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Syphilis in pregnancy

Presented by Lochan Shrestha


Intern, Department of Obstetric and Gynaecology
Nepal Medical College Teaching Hospital
Case Presentation
NEPAL MEDICAL COLLEGE TEACHING HOSPITAL SURNAME
(BLOCK LETTERS)

HISTORY SHEET
FIRST
GYNAE & OBST (NAMES)

CLINICAL NOTES
DATE (EACH ENTRY MUST BE SIGNED)

Mrs PT, A 20 year old female patient from


Nayapati, primi at 40 weeks + 4 days of
POG was admitted on kartik 8, 2063
c/o
Cessation of menstruation for 9 months
LMP: 27th poush, 2062
EDD: 4th kartik, 2063
By date: 40 weeks + 4 days
ANC check up at health post , she has taken iron and
calcium for only 2 months. TT immunization done
Pain in the lower abdomen for 10 hrs
Normal bowel and bladder habit, no burning micturation.
Sleep and appetite normal
No hx of P/V leaking or bleeding.
Continued..
Obstetric History
Married for 1 year
Primigravida
Menstrual History
K 15 yrs, f/c: 3-4 days/26-30 days, regular, no
dysmenorrhea
No history of contraceptive use
Past history- not significant
Family history not significant
Personal history- non smoker who drinks
occasionally.
On Examination
General Condition- fair
No pallor, icterus or oedema
Vitals
Blood pressure: 110/80 mm of hg
Pulse 80/min, regular
Temperature: afebrile
P/A
uterus 36 weeks of size,
cephalic presentation of the fetus, head 4/5th palpable,
FHS 140/min
Mild contractions present
P/V
Vulva/vagina normal
Os closed, cervix 25% effaced, membrane+nt
Head high up, pelvis seems to be adequate
Investigations
Blood tests (DOA)
Hb % 11.1 gm%
Urine : WNL
Blood Group A +ve
HBSAg negative
VDRL Reactive, 1:32 titer,
Husbands VDRL NR
TPHA +ve
USG- Obstetric Scan (1st DOA)
34+ weeks single live intrauterine pregnancy
Cephalic presentation
Posterior upper and mid uterine placenta
Oligohydroamnios (amniotic fluid index=5.5
cm)
Estimated fetal weight = 2435 +/- 365gms
HIV I & II (2nd DOA) Negative
Diagnosis

Primi at 40 weeks + 4 days Period of


Gestation with syphilis and
oligohydroamnios.
Plan
Treatment of syphilis with penicillin
Induction of labor with cerviprime
Indication
term + 6 days with oligohydroamnios
Management
Inj. Benzyl penicillin 12 lakh units in each
buttock IM received on 2nd DOA at11:30 am
Induction of Labor with cerviprime
2nd DOA, 10:50am under aseptic condition
cerviprime gel was inserted intracervically.
2nd DOA, 7pm 2nd dose was administered
intracervically
FHS monitored every 5 minutes for hr then
hrly after each dose.
Delivery Note
10:15pm on kartik 10,2063 (2nd DOA)
spontaneous delivery
Normal Delivery with 2nd degree tear
Delivery of an alive term female baby of
weight 2.5 kgs with APGAR 8/10, 9/10
No obvious gross congenital abnormalities
of the baby
Discharge
Kartik 12, 2063 (2nd PPD)
Advice on Discharge
Cap ferrous-Z 1 cap PO OD for 6 weeks
Tab calvit 1 tab PO OD for 6 weeks
Follow up
Of baby with VDRL titre report on paediatrics OPD
Of mother in gynae OPD after 6 weeks
Literature Review
Sexually Transmitted Diseases
STDs are a group of contagious conditions
whose principal mode of transmission is by
sexual contact
some common STDs
Syphilis
Gonorrhea
HIV infection
Genital herpes
Hepatitis A, B, C, D
Genital warts
Chlamydial infection
Trichomoniasis
Chancroid, lymphogranuloma venerum and
granuloma inguinale ( common in tropical areas)
STD and Pregnancy
Consequences of STDs
On the mother
Does not alter the course of the disease by
pregnancy
On the fetus due to vertical transmission
Increase in incidence of abortion, preterm birth,
Low birth weight, and intrauterine death
Congenital malformations
Screening for STDs
Routine screening on 1st ANC visit
HIV I&II, VDRL of pt. and her husband, HBSAg
Syphilis
Brief review Etio-pathogenesis
Clinical
Manifestations
Laboratory Findings
VDRL test
Diagnosis
Treatment
Etiolopathogenesis
Causative Agent-Trepanoma pallidum
A spirochete bacteria
0.2 um x 5-15 um in length with spiral coils
regularly space at distance of 1 um, motile
Antigenic Structure:
Outer membrane (surrounds the periplasmic space
and the peptidoglycan complex.
Endoflagella
Hyaluronidase (increase the invasiveness)
Cause development of Ab like substance reagin
Treponema pallidum, spirochete that causes syphilis. Untreated or
inadequately treated syphilis in pregnant women can profoundly affect
fetal outcome, resulting in congenital infection, prematurity, or perinatal
death. Copyright (c) 1997, Medscape Inc.
Transmitted by direct contact with an infectious
moist lesion
Incubation Period: 10-90 days
primary chancre develops, heals after 1-5 weeks
2-6 months later (avg 6 weeks) the generalized
cutaneous eruption of secondary syphilis
Goes into latent phase or into tertiary phase
Clinical Manifestations
Primary syphilis Secondary Syphilis
Genital ulcer: painless Skin and mucous membranes
ulcer with clean base and Rash: diffuse, macular papular,
firm indurated borders pustular, both
(chanchre) Condylomata lata
Regional lymphadenopathy Mucous patches
Generalized lymphadenopathy
Constitutional Symptoms e.g.
headache, malaise, anorexia
CNS: headache, meningitis
Ocular: iritis, iridocyclitis
Others
Renal : glomerulonephritis,
nephrotic syndrome
Liver : hepatitis
Bone and joint:arthritis,
Primary lesion of syphilis. Figure courtesy of periostitis
Centers for Disease Control and Prevention.
Secondary syphilis (rash). Figure
courtesy of Centers for Disease
Control and Prevention.

