Syphilis on a Pregnant Lady

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Executive Summary

The report is based on a case study of a pregnant lady suffering from syphilis. Syphilis is a leading cause of prenatal morbidity and mortality in the United Kingdom. Pregnancy outcomes are negatively impacted by untreated maternal illness, resulting in fetal loss before the due date, stillbirth before the due date, low birth weight before the due date, neonatal and infant death, and genetic disease in infants.

The clinical signs of congenital syphilis are affected by the mother’s gestational age, the stage of her syphilis, the therapy she receives, and the immune response of the fetus. According to traditional classification, early congenital syphilis is distinguished from late congenital syphilis. Clinical symptoms and serological testing performed on clinical specimens are used to diagnose maternal infection.

Treatment of invasive infections successfully prevents illness transmission to the fetus and treats fetal infection when appropriately administered. Noninvasive and invasive methods are used to assess congenital syphilis during pregnancy. To limit the incidence of congenital syphilis, it is recommended that women undergo serological screening during pregnancy during the preconception period.

Introduction

Syphilis is a microbial infection that is typically transmitted through sexual contact. The condition begins as a painless sore on the genitals, rectum, or mouth, which can spread to other parts of the body. Syphilis is passed from person to person by skin and mucous membrane interaction with sores on the skin or self-lubricating membranes. The syphilis germs can remain dormant in the body for years and years after the first infection before becoming active once more. Initial syphilis can be healed with a single injection of penicillin, sometimes all that is required (Adhikari, 2020).

Miscarriage, pregnancy loss, or the death of the newborn within hours of birth is all possible outcomes of syphilis infection in pregnant women. Approximately 40% of kids delivered to mothers who have undiagnosed syphilis could be stillborn or die due to the infection due to their mother’s condition. It is possible for babies to be born with congenital syphilis, however the severity of the baby’s health consequences depends on whether or not the infection was acquired during maternity & if or when the woman got treatment for the disease (Čapek and Toman, 2021).

Presentation of the Case Study

Presenting Complaint

A twenty-six-year-old lady was booked in the hospital at 15 weeks of her pregnancy. In her routine antenatal screening test for syphilis, the results revealed that she had the disease the A positive result was obtained from the (TPHA) T. pallidum haemagglutination test with a titre of 1:128, and a positive result was obtained from the line/blot assay the (VDRL) venereal diseases research laboratories was negative, & the immunoglobulin M test came back negatives.

Additional confirmation sample revealed the presence of the virus. She was asymptomatic, and the serological tests performed on her current partner were negative. She had first seen vulvae ulcers about two years prior, which had resolved of their own accord at the time. There was also a background of chlamydia infection spread through sexual contact.

History of Presenting Complaint

Before starting her treatment, she had such a record of penicillin allergy that was treated by desensitized before starting her on the medication. Due to fetal discomfort during labor, she got delivered by immediate c section at 41 weeks. After three days of observation, both the baby and the mother were found to be healthy. Further serology is scheduled six, twelve, and twenty-four months following delivery.

Medical History

After repeating the serology tests at 28 and 32 weeks’ gestational, the results including both testing groups were the same, as predicted. While her pregnancy, the woman had extensive counseling in the consequences of syphilis, includes the likelihood of congenital syphilis in the infant, & she was monitored closely by her doctor, who performed regular obstetric and genitourinary medical evaluations on her. In addition to a serial development scan at 20 weeks, serial anatomy examination was performed around 28, 32, and 36 weeks. All of the scans revealed no abnormalities.

Drug History

In collaboration with her, the genitourinary physicians administered workweek doses with oxacillin antibiotic 2.4 million units over three weeks. To minimize the Jarisch Herxheimer response, she was also given oral prednisolone 10 mg three times a day, starting a day before the penicillin-based therapy.

Family History

In addition to being a housewife and living with her husband alone in an apartment, she also attended to her scheduled medical exams.

