the diagnosis of syphilis its a sexually transmitted disease should be explained to the mother in a sensitive manner and ensure confidentiality all the time.
the women is 16 weeks in her pregnancy usually spirocaetes enter the fetal circulation around 20 weeks,and stage of the infection also have impact on transmission if primary/secondary its 40% late decreases and maternal manifestations are during tertiary in form ofskin and joint involvement quaternary syphilis leads to aortitis.,aortic aneuysm,tabes dorsalis and increased morbidity and mortality and requirelong term benzyl penicillin treatment.
effect on the fetus misscarriage, preterm labour,nonimmune hydrops fetalis ,intrauterine death and survival with congenital syphilis.
during antenatal period she should receive single dose of benzyl penicillin and risk of jarisch herxheimer reaction and association with preterm labour should be explained.refer to the Gum clinic for contact tracing and counsell regarding the importance of screening for other STD\'s and blood test for Hiv,hepb,c.history of smoking ,alcohol,illicit drugs enquired and adviced against.
scanning for gross anamoly ,growth and liquor as associated with nonimmune hydrops.
regular follow up for quantitative vdrl assesment untill negative.
during labour continous monitoring is required as associated with stillbirth.vaginal delivery is not a contraindication.paediatrician should be present at the time of deliveryand features of syphylis may be delayed uptill 2 weeks so follow up is important.early feature are purulent nasal discharge,maculop[apular rash,lympadenopathy,hepatospenomegaly.late feature are interstitial keratitis,frontal bossing.,saddle nose,mulberry molars,sabre shins.
breast feeding is not a contraindication.barrier contraception should be discussed.
Posted by jyoti D.
the diagnosis of syphilis its a sexually transmitted disease should be explained to the mother in a sensitive manner and ensure confidentiality all the time.
the women is 16 weeks in her pregnancy usually spirocaetes enter the fetal circulation around 20 weeks,and stage of the infection also have impact on transmission if primary/secondary its 40% late decreases and maternal manifestations are during tertiary in form ofskin and joint involvement quaternary syphilis leads to aortitis.,aortic aneuysm,tabes dorsalis and increased morbidity and mortality and requirelong term benzyl penicillin treatment.
effect on the fetus misscarriage, preterm labour,nonimmune hydrops fetalis ,intrauterine death and survival with congenital syphilis.
during antenatal period she should receive single dose of benzyl penicillin and risk of jarisch herxheimer reaction and association with preterm labour should be explained.refer to the Gum clinic for contact tracing and counsell regarding the importance of screening for other STD\'s and blood test for Hiv,hepb,c.history of smoking ,alcohol,illicit drugs enquired and adviced against.
scanning for gross anamoly ,growth and liquor as associated with nonimmune hydrops.
regular follow up for quantitative vdrl assesment untill negative.
during labour continous monitoring is required as associated with stillbirth.vaginal delivery is not a contraindication.paediatrician should be present at the time of deliveryand features of syphylis may be delayed uptill 2 weeks so follow up is important.early feature are purulent nasal discharge,maculop[apular rash,lympadenopathy,hepatospenomegaly.late feature are interstitial keratitis,frontal bossing.,saddle nose,mulberry molars,sabre shins.
breast feeding is not a contraindication.barrier contraception should be discussed.
Posted by maria A.
