What is Congenital and Maternal Syphilis?
Congenital and maternal syphilis is a disease passed from mother to baby caused by a type of bacteria called Treponema pallidum. This disease can lead to various health conditions in babies. Some babies may show no symptoms at all, while others could be born prematurely with various signs and symptoms. In severe cases, it can lead to stillbirth and newborn death. More and more cases have been reported, with 2022 seeing the most since 1997.
This disease is tracked nationally, meaning it must be reported to the Centers for Disease Control (CDC) by all states in the US. It’s important for mothers to receive adequate prenatal care and treatment early on to prevent the effects of congenital syphilis.
What Causes Congenital and Maternal Syphilis?
The bacterium that causes syphilis was first discovered by Fritz Schaudinn and Erich Hoffmann in 1905. This bacterium, called Treponema pallidum, moves about and is shaped like a corkscrew. The first recorded outbreak of syphilis happened in Naples, Italy, in 1494 and is believed to have been brought there by Columbus after his voyage to the New World. From Naples, the disease then spread throughout Europe. While researchers have been able to grow this bacterium using rabbit cells in a lab only in 2017, humans are the only known hosts for it.
There have been several missed opportunities in public health to help reduce the rate of syphilis in pregnant women. These include not getting proper antibiotics in time despite an early diagnosis, a lack of prenatal care, not testing for syphilis during pregnancy, and late identification of this disease. About two-thirds of patients in some parts of the US are not properly followed up on, leading to avoidable complications.
Often, retesting for syphilis during the early part of the third trimester (around the 28th week of pregnancy) has shown to be effective in lessening the occurrence of syphilis passed from mother to child during birth. In addition to early detection and appropriate treatment for the mother and baby, the mother’s sexual partners should also be tested and adequately treated. Routine testing for syphilis for all pregnant women in the United States greatly reduces rates of this disease in newborns. Most cases of syphilis in newborns are seen in women who did not receive proper prenatal care or were inadequately treated.
Risk Factors and Frequency for Congenital and Maternal Syphilis
Congenital syphilis, a condition affecting around a million pregnancies globally each year, significantly contributes to infant mortality. It leads to around 305,000 yearly infant deaths, making it the second top cause for this worldwide, only surpassed by preterm birth. This condition is often seen in women who didn’t receive adequate prenatal care or received incorrect treatment, even though syphilis is a treatable disease.
- In the United States, congenital syphilis had its highest recorded rate in 1991, with around 100 cases per 100,000 live births.
- After a decline, the rate has been on an upward trend since 2012, increasing over 2.5 times between 2017 and 2022, according to the National Center for Health Statistics.
- In 2023, the U.S. reported 5,726 cases and a rate of 77.9 cases per 100,000 live births.
- The fastest increase in cases was seen in women under 24 years old.
- There has been a significant rise in congenital syphilis in the Southern, Western, and Midwestern regions of the U.S., with the lowest incidence in the Northeast.
- There is also a marked racial disparity, with higher rates among Black and Hispanic mothers compared to White and Asian mothers.
Worldwide, the World Health Organization estimates that 7 out of 1000 pregnant women have a maternal syphilis infection. This results in over 200,000 neonatal deaths and 1.5 million cases of infected newborns reported annually, with a majority of cases in Africa. Without early diagnosis and treatment, up to 40% of pregnant women with syphilis could give birth to stillborn babies, and 33% could deliver low-weight infants. The overall worldwide incidence of congenital syphilis has risen by 500% from 2011 to 2020, with some countries, like Cuba, Malaysia, Maldives, Sri Lanka, and Thailand, having virtually eliminated it.
Signs and Symptoms of Congenital and Maternal Syphilis
Congenital syphilis, an infection by the bacterium Treponema pallidum in newborns, is influenced by many risk factors. These include drug abuse, homelessness, imprisonment, domestic violence, lack of health insurance, poverty, lower education levels, multiple sex partners, and absence of prenatal care, STD testing or treatment during pregnancy. Issues like mental health, cultural aspects, and social stigma toward sexual diseases can also increase risks.
The physical signs of syphilis in pregnant women don’t differ compared to other women of their age. One may witness a painless hardened sore where the infection entered the body. Other signs could be swollen lymph glands or a rash, mostly on the palms of the hands or bottoms of the feet. Even without treatment, these symptoms can disappear, leading to a dormant stage of the disease, which could progress to a serious stage in some instances.
It’s crucial to test newborns of syphilis-positive mothers for any signs of the disease. They should also have follow-up checkups after three months. Although congenital syphilis can lead to serious illness and death in fetuses, 70% of newborns with the disease don’t show symptoms at birth. If infected in the later stages of pregnancy, the child is usually born asymptomatic and might appear healthy. The worst outcomes usually occur when the infection is transmitted from the mother in the early stages of pregnancy.
Symptoms of infant congenital syphilis might appear within the first three months after birth or up to two years of age. Without treatment, infants usually start displaying symptoms by the age of three months. Symptoms that appear after the child is two years old are categorized as late congenital syphilis.
