What is the management approach for a neonate born to a mother with a positive Venereal Disease Research Laboratory (VDRL) test?

Management of Neonates Born to VDRL-Positive Mothers

All neonates born to mothers with positive VDRL tests should be thoroughly evaluated for congenital syphilis and treated based on maternal treatment history, clinical findings, and serologic test results. 1, 2

Initial Evaluation

• Mandatory testing: All neonates born to VDRL-positive mothers require:

  • Quantitative nontreponemal test (RPR or VDRL) on infant serum (not cord blood)
  • Thorough physical examination for signs of congenital syphilis (hydrops, jaundice, hepatosplenomegaly, rhinitis, skin rash, pseudoparalysis)
  • Review of maternal treatment history and serologic response 1

• Additional testing when indicated:

  • CSF analysis for VDRL, cell count, and protein
  • Complete blood count with differential and platelet count
  • Long-bone radiographs
  • Liver function tests
  • Other tests as clinically indicated (chest radiograph, cranial ultrasound, ophthalmologic examination, auditory brainstem response) 1

Treatment Decision Algorithm

Scenario 1: Definite or Highly Probable Congenital Syphilis

Treat with parenteral penicillin if ANY of the following:

• Abnormal physical examination consistent with congenital syphilis
• Infant's nontreponemal titer is ≥4-fold higher than mother's
• Positive darkfield test of body fluids 1

Treatment:

• Aqueous crystalline penicillin G 100,000-150,000 units/kg/day IV (divided doses) for 10 days OR
• Procaine penicillin G 50,000 units/kg/dose IM daily for 10 days 1

Scenario 2: Maternal Treatment Inadequate or Uncertain

Treat if ANY of the following maternal conditions:

• Untreated syphilis at delivery
• Treatment with non-penicillin regimen during pregnancy
• Treatment <4 weeks before delivery
• Inadequate documentation of treatment
• No appropriate serologic response to treatment
• Evidence of relapse or reinfection 1

Treatment: Same as Scenario 1

Scenario 3: Adequately Treated Mother with Appropriate Response

If ALL of the following:

• Mother received appropriate penicillin treatment during pregnancy
• Treatment was >4 weeks before delivery
• Mother showed appropriate serologic response
• Infant has normal physical exam
• Infant's nontreponemal titer ≤4-fold the maternal titer

Management:

• No treatment needed if maternal treatment was before pregnancy with multiple follow-ups showing low, stable titers
• Some experts recommend benzathine penicillin G 50,000 units/kg IM as single dose if follow-up uncertain 1

Follow-Up

• All seroreactive infants should receive follow-up examinations and nontreponemal testing every 2-3 months until:

  • Test becomes nonreactive OR
  • Titer decreases fourfold 1

• Nontreponemal antibody titers should:

  • Decline by 3 months of age
  • Become nonreactive by 6 months if infant was not infected or was adequately treated 1, 3

• If titers are stable or increasing after 6-12 months:

  • Re-evaluate infant including CSF examination
  • Treat with 10-day course of parenteral penicillin G 1

Important Considerations

• Transplacental transfer of maternal IgG antibodies can complicate interpretation of serologic tests in infants 1, 3
• CSF findings in neonates can be difficult to interpret; normal values differ by gestational age 1
• Most uninfected infants born to treated mothers will have negative VDRL within 6 months and negative treponemal tests within 12 months 3
• Despite adequate maternal treatment, congenital syphilis can still occur, particularly with high maternal titers, early stage syphilis, short interval from treatment to delivery, and preterm birth 4
• Infants with normal physical examinations and nonreactive nontreponemal tests rarely have abnormalities on conventional laboratory and radiographic testing 5

The incidence of congenital syphilis is increasing worldwide despite penicillin availability, highlighting the importance of thorough evaluation and appropriate management of all at-risk neonates 6.