Congenital Syphilis in Montana 

Core Message

• In Montana, cases of primary, secondary, and congenital syphilis are increasing at concerning rates. To date in 2022, Montana has reported 12 cases of congenital syphilis, including 2 syphilitic stillbirths. Even one case of congenital syphilis is a sentinel public health event and the current trends in Montana warrant immediate attention from the medical and public health communities. Syphilis is a preventable and treatable disease. Providers should screen all pregnant patients for syphilis, stage their disease, and provide timely treatment for the patient and their partner. Triple screening during pregnancy is recommended among high-risk populations. Postnatal evaluation of infants born to mothers with untreated or inadequately treated syphilis is crucial. Timely case investigation by local and Tribal public health is critical to identify and treat partners to minimize disease transmission.

Background

• Syphilis is a treatable disease caused by the bacterium Treponema pallidum. Left untreated, it can have serious health consequences, including congenital infection and stillbirth. Women at risk for syphilis in pregnancy include those with multiple sexual partners, sex in conjunction with drug use or transactional sex, late entry to prenatal care, no prenatal care, methamphetamine or heroin use, incarceration of the woman or her partner, and unstable housing or homelessness. Among pregnant women with untreated early syphilis, up to 40% of their pregnancies will result in spontaneous abortion, stillbirth, or perinatal death.
  Congenital syphilis may or may not be evident at birth. Affected infants can demonstrate a host of physical manifestations, including hepatosplenomegaly, snuffles (copious nasal secretions), lymphadenopathy, mucocutaneous lesions; pneumonia; osteochondritis, periostitis, and pseudoparalysis; edema; maculopapular rash consisting of small dark red-copper spots that is most severe on the hands and feet; hemolytic anemia; or thrombocytopenia at birth or within the first 4 to 8 weeks of age.
  Untreated infants, including those asymptomatic at birth, may develop late manifestations, which usually appear after two years of age and involve the central nervous system, bones and joints, teeth, eyes, and skin. Some findings may not become apparent until many years after birth, such as interstitial keratitis, eighth cranial nerve deafness, Hutchinson teeth (peg-shaped, notched central incisors), anterior bowing of the shins, frontal bossing, mulberry molars, saddle nose, rhagades (perioral fissures), and Clutton joints (symmetric, painless swelling of the knees). Late manifestations can be prevented by treatment of early infection.

Congenital Syphilis Trends

• The rate of reported congenital syphilis in the United States has increased dramatically since 2012. From 2015 to 2019, the rate increased by 291.1%, mirroring the rates of primary and secondary syphilis among females aged 15-44 years. In Montana, cases of primary and secondary syphilis increased by over 250% from 2021 to 2022. To date in 2022, Montana has reported 12 cases of congenital syphilis and 2 syphilitic stillbirths.
• A descriptive analysis from 2019 through 2022 year-to-date examined the circumstances of nineteen pregnant women in Montana who delivered babies with congenital syphilis or had syphilitic stillbirth compared to 25 pregnant women diagnosed with syphilis during pregnancy who delivered healthy babies. Among this sample, 47% of pregnant mothers with poor birth outcomes did not receive prenatal care and among those who did receive care, 70% entered care in the 2nd trimester or beyond. Cited barriers to receiving appropriate treatment included lack of transportation required for receipt of care, lack of reliable communication method (e.g., cell phone), concurrent intravenous drug use, and administration of the incorrect treatment.

