Maternal and congenital syphilis in Brooklyn, NY. Epidemiology, transmission, and diagnosis

Maternal and perinatal risk factors associated with congenital syphilis

OBJECTIVE

Mother-to-child transmission of syphilis remains an important global public health problem. Untreated intrauterine infection may result in adverse events for the fetus or newborn (NB). Maternal risk factors, such as prenatal care, early diagnosis, and appropriate treatment, significantly impact the likelihood of vertical transmission of syphilis. The purpose of this review is to evaluate maternal risk factors for congenital syphilis and the characteristics of exposed NB.

METHODS

A total of 14 studies were evaluated, including 8 cohort studies, 4 cross-sectional and 2 control cases. A total of 12,230 women were included, with confirmed or highly probable congenital syphilis outcome, and 2285 NB. The studies evaluated risk factors for congenital syphilis, which were maternal, demographic, obstetric factors and characteristics of the exposed NB.

RESULTS

Included in the risk factors studied, inadequate prenatal care and late onset, as well as inadequate or late treatment of maternal syphilis were significant risk factors for the outcome of congenital syphilis. When the time set of maternal diagnosis was correlated with neonatal infection, there was a tendency to worsen prognosis (more infected NB) in women diagnosed later in pregnancy, as well as in women who underwent few prenatal consultations and inadequate treatment. Women with recent syphilis with high VDRL titres had a higher rate of vertical transmission. The prior history of syphilis with adequate treatment was identified as a protective factor, resulting in lower rates of congenital syphilis. Among the epidemiological and demographic aspects surveyed, it was observed that young age, lower schooling, unemployment, low family income and no fixed residence were associated with higher risk of congenital syphilis.

CONCLUSIONS

The association of syphilis with adverse socio-economic conditions and inadequate prenatal care suggests that the improvement of the population's living conditions and equitable access to quality health services may have an impact on the reduction of congenital syphilis.

A Narrative Review of the Epidemiology of Congenital Syphilis in the United States From 1980 to 2019

OBJECTIVES

Congenital syphilis (CS) is the result of antepartum transmission from mother to fetus of the spirochete Treponema pallidum. Although preventable through timely screening and treatment, the incidence of CS in the United States is increasing. This review describes the epidemiological trends in CS in the United States from 1980 to 2019 and characteristics of mothers of infants with CS.

METHODS

We performed a narrative review of epidemiological studies of CS following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for reporting of observational studies in epidemiology. Quality and bias of included studies were assessed using the Newcastle-Ottawa Scale. Studies that described the demographics and characteristics of pregnant women with syphilis or who delivered an infant with CS in the United States were identified from PubMed and Embase.

RESULTS

We identified a total of 2771 studies, of which 309 were selected for further review and 27 were included in the final analysis. Substance use during pregnancy was a risk factor for CS in 16 studies. Maternal cocaine use was described in 11 of the 16 studies, 10 of which were published between the years 1980 and 1999. No prenatal care was a risk factor for CS in 17 studies. Evidence of inadequate syphilis testing (i.e., no maternal screen, first screen after the first trimester, or no repeat screen in third trimester) or treatment (i.e., no treatment, treatment <30 days before delivery, or nonpenicillin treatment) was significantly associated with CS in 13 studies. Finally, higher rates of CS were reported among African American women in 11 studies.

CONCLUSIONS

Infection with and antepartum transmission of syphilis disproportionately affect certain subgroups of women. Women who report substance use during pregnancy are more likely to give birth to an infant with CS. No prenatal care and evidence of inadequate syphilis testing and treatment during pregnancy are also significantly associated with giving birth to an infant with CS. Finally, cases of CS disproportionately affect African American women. Addressing the CS epidemic will require identification and targeted allocation of resources to communities at elevated risk for syphilis, removal of barriers to prenatal care, and ensuring timely treatment and adequate partner notification of identified cases.

Use of National Syphilis Surveillance Data to Develop a Congenital Syphilis Prevention Cascade and Estimate the Number of Potential Congenital Syphilis Cases Averted

BACKGROUND

Recent increases in reported congenital syphilis have led to an urgent need to identify interventions that will have the greatest impact on congenital syphilis prevention. We sought to create a congenital syphilis prevention cascade using national syphilis surveillance data to (1) estimate the proportion of potential congenital syphilis cases averted with current prevention efforts and (2) develop a classification framework to better describe why reported cases were not averted.

METHODS

We reviewed national syphilis and congenital syphilis case report data from 2016, including pregnancy status of all reported female syphilis cases and data on prenatal care, testing, and treatment status of mothers of reported congenital syphilis cases to derive estimates of the proportion of pregnant women with syphilis who received prenatal care, syphilis testing, and adequate syphilis treatment at least 30 days before delivery, as well as the proportion of potential congenital syphilis cases averted.