In the last few years, there has been a resurgence of syphilis in the developed world. As the condition is mainly asymptomatic it is usually detected during routine antenatal screening. In this woman who presents with positive screening test confirmatory tests are done like VDRL/RPR, cardiolipin antibody test, TPHA treponema pallidun haemagglutination test and FTA-ABS fluorescent treponemal antibody absorption test. After confirmatory tests have been performed, women should also be carefully examined for other sexually transmitted diseases such as gonorrhoea, Chlamydia, hepatitis B and HIV. Infection can be transmitted from the mother to the fetus when her infection is untreated and in the primary, secondary or early latent phase of infection, mainly after 18th week of pregnancy. The risks to the pregnancy following infection are miscarriage, preterm labour, fetal growth restriction, still birth, nonimmune hydrops and congenital syphilis. Trans-placental passage occurs at all stages, though less so with the later stages The most common findings in newborns with congenital syphilis are hepatosplenomegaly, osteochondritis or periostitis, jaundice, petechiae, purpura, lymphadenopathy, ascites and hydrops. The most common clinical feature of late congenital syphilis is interstitial keratitis, which occurs in about 40% of infected children. Regarding antenatal management of her pregnancy, the mother should be treated with high-dose penicillin and referred to the genitourinary team to ensure effective management and contact tracing. She should be screened for other sexually transmitted diseases and her partner should also be screened. Penicillin G cures maternal infection and prevents congenital infection in 98% of cases. Howevar a Jarisch-Herxheimer reaction during treatment may precipitate pre-term labour. The Jarisch-Herxheimer reaction describes the release of endotoxin when large numbers of organisms are killed by antibiotics. The disease should be followed up in mother with quantitative VDRL / RPR until negative. Regarding mode of delivery, vaginal delivery should be the aim. Breast-feeding is not contra-indicated. Neonatal follow-up is required including long bone X-ray studies.
Posted by uma M.
A 34 year old woman has been referred to the antenatal clinic at 16 weeks gestation because of a positive syphilis screening test which has been confirmed by the reference laboratory. (a) Explain the implications of this finding (b) Justify your antenatal management of her pregnancy
Syphilis caused by treponema pallidum ,a spirocheate is a STD associated with significant risk to fetus &mother
Syphilis is a systemic disease , causative organism crosses the placenta to infect the fetus.Severity of infection & risk depend on stage on the disease.
Diagnosis of syphilis has implications both in pregnancy & out with pregnancy. Syphilis is manifest in 3 stages in mother
Primary syphilis is manifested as painless ,indurated ulcer on genital or extragenital sites whic may go unrecognised, resolve spontaneously in 2-6 wks. secondary syphilis is wide spread dissemination of infection 6-8 wks after primary syphilis . women is likely to suffer from generalized maculopapular rash, fever ,malaise ,generalized lymphadenopathy,genital condyloma lata. these resolve spontaneously in 2-6 wks. highesk risk to fetus is in these 2 stages with 50% risk of congenital infection if un treated. There is also significant increase in preterm delivery , stillbirths if not treated. Untreated at this stage patient enters latent stage ,lasts for years , with out clinical manifestations but
with 10% risk of fetal infection.Perinatal mortality in this stage is also increased 10 fold. There is 30% chance of she entering into tertiary syphilitic stage if left untreated leading to CNS, CVS,Skin manifestations.
Fetus get infected from trans placental passage of organism from early pregnancy ,but more so after 18 weeks leading to congenital syphilis.Spectrum of this range from still births, Non immune hydrops, early congenital syphilis manifesting as maculopapular rash, petechiae,rhinitis ,jaundice,
hepatospleenomegaly,chorioretinitis, lymphadenopathy, pseudo paralysis or as late congenital syphilis in untreated cases. Late cong . syphilis is charecterised by CVS lesions , sensorineural deafness, interstitial keratitis, huthisons teeth,saddle nose &saber shin.
Antenatal management of this pregnany involves treating syphilis, identify other STD\'s,counselling. Initially it is essential that
nature of the diagnosis is explained to woman .Reassure her that confidentiality will be maintained. Give information regarding fetal risk , treatment . Elicit brief history regarding the disease _ h/o rash with fever, generalized lymphadenopathy ,genital &mouth ulcers, joint problems, pneumonia,etc Note h /o other STD\'s Previous obstetric history if any putting syphilis specifically into context _ h/o affected babies, still births, h/o hydrops .Enquire about multiplicity of sexual partners , drug abuse, smoking as all these factors are interrelated.Advice against these.
Examine woman for anylesions suggfestive of syphilis like rash ,condyloma lata, ulcers on genitalia, mouth ulcers,gumma ,joint involvement, which gives a clue regarding stage of syphilis.
It should be noted that syphilis is an STD and that woman at risk of other STD\'s . Screening for other infections including HBsAg ,HCV, HIV (after pre test opt out counselling)
should be offered. Contact tracing and treating all infected partners to prevent risk of recurrent infection.
