Syphilis in pregnancy mode of delivery

If left untreated, syphilis in pregnancy can have very serious, long-term health consequences and put you at risk for miscarriage, stillbirth, and even infant death. A pregnant mother who’s infected can transmit the infection to her baby through the placenta or exposure to a sore during vaginal birth. This is known as congenital syphilis. Congenital syphilis can put a baby at risk for deafness, blindness, anemia, jaundice, and a host of other health issues. The good news is that getting tested early for syphilis can help prevent these complications down the road.

What is syphilis?

Syphilis is a sexually transmitted infection (STI) that's caused by the Treponema pallidum bacterium. It's transmitted by direct contact with a sore called a chancre on an infected person. The most common way to get syphilis is through vaginal, anal, or oral sex, but it's also possible to get it by kissing someone with a chancre on or around the lips or in the mouth or by exposing an area of broken skin to a sore.

If left untreated, syphilis can have very serious long-term consequences. Fortunately, if caught in time, it can be treated with antibiotics, specifically penicillin.

The infection was nearly eliminated in 1957, but the number of cases of both syphilis and congenital syphilis have been climbing in recent years. In 2019, there were 129,813 new cases of syphilis – that's 91,845 more cases than HIV in 2018. While the rates of infection are higher among men than women, rates increased 30 percent between 2018 and 2019 and 178.6 percent from 2015 to 2019, according to the U.S. Centers for Disease Control and Prevention (CDC). About 16.7 percent of syphilis cases in 2019 were women and 18.7 percent were men who have sex with women only (41.6 percent were men who have sex with men only).

The rates are significantly higher in communities with high levels of poverty, low levels of education, and inadequate access to health care.

When a pregnant woman has syphilis, she can transmit the disease to her baby via the placenta, or if the baby comes in contact with the sore during a vaginal birth. Syphilis in pregnancy can be very serious and cause miscarriage, stillbirth, and even infant death. That's why all pregnant women need to get tested for syphilis during their first prenatal appointment. It's also recommended that women who are high risk for syphilis be rescreened early in the third trimester and again at delivery.

Syphilis symptoms in pregnancy

Syphilis progresses in stages: primary, secondary, latent, tertiary, and neurosyphilis and ocular syphilis. Syphilis symptoms differ from one stage to the next. In fact, you may not notice symptoms for years.

Primary Stage

In the first stage, known as primary syphilis, one or multiple chancres on the vagina and genital area are the first signs of the infection. They can also develop in your anus and rectum and the inside your mouth, which is why you might not initially notice them. Chancres are usually painless and are round with raised edges, and they tend to show up about three weeks after exposure to the bacteria. Chancres typically take three to six weeks to heal, whether you receive treatment or not.

If you don't receive treatment, the bacteria (known as spirochetes) are likely to continue to multiply and spread throughout the bloodstream. And when this happens, the disease progresses to the secondary stage.

Secondary Stage

In the secondary stage, syphilis can have a variety of symptoms that show up in the weeks or months after the chancre has healed, but again, they might not be noticeable. At this stage, most people develop a non-itchy syphilis rash on one or more parts of the body, such as your torso, the palms of your hands and the soles of your feet. The syphilis rash usually appears as red or reddish-brown spots that are rough.

Moreover, you may develop condyloma lata, which are large grey or white lesions, in your mouth, underarm and genital area.

In addition to a rash, you may also experience hair loss, muscle aches, a fever, sore throat, and swollen lymph nodes. Syphilis symptoms are recurrent and can disappear for periods of time and then come back again.

Just like the primary stage of the infection, your symptoms may go away with or without treatment, so it's important to get tested if you think you've been exposed or are at high risk. That said, if you don't seek treatment, the infection stays in your body but you may not have any syphilis symptoms for years, or it could develop into tertiary syphilis.

Tertiary Syphilis

About 15 to 30 percent of people who don't get proper treatment will have what's called tertiary syphilis.

This late stage of the disease that can develop up to 30 years after you were first infected and can cause serious health issues. Large sores called gummata can develop on the skin and in a host of organs, including the heart, brain, eyes (ocular syphilis), and liver. It can also affect your bones and joints. Fortunately, most people get treated early enough these days that very few end up with tertiary syphilis.

Syphilis that infects your central nervous system – your brain and spinal cord – is called neurosyphilis, and it can occur at any stage of the disease. Early on, it may cause problems like meningitis. Late neurosyphilis can lead to seizures, blindness, hearing loss, dementia, psychosis, spinal cord problems, and eventually death.

Will having syphilis in pregnancy affect my pregnancy or baby?

Syphilis can travel from your bloodstream across the placenta and infect your baby anytime during pregnancy. This is called congenital syphilis. The infection can also infect your baby during delivery if she comes in contact with a chancre. The good news is that getting tested early in your pregnancy can help protect you and your baby from complications. In fact, the risk of fetal infection is highest during the primary and secondary stages of the disease.

Syphilis in pregnancy can put you at risk for miscarriage, premature birth, fetal growth restriction (low birthweight), and issues with your placenta and umbilical cord. For example, the infection may cause your placenta to grow overly large and the umbilical cord to be swollen.