Within the first three months of life, a newborn might show one or more of the following signs:
- Anemia and low platelet count
- Bone abnormalities
- Enlarged liver and complications with liver function
- Swollen lymph glands
- Persistent runny nose
- Rashes, mostly on the back, buttocks, posterior thighs, palms, and soles
If the disease isn’t diagnosed and treated early, continuous inflammation can lead to scarring and other symptoms. Additionally, a lot of other physical conditions might also occur, including cataracts, enlarged collarbone, nerve difficulties, chorioretinitis, loss of eyebrows, diabetes insipidus, facial changes, failure to thrive, low fever, gastrointestinal disorders, glaucoma, Hydrocephalus, peculiar incisor teeth, and many others.
Untreated or undiagnosed congenital syphilis during infancy might result in severe symptoms similar to adult secondary syphilis. This includes swelling at the back of the head, nerve difficulties, widened condylomata, enlarged liver and spleen, rashes, seizures, unexplained fevers, and more. Some of these children might also develop a dormant form of the disease and develop symptoms of tertiary or neurosyphilis, such as nerve-related deafness, ocular syphilis, syphilitic paresis, and tabes dorsalis as adults.
Testing for Congenital and Maternal Syphilis
Congenital syphilis, a condition which a baby is born with because the mother has syphilis, is hard to diagnose immediately after birth. Often, newborns with the disease don’t show symptoms at birth. Certain antibodies from the mother may transfer to the baby and interfere with testing. These can remain for over a year, making testing unreliable during that time.
Nontreponemal tests are performed on the baby, as they use specific antibodies, known as IgM, that don’t cross the placenta. If the results show an increase of certain antibodies, doctors will monitor the baby with regular testing every 2 to 3 months. If these levels remain high, it suggests the baby has syphilis or has not been effectively treated.
Screening the afflicted mother is crucial in preventing congenital syphilis. Serological tests, which measure the presence of certain antibodies in the blood, are done to confirm syphilis in the mother. These tests include nontreponemal serum assays and treponemal antibody tests.
All pregnant women are recommended to be screened during the first prenatal visit by significant health organizations like the CDC, WHO, and American College of Obstetrics and Gynecology.
For those who live in areas where syphilis is more common, there should be additional testing during the pregnancy and at delivery since it’s possible to have contracted syphilis during pregnancy.
There are booths that provide rapid screening tests. These tests only take 20 minutes and may lead to immediate treatment. It’s not a replacement for standard laboratory testing. But it’s useful for high-risk populations, where there are limited health resources and follow-up care is uncertain.
Ultrasonography can help identify syphilis in the fetus after 18 weeks of pregnancy. This can show symptoms like an enlarged liver, anemia, excess amniotic fluid, and fetal hydrops. If these are present, aggressive treatment with specific medications are suggested.
The baby or infant suspected of syphilis is evaluated based on the mother’s condition and other lab tests. The best test is a quantitative nontreponemal serological assay, like RPR or VDRL, on the infant’s serum. If the mother tested positive for syphilis or the child is suspicious for having the disease, these tests are critical.
Certain tests aren’t readily available in the US or other parts of the world. Mostly, serological testing is done for both the mother and the baby. Infants born with symptoms of congenital syphilis might also have neurosyphilis, a more severe form that affects the nervous system.
Neurosyphilis can be diagnosed by tests on the infant’s cerebrospinal fluid. While the symptoms of neurosyphilis in an infant are rare, it could occur in those with untreated congenital syphilis.
Treatment Options for Congenital and Maternal Syphilis
Syphilis in pregnant women (known as maternal syphilis) can be treated with a drug called benzathine penicillin G. It’s very effective in preventing the baby from getting syphilis during pregnancy. However, the best time and amount to give this treatment isn’t fully known yet. Sometimes, a mother may need a second dose of the drug, particularly when there are signs that the baby is also affected by the disease.
Early diagnosis and treatment of maternal syphilis can sometimes be difficult due to various factors. These might include late prenatal care, lack of quick testing options, irregular supply of antibiotics, issues with drug dispatch, poor healthcare monitoring, delays in treatment, poor postnatal care, or the tendency of sexual partners to not seek treatment.
In places where it’s hard for medical follow-up to take place, immediate treatment is advised for pregnant women who test positive for syphilis. For syphilis infections that have gone unnoticed or have an unknown start date, multiple doses of benzathine penicillin G are recommended. Any delays in treatment that last 10 days or more will require the full treatment again.
If a mother is allergic to penicillin, tests are done to determine the severity of the allergy, as this drug is the most effective treatment for maternal syphilis. A significant rise in particular test scores after treatment can suggest reinfection or treatment failure.
The newborn child’s treatment depends on how likely they are to have the disease. Treatment can be administered in various ways, depending on the severity of the disease. Tests may also be done on the newborn to check if they have syphilis. However, in case of penicillin allergic mothers, the baby may need to undergo treatment to reduce the allergic reaction, as penicillin is the best treatment for syphilis.
In cases when pregnant women can’t be treated with penicillin due to allergies or a shortage in supply, sometimes other drugs like ceftriaxone can be used, though they require careful monitoring.