Management should be in liasion with GUM clinic.Traetment should aim to cure maternal disease and prevent congenital syphilis.At this stage it is essential to reassure women that though risk to fetus is more ,most of this can be prevented by treatment, Drug of choice is benzathine pencilline G
, dose depending on stage of syphilis.This is effective in preventing 98% of congenital infection.Non pencillin regimes are
not recommended in pregnancy as they are not effective in prevevting cong infection. If woman is allergic to pencillin
consideration should be given for pencillin desensitisation ,as pencillin treatment is very effective.But this requires hospitalisation, and is only a temporary effect, not widely practised
While treating with pencillin one shoulld be vigilant for Jarish hexeimer reaction as it precipitates preterm labour.Following treatment maternal response tested by Quantitative VDRL/RPR testing. Follow these untill negative.
US scan should be performed to exclude hydrops, structural abnormalities as pregnancy progress. this should be arranged at a tertiary center.If hydrops is identified termination can be offered.
Other STD\'s if identified are treated appropriately.
pregnancy can be taken as oppurtunity for education regarding safe sexual practises.
Intrapartum management no different from other pregnancies
Neonatal follow up arranged , many manifest after 2 weeks . If woman is treated with non pencillin regimes neonate should be treated with pencillin regime.
Breast feeding no containdication.
Discuss safe sexual practises, barrier methods and advise regarding variuos contraceptive options.
Posted by Farzana N.
Syphilis diagnosed in pregnancy has major implications on growing fetus and profound effects on the pregnancy outcome.
The disease is transmitted transplacentally to the fetus, or by contact with genital lesions to the new born.Causative organism-Treponema Pallidum can infect the fetus from as early as 9-10 weeks of gestation, at all stages of disease.
Risk of transmission depends on the stage of mother?s disease-Primary, secondary, latent or tertiary. In untreated cases, risk is. 40% in early latent stage and 10% in late latent stage.
Pregnancy outcome in these cases is adversely affected resulting in, spontaneous abortion, still birth, non immune hydrops, IUGR, preterm delivery and neonatal death. Live born infants are affected with congenital syphilis, which may present as,
Early congenital syphilis?infants are asymptomatic at birth, the following sequelae may appear 10-14 days after birth-such as maculopapular rashes, hepatosplenomegaly, lymphadenopathy, chorioretinitisand osteochondroitis, which may lead to pseudo paralysis.
LATE Congenital syphilis ?appears after 2yrs of age in untreated cases, showing Hutchison?s teeth, mulberry molars, 8th nerve deafness, saddle nose, sabre shin or interstitial keratitis.congenital syphilis is a major cause of perinatal morbidity and mortality worldwide.
Pregnancy has no effect on the course of disease.
MANAGEMENT of this patient during the antenatal period should be taken jointly with GUM physicians. Aim should be to treat maternal infection and thus prevent congenital syphilis. An important part of the management would be to trace contacts and treat sexual partner. Since syphilis is a sexually transmitted disease, patient should be screened for other STIs such as HIV and Hepatitis B.
The mainstay of therapy is benzathine penicillin. Retrospective data suggest that it cures maternal infection ant prevents congenital infection in 98% of cases. Alternative therapy with other non-penicillins is not recommended for pregnant patients because of treatment failures in preventing congenital infections. Especially, Erythromycin.Te.tracycline(500mg orally QID for 15days) causes discoloration of teeth and bones but can be taken if no other alternative.
Duration of treatment with penicillin is according to stage of disease. In EARLY SYPHILIS?(PRIM, SEC or latent <1yr of duration) Benzathine penicillin G 2.4million units in a single dose.
LATE syphilis (>1yr duration and cardiovascular syphilis) Benzathine pen 2.4 million units weekly for three consecutive weeks.
NEUROSYPHILIS-Aqueous crystalline penicillin G 3-4 million units/4hr for 10- 14 days followed by Benzathine penicillin 2.4 million units for 3 consecutive weeks.
During treatment with penicillin, pregnant patients with early syphilis may experience
Jarish-Hexheimer reaction and present with fever, myalgia and vasodilatation, leading to premature labor or fetal distress. Women pregnant >20 wks should be hospitalized before initiating treatment to permit early recognition and treatment of premature labor.