Critical Analysis of the Case

The Chronic Condition

The site of the principal inoculation in main syphilis develops a singular hassle free ulcer with only an indurated base and elevated border (chancre) following a 10- to 90-day initial incubation period (incubation period = 10–90 days), followed by the second painless ulcer with an indurated base and raised border (chancre). Despite the fact that it is very contagious, it normally heals on its own within 4 to 6 weeks, even when left untreated. It is possible that the original vulvae ulcer, which was disregarded by the patient, was the primary lesion in this instance (Marques dos Santos et al., 2020).

It is possible that spirochetes will spread through the bloodstream 3 to 6 weeks following the formation of the chancre, culminating in the development of a syndrome of subsequent syphilis. Moreover, syphilis is distinguished by the presence of positive serological tests but the absence of clinical signs of the illness.

Early dormant infection (latency less than a year) can exacerbate infected secondary-type lesions in up to 25% of patients. However, the likelihood of such a recurrence inside the later dormant phase (latency greater than a year) is extremely low. Central nervous system and generalized inflammation (gummas &aortitis) problems are the hallmarks of tertiary syphilis (also known as chronic syphilis).

The acute presentation

Worsening Symptoms

Most importantly, these patients identified at 15 weeks gestation and treated as soon as possible, significantly minimizing the risk of vertical transmission, which is believed at between 70 & 100 percent in this situation. The false conclusion that transmission happened commonly after 4 months of pregnancy was reached as a result of the assumption that treponemes from the maternal plasma are hard to fail through the Langhan’s cell membrane of an early placenta. While doing their research, they noticed that the layers of Langhan’s cells maintained throughout the pregnancy, highlighting the fact that transmissions could occursany moment of the gestational cycle.

Consultation

ANTEPARTUM screening can be accomplished using manually non-treponemal antibodies testing (e.g., RPR) using the classic syphilis screening algorithm and through treponemal antibodies testing (e.g., immunoassays) with the reversed sequence algorithm.

Clinical assessment

The fact that you are pregnant does not affect how quickly the infection progresses, but it can increase the risk of serious consequences such as miscarriage, premature birth, and stillbirth.

Findings and Impressions

As indicated in this example, those of a younger age and those who have a background of other sexually transmitting infections are more susceptible to the virus. It’s also critical that such patient &spouse are examined by a genitourinary medication professional for an accurate valuation, therapy, and treatment of their condition.

It is caused by the spirochete Treponema pallidum, which infects the body through minor skin abrasions or mucous membrane irritation. Syphilis is a contagious disease that affects the entire body. It is a chronic disease transmitted through sexual intercourse, blood borne transfer, or trans placental transmission. It is estimated that exposure to an affected individual results in a transmitting rate of approximately 30%, with the rate being highest during major or minor syphilis.

Investigations

Research Evidence and Local & International Guidelines

A pregnancy does not appear to affect the clinical signs of acquired syphilis. Through direct touch with a symptomatic sore, known as a chancre, syphilis is spread from person to person. Transmission of a organism happens during sexual contact, whether it is vaginal, anal, or oral. They are frequently overlooked in women because they are asymptomatic.

Generally speaking, a syphilitic sore is hard, round, tiny, and painless, usually lasting three to six weeks. In contrast to Genital Herpes, which creates tiny, unpleasant blisters filled by clear or straw-colored fluid, genital herpes is a viral infection. When blisters rupture, they create shallow ulcers which are extremely painful for many days before crusting over and gradually healing over 7–14 days or longer (Merriam, 2020).

Streptococci could penetrate the placental and infect the fetus as early as 14 weeks’ gestation in a pregnant woman. The risk of fetal infection increases with the gestational age of the pregnant woman. The signs of CS are affected by the mother’s gestational age, the stage of her syphilis, the treatment she receives, and the fetus’s immunological reaction.

If left untreated, CS can result in spontaneous miscarriage, generally after the first trimester, or delayed stillbirth in 30 to 40% of cases. It can also result in premature or term delivery of live newborns, who may show visible indications of infection or be completely healthy (approximately two-thirds of live born cases). The most prevalent causes of fetal death include infection of the placenta and a decrease in blood supply to the fetus during pregnancy (Pardhan and Jain, 2020).

