Syphilis in pregnancy Flashcards
What is the aetiology of syphilis
spirochete bacterium Treponema pallidum
Transmission:
- Sexually (most common): direct contact with an infectious lesion, often involving the genital, rectal, or oral mucous surfaces
- Vertically from mother to child in pregnancy
- Sharing or needles in IVDU
- Blood products/organ transplant
Incubation: 21 days
What are the risk factors for syphilis
Unprotected sex
Multiple or anonymous sexual partners
Substance use (including alcohol and illicit drugs) before sex
Transactional sex (commercial sex work, exchange of sex for drugs)
Previous or current diagnosis of any sexually transmitted infection
Social vulnerability e.g. poverty, homelessness, migrant, refugee status
Needle-sharing contact with a known syphilis case
Serosorting among MSM living with HIV (choosing a partner based on perceived HIV status)
Risk compensation related to pre-exposure prophylaxis for HIV
What are the symptoms of syphilis
Genital warts: Usually a single painless wart, but may be painful
Non-pruritic rash on the palms and soles
Moist warts at the sites of skin friction e.g. perianal, vulval, breasts, axillae
Lesions on the inside of the mouth
Constitutional: fever, malaise, fatigue, arthralgia
Lumps (lymphadenopathy)
Neurological symptoms (seizure, hearing loss, headache and meningism, peripheral neuropathy)
Ophthalmological symptoms (visual impairment, eye pain)
Rhinitis (sign of congenital syphilis)
What are the stages of syphilis
- Primary (resolves in 3-8w):
- painless ulcer (chancre) at the site of infection (most commonly genital area)
- local lymphadenopathy - Secondary (Systemic involvement, resolves in 2-12w):
- Skin and hair changes such as a maculopapular rash, condyloma lata (Moist wart-like lesions) and patchy alopecia
- Oral lesions (snail tract lesions)
- Generalised lymphadenopathy
- Low-grade fever, headache, and malaise - Late (defined as more than 2 years after infection):
- Late latent syphilis - confirmed infection in the absence of any current clinical features
- Tertiary syphilis - rare, but may present with cardiac disease e.g. aortic aneurysm, cutaneous disease e.g. gummatous lesions, and/or neurological disease
What are the features of congenital syphilis
Rhinitis
Hepatosplenomegaly
Premature labour and IUGR
Neonatal skin rash
A sign of late congenital syphilis (occurring >2 years of age). Hutchinson’s teeth → (peg-shaped incisors, notched at the apex), mulberry molars dome-shaped with small cusps at the apex.
What are the signs of syphilis on examination
General exam (scalp, mouth, palms, soles)
- Symmetrical, non-pruritic maculopapular rash (palms of the hands and soles of the feet)
- Moist wart-like lesions (condylomata lata) — usually develop at sites of skin friction such as perianal and vulval regions, under the breasts, and axillae.
- Patchy lesions on the oral mucosa (‘snail tract’ lesions).
- Regional (primary) or generalised (secondary) lymphadenopathy (moderately enlarged, rubbery)
Genital exam
- Genital lesion(s) - solitary, painless, indurated, genital ulcer (chancre) with a clean base and sharp border.
- Regional lymphadenopathy
Neuro: ?neurosyphilis
Eye: optic neuropathy, uveitis, retinitis
Cardio: murmurs (aortic regurgitation), signs of HF
What are the features of neurosyphilis
Areflexia
Meningitis.
Cranial nerve palsies (in particular II and VIII).
Hearing loss.
Tabes dorsalis (inflammation of spinal dorsal column/nerve roots) — may present with ‘lightening pains’, paraesthesia, Charcot’s joints, pupillary change (Argyll-Robertson pupils), absent reflexes, joint position and vibration sense.
General paresis (cortical neuronal loss) — may present with forgetfulness and personality change which develop into severe dementia
Seizure
Peripheral neuropathies
What investigations should be done for syphilis
- Refer to a genito-urinary medicine (GUM) specialist for laboratory investigations (such as dark-field microscopy and serology) and a full sexual health screen (including HIV testing).
Bedside: Swabs from active lesions for dark-field microscopy or PCR → Coiled spirochaete bacterium with a corkscrew appearance and motility
Bloods:
- rapid plasmin reagin (RPR) (non-treponemal, requires specific test follow up)
- venereal disease research laboratory test (VDRL) (non-treponemal, requires specific test follow up)
- Treponemal enzyme immunoassay (EIA) or treponemal chemiluminescent assay (CLIA)
- Treponema pallidum haemagglutination/particle assay (TPHA/TPPA)
- Fluorescent treponemal antibody absorption test (FTA-abs)
Other
- LP: ? neurosyphilis
- CXR: ?aortic regurg, HF
- Echo: ?aortic regurg, HF
Describe syphilis testing in pregnancy
Syphilis is part of the routine antenatal screening (done at the booking scan 8-12 weeks) - detection of treponemal antibodies, but pregnancy can be associated with an increased chance of false positive serology
All babies born to mothers with syphilis should undergo Auditory brainstem response or audiometry
What is the management for syphilis
- Refer to GUM specialist
- Advise the person to avoid all sexual contact and exposure of other people to active lesions until the diagnosis is excluded, or successful treatment of the condition has been confirmed.
- Admit if >22w
- Abx:
- Early infection: Benzathine benzylpenicillin IM single dose
- Late infection: Benzathine benzylpenicillin IM x3
- (Alternative doxycycline if PenAll) - Consider corticosteroid therapy
- Repeat bloods 3/12 (4 fold drop in RPR)
What is the management for neurosyphilis
- IV aqueous benzylpenicillin 4 hourly, 14/7
- IM procaine benzylpenicillin + oral probenecid
- Consider corticosteroids (prednisolone)
What are the risks of treatment for syphilis in pregnancy
Jarisch-Herxheimer reaction
- fever, rash, tachycardia after the first dose of antibiotic
- in contrast to anaphylaxis, there is no wheeze or hypotension
- it is thought to be due to the release of endotoxins following bacterial death and typically occurs within a few hours of treatment
- No treatment is needed other than antipyretics if required
What are the complications of syphilis
Neurosyphilis
Psychological and social complications
Congenital syphilis
HIV infection
What is the prognosis for syphilis
Syphilis can be cured if treated with appropriate antibiotics before complications develop
Untreated, around 1/3 of cases progress to later stages of disease, resulting in severe, sometimes irreversible, CVD, neurological and ocular complications
Treatment in late syphilis usually halts infection, but some Treponema spirochetes can persist in protected sites like the eye and CNS
