theoretical risk of iatrogenic or spontaneous pre-term labour.
Patients should be counselled about this potential reaction and advised to contact obstetric triage for advice and review.
If these symptoms occur:
• Patient should be admitted for observation and fetal monitoring.
• Treatment should be symptomatic with paracetamol for pyrexia.
• There is no evidence to support the use of high dose prednisolone to reduce uterine contractions.
5. Neonatal Management
Advice can be sought either from on-call GUM or from Dr Jones when available.
• Paediatric registrar should perform an examination at delivery for signs of congenital syphilis.
• If the mother has been adequately treated in pregnancy, syphilis titres are not required from the baby
• If there has been inadequate treatment, or reinfection, the baby needs to be evaluated for congenital infection. This includes taking venous bloods and CSF, and if required long bone xrays. Syphilis titres should be taken from baby at birth (venous sample, not cord blood).
• Swabs for syphilis PCR (red top swab) should be taken if the baby has suspicious lesions/discharge.
Treatment should be given to the baby in the following circumstances:
• Babies with suspected congenital syphilis
• Babies born to untreated (or inadequately treated) mothers, non-penicillin treated or those treated within 4 weeks of birth.
• Treatment: benzylpenicillin sodium (50,000 iu)30mg/kg 12-hourly IV for 7 days then 8-hourly for a further 3 days.
Follow-up should be arranged for six weeks of age.
• Dr Laura Jones (Paediatric Consultant) should be informed of the delivery. Subsequent follow-up should be at 6 weeks, 3, 6 and 12 months with clinical evaluation and syphilis serology.
6. Postnatal
• Breastfeeding can be safely initiated and should be supported.
• Advise GUM team of delivery. Postnatal follow-up testing will be arranged by GUM.
NHS Lothian neonatal guidelines (in development)