It’s also possible for mothers being treated for syphilis to experience a Jarisch-Herxheimer reaction, a side effect of the dying bacteria causing flu-like symptoms. The mother and baby should be closely monitored during this reaction.
What else can Congenital and Maternal Syphilis be?
Congenital syphilis, an infection passed from mother to child during pregnancy, can sometimes look like other illnesses. These can include:
- Anthrax
- Bejel (a bacterial skin disease)
- Gonorrhea
- Chorioretinitis (inflammation of the eye)
- Lyme Disease
- Neonatal hepatitis (inflammation of a baby’s liver)
- Rat-bite fever (a bacterial illness)
- Pediatric HIV
- Pediatric tuberculosis
- Neonatal sepsis (a severe infection in an infant)
- Parvovirus B19 Infection (a viral illness)
- Granuloma inguinale, lymphogranuloma venereum, and venereal warts (sexually transmitted infections)
- Several infections often detected in newborns (Toxoplasmosis, Rubella, Cytomegalovirus, Herpes simplex; also known as TORCH infections)
- Various skin conditions in children like pediatric acropustulosis, pediatric enteroviral infections, pediatric erythema toxicum
However, it’s noteworthy that congenital syphilis is commonly linked with increased weight of the placenta, the organ that develops in the womb during pregnancy. If a baby’s placenta is heavier than normal, but tests rule out syphilis, doctors may consider other possibilities such as:
- Beckwith-Wiedemann syndrome (a growth disorder)
- Cerebral palsy (a group of disorders affecting movement and muscle tone)
- Hydrops fetalis (a severe swelling in an unborn baby or fetus)
- Cytomegalovirus infection in the fetus
- Maternal diabetes
What to expect with Congenital and Maternal Syphilis
If diagnosed and treated quickly and correctly, the outcome for someone with syphilis is usually very good as the disease can be easily treated with penicillin. However, there are certain situations where the disease can have more serious effects and could even be fatal. These include:
* Premature infants,
* Individuals who don’t start treatment promptly or who aren’t treated properly,
* Patients in which the disease has spread extensively and caused multiple organs to fail,
* Infants who experience an intense reaction, known as a Jarisch-Herxheimer reaction, to the treatment.
The World Health Organization (WHO) has set out some goals to reduce instances of maternal and congenital syphilis around the world. Achieving these goals will need a big commitment on a global scale, involving public health resources, political backing, funds, and educating both patients and the public. The goals are:
* To have at least 90% of pregnant women tested for syphilis, ideally when they have their first prenatal visit,
* To ensure at least 90% of pregnant women who test positive for syphilis receive the necessary treatment.
Possible Complications When Diagnosed with Congenital and Maternal Syphilis
About 40% of babies born to mothers with untreated syphilis can unfortunately be stillborn or may die soon after birth.
If a baby’s syphilis is not diagnosed and treated promptly, it can result in long-term complications. These may include:
- Intellectual disability
- Skin rashes or gummas (soft tissue tumors)
- Scarring
- Hearing or vision problems
- Severe anemia
- Meningitis (inflammation of the membranes around the brain and spinal cord)
- Jaundice (yellowing of the skin and eyes)
- Liver failure
- Splenomegaly (enlarged spleen)
- Skeletal abnormalities
- Tertiary syphilis (late stage syphilis)
Starting treatment in some babies can cause a Jarisch-Herxheimer reaction. This is a response to the treatment and can cause symptoms such as fever, chills, low blood pressure, and in extreme cases, can result in death due to the inflammation caused by the dying bacteria.
If left untreated, babies who survive through congenital syphilis (syphilis present at birth) might display signs of tertiary syphilis or neurosyphilis (syphilis that affects the nervous system) when they grow up.
Preventing Congenital and Maternal Syphilis
Keeping a close eye on all pregnant women for signs of syphilis and treating it promptly during pregnancy is the most effective way to prevent congenital syphilis, which is when the disease is passed from mother to baby.
Here are some ways we can lower the rates of congenital syphilis:
* Overcome the hurdles to treatment, such as a fear of injections or loss of dignity
* Provide education on safe sex and using condoms to prevent the spread of syphilis
* Eliminate fear of legal consequences or losing child custody
* Ensure there is no shortage of the antibiotic penicillin used for treatment.
* Make sure prenatal care is available to all pregnant women, which can help detect syphilis early during pregnancy
* Increase the number of free clinics for sexually transmitted diseases for early diagnosis and treatment
* Implement routine testing in emergency departments and urgent care centers
* Make rapid testing kits more readily available, along with immediate antibiotic treatment for individuals at high risk
* Improve the testing and treatment of sexual partners of pregnant women with syphilis
* Include syphilis testing when the initial pregnancy test is done.
Congenital syphilis is a disease that can be prevented, yet it continues to be a frustratingly common issue. Current public health measures have not succeeded in slowing its rapid spread, making it a growing global health problem that causes significant illness and death. However, improved public health programs with prenatal screening and treatment of syphilis, better access to prenatal care, rapid testing with immediate antibiotic treatment in high-risk groups, and increased treatment of sexual partners have shown to be effective in tackling this global issue. It’s estimated that such programs could reduce syphilis-related stillbirths and deaths of newborns by at least 50%.