Mucinous Patches in secondary syphilis


Primary canchre
Clinical Manifestations
Late syphilis
Late benign (gummatous): granulomatous lesion
usually involving the skin, mucous membranes and
bones, but any organ can be involved
CVS
Aortic insufficiency
Coronary ostial stenosis
Aortic aneurysm
Neurosyphilis
Asymptomatic
Meningovascular: seizures, hemiparesis or hemiplegia
Tabes dorsalis: impaired proprioception and vibratory sense,
argyll robertson pupil
General paresis: personality changes, decreased memory,
slurred speech
Gumma scar in gluteal region
Labarotary Findings
Identification of the specimen
Darkfield examination of cutaneous lesions
Immunoflorescent technique for dried smears
Silver staining in biopsy materials may confirm the
diagnosis in difficult cases.
Serological Tests
Non-treponemal tests
VDRL most widely used. Others RPR test, automated reagin
test.
Mostly used for screening purposes.
Treponemal antibody tests
Fluorescent treponemal antibody absorption (FTA-ABS) test,
micro agglutination assay (MHA-TP), T. Pallidum
haemagglutination assay (TPHA)
Sensitive and specific
Tests remain positive despite therapy, and so are not given in
tiers or used to follow serologic response to treatment.
Venereal Disease Research
Laboratory (VDRL) Test
Principle (Slide test)
A drop of Ag (cardiolipin-lecithin antigen) + antiserum
(reagin) placed in a slide and mixed by shaking (180 Hz).
Formation of floccules indicate a +ve result.
Becomes positive 3-6 weeks after infection or 2-3
weeks after the appearance of the primary lesion.
VDRL titer
High in secondary syphilis and tends to be lower or even nil
in late forms of syphilis
A 4-fold falling titer in latent or late syphilis or a falling or
stable titre indicates satisfactory therapeutic progress.
False Positives
Collagen diseases, infectious mononucleosis, malaria
and many febrile diseases, leprosy, vaccination, drug
addiction, old age and possibly pregnancy.
Usually low in titer and transient and may be
distinguished by specific treponemal antibody tests.
Very high titers can give a false negative
reaction, known as the prozone phenomenon.
The prozone effect can be overcome by diluting
the serum prior to testing. This is a recognized
reason for failure to treat during pregnancy, and
clinicians must be aware of this phenomenon.
Essentials of Diagnosis
Primary Syphilis
Painless genital sore
Painless rubbery regional lymphadenopathy followed by
generalized lymphadenopathy in 3rd to 6th week
Darkfield microscopic findings
Positive serologic test in 70% cases
Secondary Syphilis
B/L symmetric extra genital papulosquamous eruption
Condyloma latum, mucous patches
Darkfield findings positive in moist lesion
Positive serologic test for syphilis
Lymphadenopathy
Tertiary Syphilis
Cardiac, neurological, ophthalmic and auditory lesions
Gummas
Latent Syphilis
History or serologic evidence of previous infection
Treatment
Early syphilis and contacts
less than 1 year duration
1. Benzathine penicillin G 2.4 million units IM once
2. Tetracycline 500 mg PO 4 times daily, or 100 mg
doxycycline twice daily, or erythromyin 500 mg PO 4
times a day for 14 days, for non pregnant penicillin
allergic pts
Late syphilis
Indeterminate duration or more than 1 year duration
1. Benzathine penicillin G 2.4 million units IM weekly for
3 successive weeks (7.2 million units total)
2. Tetracycline 500 mg orally 4 times daily or 200 mg
doxycycliine twice daily for 28 days for penicillin
allergic patients.
Syphilis and Pregnancy
Risk of fetal infection
Effects on pregnancy
Congenital syphilis
Laboratory findings
Essentials of
diagnosis
Treatment
Risk of fetal Infection
Depends on the degree of spirochetemia and the
gestational age of the fetus
Treponemes may cross placental barrier at any stage of
the pregnancy, but fetal involvement rare before 18
weeks of GA because of immunoincompetence.
Earlier in the pregnancy more serious the risk of
premature labor or stillbirth
Ante partum infection in late pregnancy: 40-50% have
definite infection
Placental infection:
endarteritis, stromal hyperplasia, and immature villi.
Grossly the placenta looks pale, yellow, waxy and enlarged.
Effects on pregnancy
Mother
Accelerates the course of HIV infection in pregnant
woman
Baby
T. pallidum enters the fetal circulation with
disappearance of cytotrophoblast in the villi
Obliterative endarteritis:
Perivascular infiltration of lymphocytes and plasma cells
within the developing fetus.
The placenta
Bulky from increase connective tissue
Villi become bulky due to increased cellularity, the vascularity
being diminished.
Congenital Syphilis
Intrauterine infection (on birth)
Hepatospleenomegaly, osteochondritis, jaundice, anemia, skin
lesions, rhinitis, lymphadenopathy, nervous system involvement.
Weeks or months later
Examination of the baby at intervals of 3 weeks to 4 months for
stigmata of syphilis.
Stigmata of syphilis
Hutchinsons incisors (anterior-posterior thickening with notch on
narrow cutting edge)
Mulberry molars
High arched palate, maxillary hypoplasia, saddle nose
Salt and pepper scars on retina (chorioiditis), corneal scars (from
interstitial choroiditis)
Sabre tibia (from periostitis), bossing in frontal and parietal bones
(healed periosteal nodes)
Analogous to adult secondary syphilis
newborn with congenital syphilis. Characteristic features include oral and
skin lesions and saddle nose. Figure courtesy of Centers for Disease
Control and Prevention.
Stigmata of Syphilis