RESULTS

Among the 2508 pregnant women who were reported to have syphilis, an estimated 88.0% received prenatal care at least 30 days before delivery, 89.4% were tested for syphilis at least 30 days before delivery, and 76.9% received an adequate treatment regimen that began at least 30 days before delivery. Overall, an estimated 1928 (75.0%) potential congenital syphilis cases in the United States were successfully averted. Among states that reported at least 10 syphilis cases among pregnant women, the estimated proportion of potential congenital syphilis cases averted ranged from 55.0% to 92.3%.

CONCLUSIONS

Although the majority of potential congenital syphilis cases in the United States were averted in 2016, there was substantial geographic variation, and significant gaps in delivering timely prenatal care, syphilis testing, and adequate treatment to pregnant women with syphilis were identified. The congenital syphilis prevention cascade is a useful tool to quantify programmatic successes and identify where improvements are needed.

Congenital syphilis: A guide to diagnosis and management

Although congenital syphilis is a rare disease in Canada, infected infants may experience severe sequelae, including cerebral palsy, hydrocephalus, sensorineural hearing loss and musculoskeletal deformity. Timely treatment of congenital syphilis during pregnancy may prevent all of the above sequelae. However, the diagnosis of suspected cases and management of congenital syphilis may be confusing, and the potential for severe disability is high when cases are missed. The present review provides assistance to practitioners in the diagnosis of suspected cases and management of children with presumed or confirmed infection.

Inadequate syphilis screening among women with prenatal care in a community with a high syphilis incidence

OBJECTIVES AND GOAL

This study was designed to evaluate the extent to which pregnant women in a community with a high syphilis incidence were screened for syphilis according to standard recommendations of twice during prenatal care and at labor and delivery.

STUDY DESIGN

Labor and delivery records from 4 hospitals in Miami-Dade County, Florida, were abstracted to obtain maternal and prenatal care characteristics and syphilis screening practices.

RESULTS

Of the 1991 women, records indicated that 1655 (83%) were screened at least once during prenatal care, 220 (11%) were screened twice during prenatal care before delivery, and 184 (9%) were screened twice during prenatal care and at delivery. Attending a private clinic, having more than adequate prenatal care and having private insurance were associated with not being screened at least twice before delivery.

CONCLUSIONS

Few women were screened according to standard recommendations, and provider or institutional-related factors affected adequacy of screening.

Coverage of Antenatal Syphilis Screening and Predictors for Not Being Screened in Ulaanbaatar, Mongolia

OBJECTIVES

To measure the coverage of antenatal syphilis screening and identify factors related to women not being screened.

GOAL

To assess the syphilis control program in Mongolia.

STUDY DESIGN

Antenatal care records of women in 16 antenatal care clinics of 6 districts were reviewed. Additionally, postpartum women were interviewed to identify potential factors for not being screened.

RESULTS

Among 3,519 antenatal records, the coverage of syphilis screening was 77.7%. Of 2,735 screened women, 54 (2.0%) had reactive serological results and subsequently received treatment. Four late antenatal care comers delivered infants with congenital syphilis. Being unscreened was significantly associated with late antenatal care (odds ratio OR=2.6), lack of knowledge (OR=5.5), history of previous sexually transmitted infection (OR=3.7), and living far from screening services (OR=4.9).

CONCLUSIONS

The coverage of antenatal syphilis screening is still low, with poor contact tracing. More efforts are needed to promote early antenatal care visit and improve syphilis screening systems.

Evaluation of a Treponema pallidum-Specific IgM Enzyme Immunoassay and Treponema pallidum Western Blot Antibody Detection in the Diagnosis of Maternal and Congenital Syphilis

BACKGROUND

Congenital syphilis (CS) is a result of untreated or inadequately treated maternal syphilis. CS is more likely with early stages of maternal syphilis, but most mothers lack signs or symptoms and the risk of CS is unclear.

GOAL

The goal of this study was to evaluate Treponema pallidum IgM Western blot (TP IgM WB) and a T. pallidum IgM enzyme immunoassay (TP IgM ELISA) in mothers with syphilis to determine if positive tests better indicate a risk of CS than a rapid plasma reagin titer >/=1:16.

STUDY DESIGN

Ninety-seven mother-baby pairs with reactive syphilis serology were evaluated.

RESULTS

TP IgM WB tests were positive in 18 pregnancies (7 of 18 babies had CS) and negative in 79 pregnancies (7 of 82 babies had CS). Thirty-two mothers had titers >/=1:16 (6 babies with CS) and 65 mothers had titers </=1:8 (8 babies with CS).

CONCLUSION

TP IgM tests better identify mothers at risk of delivering babies with CS than maternal titer >/=1:16.