After treatment, quantitative RPR or VDRL titers should be followed until negative.
Patients can have vaginal delivery except for obstetric reasons. Neonates should be
Managed by GUM physician and pediatrician and treated at birth.
There is no contraindication to breast-feeding in treated cases.
Posted by Sreekala S.
The woman should be asked to why she underwent the test -whether it was a part of the universal screening programme or because of any symptoms. Syphilis has implications on the health of the mother and her unborn baby.
Syphilis ca adversely affect the health of the woman depending on the stage of the disease, especially tertiary syphilis involving the CVS,CNS and musculoskeletal system.
If left untreated, transplacental transmission from the mother to the fetus can occur during the primary, secondary or early latent phase of infection, mainly after the 18th week of pregnancy. Syphilis in pregnancy can cause Miscarriage, preterm labour, IUGR , Stillbirth and congenital syphilis. Untreated Primary or secondary syphilis in the mother can lead to congenital syphilis in 50% of neonates while it affects 40% of babies if mother has early latent syphilis and 10% of babies if mother has late latent syphilis.
Congenital syphilis may present as Hepatosplenomegaly, jaundice, petichiae, purpura, lymphadenopathy, rhinitis(snuffles), hydrops ascites, osteochondritis, periostitis. if left untreated, it can progress to late congenital syphilis with Hutchinsons teeth, mulberry molars, saber shins, Interstitial keratitis, 8th nerve deafness, saddle nose and cardiovascular lesions.
The woman should be encouraged to inform the sex partners . Contact tracing should be done and counselling with screening for STI offered to the partners.
It should be explained that adequate treatment can control the disease and curtail the transmission to the fetus. she should know that she may need frequent antenatal visists to monitor the fetal growth and fetal well being.
Antenal management;
A detailed history regarding IV drug abuse and possibility of other STI should be explored. The woman should be offered counselling and screening for HIV,Hep B, Hep c. Infection with Gonococci, chlamydia should also be screened by taking swabs from endocervix, urethra and rectum and appropriately treated if present.
Referral to a local GUM clinic is essential for the accurate staging of syphilis, effective management and contact tracing.
The main stay of treatment is Benzathine penicillin. The aim of treating the mother during pregnancy is to cure her of the infection and prevent congenital syphilis in the neonate.
The treatment depends on the stage of syphilis. In primary, secondary and ealry latent phase, Benzathine penicillin G, 2.4 million units IM as single dose is recommended. If allergic to penicillin then Erythromycin 500 mg QID for 2 weeks or ceftriaxone 1 gram IM daily for 10 days. Tetracyclines are contraindicated because of discolouration of the fetal teeth and bones.The non-penicillin regimens are not usually recommended in pregnancy beacuse of treatment failures in preventing congenital infection. If non penicillin regimens are used, the neonate should be carefully evaluated fro active disease and treated with Benzathine Penicillin 50,000units/kg IM as a single dose.
In late latent phase, 3-4 million units of acqeous Penicillin G IV 4hrly for 10-14 days followed by Benzathine penicillin 2.4 units IM weekly for 3 consecutive weeks is recommended. Retrospective studies show that adequate treatment with Penicillin G cures maternal infection and prevents congenital infection in 98% of cases.
occasionally treatment of early syphilis usually after 20 wks pregnancy may initiate the Jarisch herxheimer reaction which may stimulate preterm labour and may require hospitalization for the penicillin therapy.
The woman should be offered serum screening for Fetal anomalies (AFP/hCG) and an anomaly scan a t20 wks. Fetal surveillance may be needed as there is a high risk for preterm labour, IUGR and stillbirth.
The importance of condom usage during should be emphasised to prevent transmission to other partners or acquire new infections.
Follow up should be done with quantitative RPR or VDRL which would show low titres or negative titers in 3-4 months.
Effective management by a multidisciplinary approach including the obstetrician, midwives, GUM team and paediatricians may help to curtail the disease and prevent transmission to the newborn.
Posted by Farzana N.
Dear Paul,
you have not corrected my answer. kindly correct and mark my answer.
Farzana
Posted by Vandana D.