Pregnant women should be tested for syphilis during their first antenatal care appointment, according to the World Health Organization’s (WHO) sexually transmitted infection (STI) guidelines (strong recommendation, moderate-quality evidence).

Instead of using the standard off-site experimentally diagnostic and counseling strategy, the WHO STI guidelines suggest using on-site testing procedures in settings with low exposure to syphilis detection & therapy for women who are pregnant, a large loss to follow-up percentage among pregnant women, or a limited capacity for laboratory testing and treatment (conditional recommendation, less-quality evidence) (Soares et al., 2020).

The WHO STI guideline recommends using only one on-site quick syphilis test (RST) to screen pregnant women in configurations with low syphilis prevalence (below 5 percent), rather than using a single on-site (RPR) rapid plasma regain test (Strategy B) to screen pregnant women in configurations with reduced syphilis prevalence (less than 5 percent) (conditional recommendation, less-quality evidence).

The World Health Organization recommends that pregnant women with late syphilis (lasting more than two years) or an indeterminate stage of syphilis should be given benzathine penicillin G 2.4 million units intramuscularly every week for three consecutive weeks (Adhikari, 2020). The WHO also suggests that all pregnant women in their first trimester undergo serological screening tests. This is standard procedure in the United Kingdom. Its relevance has been underscored by this case, for which screening may have prevented a poor pregnancy outcome and the catastrophic implications of congenital syphilis in the infant (Liew et al., 2021).

Management Plan

If it is suspected that a child has congenital syphilis, a professional should be sought. Prenatal syphilis testing is suggested throughout the first trimester of pregnancy as the lady, in this case, did not get medication at the beginning to avoid any serious issues. Patients at elevated risk, such as Female victims, should have a second test performed in the third trimester of pregnancy. During syphilis epidemics, additional antenatal testing is required in high-risk groups; the first antenatal appointment (routine) should be held at 28 weeks and 36 weeks at birth, with a 6-week post-natal check.

Test results during pregnancy should be examined quickly based on the history and physical examination, screening contacts. If the situation remains unresolved, a further RPR should be performed two weeks after the first test.  Syphilis in gestation should be treated with the same standard regimen used to treat the same clinical phase of syphilis in non-pregnant persons at the time of diagnosis. The sole exception is early syphilis discovered in the prenatal period, which should be cured with Benzathine penicillin G 1.8 gm (2.4 million units) once a week for two weeks, starting after the birth of the child (Pradhan & Jain, 2020).

Coordinating prenatal and post-natal care is critical for a healthy pregnancy and childbirth. When syphilis is discovered in the second part of pregnancy, an ultrasound assessment for congenital abnormalities should be performed; however, treatment should not be postponed until the diagnosis is confirmed, the treatment session for early syphilis if active STD cannot be eliminated with reasonable certainty by this approach, to reduce the risk of fetal infection during pregnancy.

Patients who are pregnant and have a history of penicillin allergy should be desensitized and treated with penicillin before delivery. There are no established options for infection in either the mother or the fetus (Soares et al., 2020). Treatment for syphilis in pregnancy should be followed up with RPR at 28 to 32 weeks gestation and upon birth, as well as at any time after that, depending on the clinical stage of the syphilis infection.

A Jarisch-Herxheimer response may occur during treatment in the second part of pregnancy, increasing the likelihood of preterm labor and fetal discomfort. Before treating syphilis in pregnant women above the age of 20 weeks, the patient should consult with the attending Obstetrician, although the treatment should not be postponed.

Impact on Vulnerable Groups

If a pregnant woman with syphilis is not recognized or treated, the illness can be transferred to her unborn child, resulting in severe infant morbidity and death. It is pretty simple to avoid congenital syphilis if women receive prompt and effective prenatal treatment. Patients with congenital syphilis are regarded as signs of difficulties with the social safety net.

However, even when clinicians follow recommendations, social and behavioral issues in the mother might make it difficult for them to get adequate care. Homelessness, drug addiction, and imprisonment were among the social vulnerabilities experienced by most women (Nunes et al., 2021). Pregnancy complications are frequently related to social vulnerability and hardship in mothers.