Congenital syphilis and fluorescent treponemal antibody test reactivity after the age of 1 year

BACKGROUND

Many believe that a persistently reactive fluorescent treponemal antibody absorption (FTA-ABS) is manifested with congenital syphilis after the age of 1 year, that it is useful in the retrospective diagnosis of children with congenital syphilis, and that it can be used to confirm other treponemal tests.

GOAL

To determine whether a reactive FTA-ABS after the age of 12 months is indicative of congenital syphilis.

STUDY DESIGN

Prospective outpatient follow-up evaluation until at least the age of 12 months was conducted for 194 babies born to mothers with reactive syphilis serology at delivery, and for two additional children with congenital syphilis diagnosed when they were younger than 1 year (total, 196 children).

RESULTS

In the study group, 54 children had reactive FTA-ABS (reactors) until the age of at least 12 months or more, and 142 children had nonreactive FTA-ABS (nonreactors) at the age of 12 months or more. Of the 54 reactors, 17 (31%) had evidence of congenital syphilis at birth, whereas evidence of congenital syphilis was seen in 14 of the 142 (10%) nonreactors (P = 0.0002). At 15 months, nonreactive FTA-ABS developed in six reactors, and eventually in 15 of 44 reactors (34%) tested.

CONCLUSIONS

A reactive FTA-ABS may be seen at 12 months in children with and without evidence of congenital syphilis at birth. Not all children with congenital syphilis will manifest reactive FTA-ABS at 12 months, and FTA-ABS reactivity wanes with time.

An epidemic of congenital syphilis in Jefferson County, Texas, 1994-1995: inadequate prenatal syphilis testing after an outbreak in adults

OBJECTIVES

After a syphilis epidemic in Jefferson County, Texas, in 1993 and 1994, congenital syphilis prevalence and risk factors were determined and local prenatal syphilis screening practices were assessed.

METHODS

Medical records were reviewed, pregnant women with syphilis were interviewed, and prenatal care providers were surveyed.

RESULTS

Of 91 women, 59 (65%) had infants with congenital syphilis. Among African Americans, the prevalence per 1000 live births was 24.1 in 1994 and 17.9 in 1995. Of the 50 women with at least 2 prenatal care visits who had infants with congenital syphilis, 15 (30%) had received inadequate testing. Only 16% of 31 providers obtained an early third-trimester syphilis test on all patients.

CONCLUSIONS

Inadequate prenatal testing contributed to this outbreak of congenital syphilis.

Dental defects of congenital syphilis

Diagnosis of the congenital form of syphilis is an important part of the palaeopathology of this disease. In theory, there are clear clinical signs to be found in the long bones and teeth, but it has rarely been possible to recognise the latter with a confidence in archaeological material, partly because the original descriptions of the dental deformities are sometimes contradictory and partly because it is nowadays difficult to find reference specimens in museums. This article describes two such specimens which have recently been rediscovered, and discusses the form of the dental defects which they show (Hutchinson's incisors, Moon's molars, and mulberry molars) in relation to the developmental sequence of the teeth.

Syphilis

Syphilis was first recognized as a distinct syndrome in Europe in the fifteenth century. Despite knowledge of congenital infection for more than 450 years and the existence of adequate therapy for 55 years, congenital infection remains a problem for the practicing clinician. Syphilis is caused by Treponema pallidum. Infection may be transmitted horizontally by sexual contact and vertically as a result of hematogenous dissemination across the placenta. Syphilis is classified as primary, secondary, latent, and tertiary. The diagnosis may be established by darkfield examination of clinical lesions and by serological assays. The drug of choice for syphilis is penicillin. This agent is the only antibiotic of proven value for the treatment of congenital syphilis. Accordingly, infected pregnant women who are allergic to beta-lactam antibiotics must be desensitized and then treated with penicillin.

Risk factors for congenital syphilis in infants of women with syphilis in South Carolina

OBJECTIVES

This study examined risk factors for congenital syphilis in South Carolina.

METHODS

Case infants with presumptive and confirmed congenital syphilis were compared with control infants born to women with reactive serologies during pregnancy, allowing investigation of risk factors for congenital rather than acquired transmission of syphilis. Data were collected from congenital syphilis report forms and birth certificates for 186 case infants and 487 controls born from 1991 to 1993. Odds ratios were calculated for maternal risk factors.

RESULTS

Significant statistical trends were found for timing of first prenatal visit and number of visits. Other significant factors included rural residence (odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.4, 2.9) and previous pregnancy loss (OR = 0.3, 95% CI = 0.2, 0.6).

CONCLUSIONS

Prevention of congenital syphilis may be less effective among pregnant women with syphilis in South Carolina who have fewer prenatal care visits. Health care providers need further education on maternal/child syphilis management and techniques for motivating and educating patients.