Congenital syphilis

An infectious disease caused by the vertical transmission of Treponema pallidum, this prevention and detection depends on the identification of syphilis in pregnant women.

Cases of congenital syphilis increased by 754.8% from 2012 to 2021: currently one in every 1300 live births is affected.

In 2022 the CDC reported 3761 cases of congenital syphilis.

Untreated syphilis during pregnancy can lead to stillbirth, neonatal death, or infant disabilities such as deafness, neurologic impairment, and bone deformities.

A preventable disease, but it is associated with a substantial morbidity and mortality.

It is usually transmitted to the fetus transplacentally.

Congenital syphilis usually results from transplacental passage of T. pallidum to the fetus during disseminated maternal infection,but less frequently to exposure to syphilitic genital lesions the time of delivery.

T.pallidum has a small genome and limited outer membrane protein expression, rendering the organism undetectable by the fetal immune system, leading to persistent fetal infection after exposure.

The risk of congenital syphilis to the fetus is 50 to 70% in pregnancies complicated by early syphilis and decreases to 15% if maternal syphilis was contracted more than a year before the pregnancy.

The rate of congenital syphilis in the US was the highest it has been in nearly 30 years, in 2021.

The annual rate of primary and secondary syphilis among Native American, and Alaskan, native persons, Native Hawaiian and Pacific Islanders, and Black women, as compared with White women, have increased over the past five years by factors of 8, 4, and 3.5, respectively.

Cases of congenital syphilis increased by 754.8% from 2012 to 2021: currently one in every 1300 live births is affected.

Its causative agent Treponema pallidum is capable of crossing fetal membranes at any time in gestation, gaining access to amniotic fluid as early as 14 weeks gestation.

The risk of congenital infection is highest among women with early syphilis and ranges from 40-70% across all trimesters, with a decrease to approximately 10% with late stage disease.

Transmission can occur anytime during pregnancy, and the risk of transmission increases with the duration of gestational exposure.

Placental infection is followed by amniotic fluid infection, subsequently hematologic dysfunction leading to non-immune hy drops.

Fetal infection can result in anemia, hepatomegaly, hydrops, and a 30% risk for stillbirth.

40% of infected newborns have no clinical signs, but they are at increased risk for being premature and may have profound hematologic and hepatobiliary abnormalities, bone lesions, and prolonged hospitalization.

If not treated timely infected infants risk having neurologic sequelae, a characteristic of late congenital syphilis.

Can be prevented by early detection of maternal infection and treatment at least 30 days before delivery.

Changes in incidence of primary and secondary syphilis among women usually are followed by similar changes in the incidence of congenital syphilis.

About 1 in 4 pregnant women that have syphillis passed the disease on.

About 80% of pregnant women with untreated syphilis have an 80% chance of passing on the disease to her child.

As many as 40% of newborns delivered by women with untreated syphilis are stillborn or die from infection shortly after birth.

Rate among infants <1year of age increased 23% from 8.2 cases per 100,000 live births in 2005 to 10.1 during 2008.

In 2016 rate 15.7 cases per 100,000 live births. The highest since 2001.

Increase cases and rate of congenital syphilis occurring among infants born to black mothers.

In 2008 only 64% of mothers of infants with congenital syphilis received prenatal care.

Early prevention of congenital syphilis requires early prenatal care because it facilitates early detection and treatment of maternal syphilis.

It is recommended that a serologic test for syphilis be performed at the first prenatal test.

Screening for syphilis at the first prenatal visit to prevent congenital syphilis is standard of care in legally mandated in most states.

CDC recommends pregnant women at high risk the screen there early in the third trimester in at delivery. The CDC recommends it all pregnant women be screened for syphilis at their first prenatal visit.

In all communities at high risk for congenital syphilis serologic testing and sexual history should be obtained at 28nweeks gestation and at delivery.

Untreated syphilis in pregnancy carries significant risk for stillbirth with fetal loss, premature birth, low birth weight, congenital syphilis, and neonatal death.