I TYPED THIS LETTER TO YOU TWICE & SUBMITTED BUT AFTER I SUBMIT IT IS NOT REACHING.WHY?
Posted by Vandana D.
Implications Risk of fetal infection.severity of infection depends upon stage of maternal disease & degree of maternal spirochetaemia.Transplacental infection can occur at any gestational age.
Fetal infection can cause miscarriage.IUD ,IUGR,hydrops,prematurity,congenital infection.Latter may manifest early or late or asymptomatic.Early manifestations-hepatitis,spleenomegaly, anaemia ,rash lymphedenopathy,condylomata lata.Late manifestations Hutcingson\'s triad.
Maternal infection-illness,risk of transmission of infection.Untreated infection can cause relapse later /progress to Tertiary Syp.
Cont.
Posted by Vandana D.
Cont.
Antenatal Management
Assess the severity & stage of disease.
Counselling-explain the fetal risks,risks of transmission to partner,implications of untreated infection.~20% of untreated infections may progress to Tertiary Syp-aortic aneurysm,insufficiency,neurological involvement-tabes dorsalis ,GPI.
Treatmeny with penicillin is effective.1.2 MU Procaine penicillin IM for 12 or 21 days as appropriate.Involve GU Specialist.
Risk of Jarish Herxheimer reaction.May cause premature labour.
If sensitive to penicillin,consider desensitisation with help of allergist.Erythromycin is not very effective.Tetracycline is CI in pregnancy.Tests to assess response to Tt.-VDRL/RPR.
Adequate precautions to be taken by attending doctors,nursing staff &close family members.
Cont.
Posted by Vandana D.
Cont.
Screen her for other STIs.Refer her partner to GUM Clinic for screening & management.
For fetal well being ,serial US Scans to assess growth,Doppler to detect fetal anaemia.Consider invasive tests if appropriate-Amniocentesis/FBS-to detect fetal infection.Take opinion of expert in fetal medicine.
Inform neonatologist.
Posted by Mangala sundari R.
Mr.Paul,
Ihad sent 2 essays , one on syphilis and one on post op infection in this box. they are not appearing in the essay column! please verify. Dr.Mangala
Posted by Shakira B.
A) This is a serious infection that carries risk of maternal & perinatal mortality or serious morbidity. She needs to know the risk of infection to herself and foetus and what treatment & follow up will be necessary. I would reassure her that although the complications can be serious, but the infection can be easily treated with 2 weeks course of penicillin or Erythromycin if she is allergic to penicillin, Tran placental passage occur at all stages, 40% risk of Congenital infection of primary / secondary stages of infection & 10% at later stages. In case of early congenital syphilis, baby may have Rash, Hapeto Splenomegaly / lymphadenopath, Chorio retinitis / osteo chondritis, 10-14 days after delivery. In late congenital syphilis the following features must be looked for:
Hutchinson?s teeth, Mulberry Molar, 8th nerve deafness, saddle nose, sabreshin, and interstitial keratins. As this infection is sexually transmitted, so contact tracing and treatment of sexual partners is advised, these cases should be referred to gum clinic. Screening for other STD like Hepa B, C, and HIV.
An Management :- Compliance with treatment is stressed as AN treatment before 20 weeks GA prevents 98% of congenital infections. Multi disciplinary care involving internist. Microbiologist , Obstetrician and pediatrician is important.
These pregnancies can be affected by IUGR, so serial growth scan / two weeks from 26 weeks is advised. US assessment is necessary to exclude structural abnormalities and hydrops foetalis.
Jarisch Heximer reaction during treatment with penicillin can precipitate preterm labour so patient is given advise about its symptoms and to report to hospital early.
Delivery :- No indication for IOL or CS. Aim is for vaginal delivery. Breast feeding is not contradicted. Serology will be positive in neonate as anti body cross placenta. Congenital syphilis may not manifest in neonate soon after delivery, and manifest later so neonate need follow up.
From
Dr. SB
Posted by Vandana D.
Please mark my answer,though I am sorry as I COULD NOT SEND IT IN SAME MESSAGE,I then tried & sent it in 3 parts.
Thank you.
Vandana.