Social determinants interfere more with prenatal care and are more responsible for the absence of proper treatment for maternal syphilis. Numerous structural, psychosocial, and behavioral factors, such as a lack of or late enrollment in insurance or Health care, the cost of co-pays, insufficient resources or child care, being unaware of one’s pregnancy, having an unwanted or unexpected pregnancy, and mental health and addiction issues, all contribute to inadequate prenatal care.

The linkages between structural obstacles, social circumstances, and disease and how these interactions frequently focus or merge to negatively impact both people’s health have received significant attention in recent decades in public health. Poor health is frequently exacerbated by social issues such as poverty, violence, and inequality, which compound and exacerbate the negative impacts of medical conditions (Samaniego, 2021).

Referrals

During pregnancy, syphilis can cause significant complications such as spontaneous abortion, non-immune hydrops, stillbirth, intrauterine growth restriction (IUGR), neonatal mortality, and severe long-term consequences for infected mothers’ children survive. Although the accurate diagnosis of pregnant women may typically avert such consequences, the difficulty in detecting and treating infected women has been a significant disincentive in getting them to seek treatment (Pradhan and Jain, 2020).

As a result of raising awareness among the afflicted women, community-based activities aimed at reaching them and encouraging their access to prenatal care are expected to reduce the number of children born with congenital syphilis. Gynecologists and obstetricians must know the latest syphilis testing and treatment guidelines in pregnant women. End-to-end cooperation will be necessary to raise public awareness and promote access to early prenatal care in poor regions, as well as to reverse the existing pandemic of fetal-related issues.

References

Adhikari, E.H., 2020. Syphilis in pregnancy. Obstetrics & Gynecology, 135(5), pp.1121-1135.

Čapek, L. and Toman, A., 2021. Congenital syphilis as a cause of death in a newborn in 31st week of pregnancy-significance of testing for syphilis during pregnancy. Ceska gynecology, 86(4), pp.242-245.

Liew, Z.Q., Ly, V. and Olson-Chen, C., 2021. An old disease on the rise: new approaches to syphilis in pregnancy. Current Opinion in Obstetrics and Gynecology, 33(2), pp.78-85.

Marques dos Santos, M., Lopes, A.K.B., Roncalli, A.G. and Lima, K.C.D., 2020. Trends of syphilis in Brazil: a growth portrait of the treponemes epidemic. PloS one, 15(4), p.e0231029.

Merriam, A., 2020. Maternal and Perinatal Infection: Bacterial, Chlamydia, Syphilis in Pregnancy. Gabbe’s Obstetrics Study Guide, E-Book: A Companion to the 8th Edition, p.319.

Nunes, P.S., Guimarães, R.A., Rosado, L.E.P., Marinho, T.A., Aquino, É.C.D. and Turchi, M.D., 2021. Temporal trend and spatial distribution of syphilis in pregnancy and congenital syphilis in Goiás, Brazil, 2007-2017: an ecological study. Epidemiologia e Serviços de Saúde, 30.

Pradhan, M. and Jain, S., 2020. Syphilis in pregnancy. Journal of Fetal Medicine, 7(1), pp.57-63.

Samaniego Haro, V. J., 2021. Syphilis and pregnancy: Review. J Clin Images Med Case Rep, 2(3), 1151.

Soares, K.K.S., Prado, T.N.D., Zandonade, E., Moreira-Silva, S.F. and Miranda, A.E., 2020. Spatial analysis of syphilis in pregnancy and congenital syphilis in the state of Espírito Santo, Brazil, 2011-2018. Epidemiologia e Serviços de Saúde, 29.

Taylor, M.M., Kara, E.O., Araujo, M.A.L., Silveira, M.F., Miranda, A.E., Coelho, I.C.B., Bazzo, M.L., Pereira, G.F.M., Giozza, S.P., Bermudez, X.P.D. and Mello, M.B., 2020. Phase II trial evaluating the clinical efficacy of cefixime for treatment of active syphilis in non-pregnant women in Brazil (CeBra). BMC infectious diseases, 20(1), pp.1-15.

Appendix

Details of the Patient and Case

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