Health problems related to congenital syphilis include: jaundice, rashes, hepatomegaly, splenomegaly, and severe anemia.

Those children who survive the first month can end up with developmental delays, bone and joint abnormalities.

All women that deliver a stillborn should have a serological test for syphilis.

The clinical presentation of syphilis does not difference between pregnant and non-pregnant women.

The serologic, diagnosis of syphilis is the same in pregnant and non pregnant persons: VDRL test followed by a treponemal immunoassay.

The sensitivity of dark field microscopy for visualizing T pallidum from amino synthesis fluid ranges from 42 to 86% but it is an impractical testing process.

Ultrasound evidence of intrauterine infection is the most commonly used method to examine a fetus for evidence of congenital syphilis.

Ultrasound abnormalities can be identified at after 18 weeks of geststation with an immune response to T. Pallium infection with fetal hepatomegaly in 80% of cases, anemia is indicated by peak systolic velocity of the middle cerebral artery, placentomegaly, polyhydramnios, and non-immune hydrops.

The absence of ultrasound abnormalities does not rule out congenital infection: 12 to 15% at risk fetuses have no ultrasound findings of congenital infection.

Because of the paucity of diagnostic tests for the newborn, treatment decisions are based on identification of syphilis in the mother, assessment of maternal treatment, interval between initiation of maternal treatment and delivery, and comparison of maternal and neonatal  non-treponemal, serological titers at delivery in the presence, or absence of clinical laboratory, and radiographic evidence of syphilis in the neonate.

Newborns with syphilis may be preterm was small for gestational age.

Symptomatic newborns have anemia and thrombocytopenia, hepatobiliary dysfunction and bullous or mucocutaneous lesions, osteochondritis, or periositis.

Moth-eaten long bones in newborns due to demineralization are pathopneumonic for congenital syphilis.

Syphilitic,p rhinitis, known as sniffles, and fever are common manifestations in congenital syphilis.

Primary syphilis is characterized by one or more indurated chancres at the side of an inoculation, which usually is painless, and occurs within three weeks after exposure.

Newborns meeting the criteria for probable syphillis should undergo neurosyphilis evaluation and treatment with intravenous aqueous crystalline penicillin G.

Up to 60% of symptomatic newborns with congenital syphilis have neurosyphilis, manifesting with seizures, ophthalmologic abnormalities, cranial, nerve palsy, or cerebral infarcts in 5 to 40% of affected newborns.

CSF VDRL testing is approximately 50% positive IN congenital neurosyphilis with 90% specificity.

After the primary lesion resolves, a macular rash often appears in the second phase.

The rash frequently, but not always, involves the palms and soles, and may desquamate.

Other clinical manifestations of secondary syphilis include lymphadenopathy, alopecia, condyloma, and oral mucosal patches.

Pregnant women with syphilis should be treated with penicillin: benzathine, penicillin G.

Syphilis in pregnancy can be cured with just one injection with 1 or 3/weekly injections depending on the duration of infection of a long-acting penicillin, reducing the chance of maternal child transmission to virtually zero.

There is more than 95% efficacy when a single dose of 2.4 million units of benzathine penicillin G is used in early infection, with a little increasing efficay when higher or multiple doses are used.

The Jurisch-Herxheimer reaction occurs in up to 40% of women treated for syphilis during pregnancy, and is characterized by cramping, pyrexia, and myalgias.

Fetal anemia and related hydrops, usually resolved within three weeks of treatment of the maternal syphilis, with normalization of fetal liver and placenta measurements.

Detection,and appropriate treatment before the third trimester allows ultrasound normalities to resolve completely in most fetuses.

Late manifestations of congenital syphilis may occur after two years of age and include: bony abnormalities in the midline face and lower extremities, Hutchinson’s teeth, ocular abnormalities, and sensorineural hearing loss.

A large number of babies with congenital syphilis, are asymptomatic, with manifestations of disease occurring days to months later in the absence of treatment:55%.

All neonates with a reactive nontreponemal test should be monitored serologically every 2 to 3 months to ensure normalization.


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