Continue screening for syphilis in pregnancy
What is included in your practice during a first prenatal visit? If syphilis screening is not on the list, be sure to add it. Following a systematic review of current evidence, the U.S. Preventive Services Task Force has just reaffirmed its 2004 recommendation that clinicians screen all pregnant women for syphilis infection.1
"The fact that we have good evidence showing that universal screening really decreases infants with congenital syphilis is what pushed the task force to put this in an "A" recommendation, which is our strongest recommendation," says Ned Calonge, MD, MPH, task force chairman and chief medical officer for the Colorado Department of Public Health and Environment in Denver.
How important is early prenatal care when it comes to screening pregnant women for syphilis? According to Tracy Wolff, MD, MPH, medical officer for the task force program, evidence shows that universal screening of pregnant women for syphilis is effective in decreasing the likelihood that infants will develop syphilis infection. Analysts found evidence that such effectiveness is related to the receipt of early prenatal care that allows for adequate treatment and follow-up prior to delivery, says Wolff, who served as lead author for the literature compilation that lead to the task force's recommendation.2
In 2002, the Centers for Disease Control and Prevention (CDC) reported that while most women who had a fetus with congenital syphilis had received prenatal care, nearly two-thirds received care later in the pregnancy, after the first trimester3, Wolff notes. For this reason, the task force and many other organizations advise that screening occur at the first prenatal visit, and many organizations recommend repeat serologic testing in the third trimester and at delivery for women at high-risk for syphilis, she states.
Who and how to screen?
What clinical considerations come into play when screening pregnant women for syphilis? Most organizations, such as the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics, recommend testing high-risk women again during the third trimester and at delivery.1 Women who may be considered at increased risk for syphilis infection include:
- uninsured women;
- women living in poverty;
- sex workers;
- illicit drug users;
- those diagnosed with other sexually transmitted diseases;
- women living in communities with high syphilis morbidity.
Prevalence of the disease is higher in the southern United States, in metropolitan areas, and in Hispanic and African-American populations.
What tests may be used for screening? Nontreponemal tests commonly used for initial screening include venereal disease research laboratory (VDRL) and rapid plasma reagin (RPR) tests. Confirmatory tests include: fluorescent treponemal antibody absorbed (FTA-ABS) and Treponema pallidum particle agglutination (TPPA) tests.
How to treat?
What treatment should be used if syphilis is detected? In its most recent recommendation, the CDC calls for the use of parenteral benzathine penicillin G for the treatment of syphilis in pregnancy.4 Because evidence on the efficacy or safety of alternative antibiotics in pregnancy is limited, women who report penicillin allergies should be evaluated for penicillin allergies and, if present, desensitized and treated with penicillin, the task force advises.1
Follow-up serologic tests should be performed after treatment to document decline in titers, according to the task force. To make sure that results are comparable, follow-up tests should be performed by using the same nontreponemal test that initially was used to document the infection.
Study examines birth defect
What is the potential for harm to the fetus during treatment with penicillin? Analysts found one Hungarian study that used multiyear data from a national congenital abnormality registry. Investigators in the Hungarian study identified 1,374 cases of isolated orofacial clefts and reviewed medical records and questionnaire results for medication use. They then compared the prevalence of isolated orofacial clefts in children born to women who received penamecillin (an oral form of penicillin not available in the United States) with a control population and a control group with noncleft malformations. Investigators found no association between penamecillin and isolated orofacial clefts.5
References
- U.S. Preventive Services Task Force. Screening for syphilis infection in pregnancy: U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med 2009; 150:705-709.
- Wolff T, Shelton E, Sessions C, et al. Screening for syphilis infection in pregnant women: Evidence for the U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med 2009; 150:710-716.
- Centers for Disease Control and Prevention (CDC). Congenital syphilis — United States, 2002. MMWR 2004; 53:716-719.
- Centers for Disease Control and Prevention, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55(RR-11):1-94.
- Puho´ EH, Szunyogh M, Me´tneki J, et al. Drug treatment during pregnancy and isolated orofacial clefts in Hungary. Cleft Palate Craniofac J 2007; 44:194-202.
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