Prevention and detection of congenital syphilis depends on serologic screening of the mother during pregnancy. Women should be screened for syphilis with serologic testing at the first prenatal visit. Women at high risk for syphilis should be screened at 28 weeks’ gestation and at delivery, in addition to the routine early testing. Screening at delivery is also mandated in some states. In addition, a woman who delivers a stillborn infant after 20 weeks’ gestation should be screened for syphilis. All pregnant women with syphilis should also be tested for HIV. Treatment during pregnancy with penicillin is effective in preventing maternal-fetal transmission and in treating an infected fetus. Pregnant women should receive the same penicillin regimens as non-pregnant patients, appropriate for the stage of syphilis, and the same serologic follow-up testing. No alternatives to penicillin have proven efficacy for syphilis in pregnancy. Erythromycin does not reliably cure syphilis in the fetus, and there are insufficient data for the use of ceftriaxone and azithromycin. Tetracycline and doxycycline should not be used in pregnancy. Therefore, all pregnant patients with syphilis who have a history of a penicillin allergy should be desensitized and treated with penicillin, with or without the use of skin testing.
The Jarisch-Herxheimer reaction develops in up to 45% of pregnant women treated with penicillin and may precipitate uterine contractions, preterm labor, and fetal heart-rate decelerations during the second half of pregnancy. Routine hospitalization for fetal monitoring after treatment is not currently recommended, however, unless the fetus has evidence of fetal syphilis on ultrasonogram. Women being treated in early pregnancy should be counseled to stay well hydrated and to take acetaminophen for uterine cramping, pain, or fever, whereas those at greater than 20 weeks’ gestation should seek obstetric evaluation for fever, decreased fetal movement, or symptoms of labor. Treatment is largely supportive and may require continuous fetal heart rate monitoring. There is not enough evidence to recommend prophylactic therapy to prevent this reaction.
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WOMEN’S HEALTH