While most babies who become infected before birth might not have any symptoms initially, they may develop symptoms a few weeks or months after birth. Some of these symptoms include:

• Fever
• Inability to gain weight
• Cracking of skin at the mouth, genitals, and anus
• Rash on the palms and soles
• Watery fluid from the nose

Young children with late congenital syphilis might not experience symptoms until they're two to five years old. Some of the symptoms include abnormal teeth, bone pain, blindness, deafness, and deformity of the nose.

An estimated 40 percent of babies born to pregnant women with an untreated infection can be stillborn or die after birth. Babies with congenital syphilis are at risk for the following:

• Bone damage
• Severe anemia
• Enlarged liver and spleen
• Jaundice
• Nerve problems, which can lead to blindness, deafness, meningitis, or skin rashes
• Health issues affecting the eyes, ears, teeth, bones, and joints

And whether or not there are obvious symptoms early on, if the disease isn't treated, babies with congenital syphilis can develop long-term health issues. That's why it's critical for women to be tested and treated during pregnancy, and for any baby who may have syphilis at birth to be fully evaluated and treated as well.

The rate of congenital syphilis in the U.S. continues to be on the rise. Preliminary 2020 data shows that there are more than 2,000 cases of congenital syphilis and that the rates are highest among mothers who are non-Hispanic American Indian or Alaska Native, with 180.2 infections per 100,000 live births.

Syphilis treatment in pregnancy

Penicillin is the only antibiotic that's both safe to take during pregnancy and able to successfully treat both mother and baby for syphilis. If you have primary, secondary, or early-stage syphilis, you'll receive a single dose, but for adults in the late latent stage of the disease, you'll have three doses in weekly intervals. (If you have any symptoms of neurosyphilis, you'll have a spinal tap to check for it.) If you're allergic to penicillin, you'll need to be desensitized to the drug first, so you can receive it.

Having an allergic reaction to syphilis treatment, a condition called Jarich-Herxheimer,  can cause some changes in your baby's heart rate, and if you're in the second half of your pregnancy, it may cause contractions. (If you notice any contractions or a decrease in fetal movement, you should call your caregiver immediately. In some cases, your caregiver may opt to treat you in the hospital so you can be monitored.)

Your partner will also need to be tested, and he or she will be treated if he's positive or has had sexual contact with you in the last three months, even if his blood test is negative. You need to refrain from sexual contact until both of you have been treated. After syphilis treatment, you'll have regular blood tests to make sure the infection has cleared and you haven't been reinfected, and you'll have an ultrasound to check on your baby.

Syphilis test during pregnancy: When you'll get it and how it works

The CDC recommends that all pregnant women be screened for the infection at their first prenatal visit, and some states require retesting during delivery.

In some instances, pregnant women need to be retested during their third trimester (28 weeks). Women who live in communities where the rates of infection are high, weren't tested at their first prenatal appointment or had a previous positive result. Moreover, those at a high risk due to multiple sex partners and drug use need to be retested. You'll also be retested for syphilis if you've contracted another STI during your pregnancy or if you or your partner develops symptoms of syphilis.

Testing for syphilis is a two-step process: The first step is the nontreponemal antibody test, and the second step is a confirmatory treponemal antibody detection test. These tests detect antibodies to the infection instead of detection of the bacteria. But because the nontreponemal tests are a little complex, a newer alternative is the reverse sequence screening algorithm, which involves doing a treponemal test first and a nontreponemal test second. If the results of both tests don't match up, a second treponemal test is done. Although the two-step process may seem complicated, your health care provider can walk you through these appropriate steps.

If the second treponemal test result is positive, it indicates a current or previous infection. Women who were previously treated for syphilis don't have an ongoing risk and don't need further treatment. But those who didn't receive treatment must now get it, and the type of treatment depends on the stage of their disease.

On the other hand, if the second treponemal test is negative, it's likely that there was a false-positive in the previous result, especially if you have a partner who isn't infected, don't have a history of syphilis, and live in a community with low rates of the infection. Your healthcare provider may order a repeat serologic test after four weeks to see whether you continue to test positive.

Having syphilis makes you more susceptible to HIV if you're exposed to it, so if you test positive for syphilis, you should also be tested (or retested) for HIV and other STIs. And if you have primary syphilis, you'll need to be tested for HIV again in three months.

Syphilis prevention during pregnancy

Have sex with only one partner who has tested negative for syphilis. While condoms can prevent transmission of HIV and other STIs, they only offer protection from syphilis if the sore is on your partner's penis – they won't protect you from sores that aren't covered by the condom.

Remember, too, that you can get syphilis if a partner's sore touches any of your mucous membranes (such as in your mouth or vagina) or broken skin (a cut or scrape).

If you've had syphilis once, that doesn't mean you can't get it again. You can become reinfected.

If there's a possibility that you've been exposed to syphilis or any other STI during pregnancy, or you or your partner has any symptoms, tell your practitioner right away so you can be tested and treated if necessary.

Can you give birth with syphilis?

How does syphilis affect the baby during pregnancy?

Can syphilis be transmitted through placenta?

How does a fetus get syphilis?