Recommendations

• Providers

• Syphilis screening

  • 1. When anticipated receipt of prenatal care is not optimal, serologic syphilis screening and treatment of the patient and their partner should occur at the time of pregnancy testing.
  • 2. Universal syphilis screening is recommended at the first prenatal appointment with timely treatment for the patient and their partner. If follow-up is not likely, women with an isolated reactive treponemal test and without a history of treated syphilis should be presumptively treated according to the syphilis stage.
  • 3. Triple screening during pregnancy is strongly recommended for high-risk populations. In addition to universal testing at the first prenatal visit, serologic screening should also occur at 28 weeks’ gestation and delivery for women who live in communities with high rates of syphilis, women with HIV infection, or those who are at increased risk for syphilis acquisition. Repeat syphilis test is warranted if there is reinfection risk.
  • 4. When diagnosed in the second half of pregnancy, management should include a sonographic fetal evaluation for congenital syphilis. Signs of fetal or placental syphilis may indicate treatment failure and additional treatment may be required.
  • 5. Any woman who had no prenatal care before delivery or is at increased risk for syphilis acquisition during pregnancy should have the results of a syphilis serologic test documented before she or her neonate is discharged.
  • 6. Any woman who has a fetal death after 20 weeks’ gestation should be tested for syphilis.
  • 7. Providers caring for newborns should inquire about a history of maternal syphilis infection and past treatment. All infants who have reactive serologic tests for syphilis or were born to mothers who were seroreactive at delivery should receive careful follow-up evaluations during well-child care visits at 2, 4, 6, and 12 months of age. Serologic nontreponemal tests should be performed every 2 to 3 months until the test becomes nonreactive. Nontreponemal antibody titers typically decrease by 3 months of age and should be nonreactive by 6 months of age, whether the infant was infected and adequately treated or was not infected and initially seropositive because of transplacentally acquired maternal antibody.

•  Syphilis treatment

  • 1. Parenteral penicillin G is the only known effective antimicrobial for treating fetal infection and preventing congenital syphilis and pregnant women should be treated with the recommended penicillin regimen for their stage of infection.
  • 2. Consider providing a second dose of intramuscular benzathine penicillin G 2.4 million units one week after the initial dose for pregnant patients with primary, secondary, or early latent syphilis, or if there is ultrasonographic evidence of fetal or placental syphilis.
  • 3. Missed doses >9 days between doses are not acceptable for pregnant women receiving therapy for late latent syphilis. An optimal interval between doses is 7 days for pregnant women. If a pregnant woman does not return for the next dose on day 7, every effort should be made to contact her and link her to immediate treatment within 2 days to avoid retreatment. Pregnant women who miss a dose of therapy should repeat the full course.
  • 4. Pregnant women who have a history of penicillin allergy should be desensitized and treated with penicillin G.
  • 5. If syphilis is diagnosed and treated at or before 24 weeks’ gestation, serologic titers should not be repeated before 8 weeks after treatment (e.g., at 32 weeks’ gestation) but should be repeated again at delivery. Titers should be repeated sooner if reinfection or treatment failure is suspected. For syphilis diagnosed and treated after 24 weeks’ gestation, serologic titers should be repeated at delivery.

Local Public Health

• 1. Open syphilis labs in the MIDIS queue immediately and initiate case investigation. Timely case investigation to identify and treat partners will minimize disease transmission.
• 2. Key initial information to collect for syphilis cases includes pregnancy status, stage of infection, potentially affected sexual partners, and treatment administered.
• 3. During case investigation, assess barriers to receiving appropriate treatment (e.g., lack of transportation) and offer potential solutions to facilitate timely treatment.
• 4. Mobilize resources within your community, such as Community Health Workers to follow up and verify adequate treatment for patients and their partners. In cases where the individual has not completed treatment, follow up must be conducted to ensure adequate treatment is received.

Citations and Resources

• 1. Centers for Disease Control and Prevention. (2021). Syphilis. Retrieved from Sexually Transmitted Infections Treatment Guidelines, 2021: https://www.cdc.gov/std/treatment-guidelines/syphilis.htm
• 2. Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH. Red Book: 2021-2024 Report of the Committee on Infectious Diseases / Committee on Infectious Diseases, American Academy of Pediatrics; David W. Kimberlin, Editor; Elizabeth D. Barnett, Associate Editor; Ruth Lynfield, Associate Editor; Mark H. Sawyer, Associate Editor. 32nd ed. (Kimberlin DW, Barnett ED (Elizabeth D, Lynfield R, Sawyer MH, eds.). American Academy of Pediatrics; 2021.
• 3. University of Washington STD Prevention Training Center, provides excellent print syphilis resources, webinar recordings on syphilis testing, syphilis during pregnancy, and congenital syphilis: http://uwptc.org/.