Osteochondritis of femur and tibia Trophic degeneration of Knee joint


Hutchinsons Incisor

Saber Shin of tibia

Stigmata of
Syphilis
Saddle Nose deformity
Laboratory Findings
Identification of specimen
Silver staining of placental sections
Motile spirochetes can identified in amniotic fluid
obtained transabdominally in women with syphilis
and fetal death
PCR is extremely specific for detection of T pallidum
in amniotic fluid, neonatal serum and spinal fluid.
Serologic tests
Nontreponomal tests
VDRL used routinely for screening during ANC visits
Treponemal antibody tests
Confirm diagnosis
Essentials of diagnosis
Congenital Syphilis
History of maternal syphilis
Positive serological test for syphilis
Stigmata of congenital syphilis
Normal examination or signs of intrauterine
infection
Often stillborn or premature
Enlarged, waxy placenta
Treatment
Syphilis in Pregnancy
Routine test performed on 1st ANC visit
Penicillin regimen depends on stage of the syphilis
Penicillin allergy:
Erythromycin 500 mg orally 6 hrly for 14 days (early syphilis)
Consider treating mother with doxycycline after delivery
Tetracycline and erythromycin is not recommended during
pregnancy.
Congenital syphilis
Adequate maternal treatment before 16-18 weeks of gestation
Early :
Benzyl penicillin 50,000 U/kg iv 12 hrly for the first 7 days of life then
50,000 U/kg iv 8hrly for 3 days or
Procaine benzylpenicillin G 50,000 U/kg im daily for 10 days
Late :
Dose depends on the weight and age of child
Adult regimen from age 15
Follow up
Titers should be followed on a monthly basis
following treatment.
Titers can be expected to decline 4-fold by 3 to 6
months and
8-fold by 6 to 12 months after treatment of primary or
secondary syphilis.
The titer may revert to nonreactive by 12 months,
but often will stabilize at a low level (1:2 or 1:4),
indicating successful treatment
A 4-fold rise in the nontreponemal titer indicates
the need for retreatment.
Women who have signs of clinical disease and a
negative nontreponemal test should be treated.
Jarisch-Herxheimer Reaction
A febrile variation may occur in 50-75% of
patients treated in early syphilis
4-12 hrs after injection and completed by
24 hrs
Cause uncertain but may involve release
of toxic treponomal products on lysis
Benign but may trigger labor or fetal
distress
Prophylaxis with antipyretics or
corticosteroids is of unknown value
References
Current Obstetric and Gynaecologic Diagnosis and treatment
Alan H. DeCherney, Lauren Nathan

Current medical Diagnosis and Treatment


Lawrence M Tierney, jr., Stephen J.McPhee, Maxine A. Papadakis

Text book of obstetrics


Dutta

Principles and practice of Medicine, 19th edition


Haaslett, Chilvers, Boon, College, Hunter

Recognizing and Treating Syphilis in Pregnancy


Julie A. Larkin, MD, Louis Lit, MS-2, University of South Florida College of
Medicine; John Toney, MD, James A. Haley, Veteran Administration Hospital.