What are the treatment and prevention options for a pregnant wife if her husband has been diagnosed with syphilis?

Transmission and Management of Syphilis in Pregnancy

Immediate Action Required

If a husband is diagnosed with syphilis, his pregnant wife must be immediately tested with both nontreponemal (RPR or VDRL) and treponemal serologic tests, and if positive, she must receive benzathine penicillin G treatment without delay—penicillin is the only therapy proven to prevent maternal transmission to the fetus and treat fetal infection. 1, 2

Understanding Transmission Risk

• Syphilis is transmitted through direct contact with infectious lesions during vaginal, anal, or oral sex 3
• The primary and secondary stages are the most infectious periods 4
• In pregnancy, up to 40% of fetuses with in-utero exposure to syphilis are stillborn or die from their infection during infancy 3
• Sexual partners exposed within 90 days preceding diagnosis of primary, secondary, or early latent syphilis should be treated presumptively even if seronegative 1

Diagnostic Approach for the Wife

• Obtain both nontreponemal (RPR or VDRL) and confirmatory treponemal tests (FTA-ABS or MHA-TP) immediately 2, 5
• All pregnant women should be screened for syphilis at first prenatal visit, during third trimester (28 weeks), and at delivery 1, 3
• Test for HIV infection in all patients diagnosed with syphilis 1, 2, 5

Treatment Protocol for Pregnant Women

If Wife Tests Positive:

• Primary or secondary syphilis: Benzathine penicillin G 2.4 million units IM as a single dose 1, 2
• Early latent syphilis: Benzathine penicillin G 2.4 million units IM as a single dose 1
• Late latent or unknown duration: Benzathine penicillin G 7.2 million units total (three doses of 2.4 million units IM at weekly intervals) 1, 5
• Some experts recommend a second dose of benzathine penicillin 2.4 million units IM one week after the initial dose for women with primary, secondary, or early latent syphilis 1

Critical Penicillin Allergy Management:

• Pregnant women with penicillin allergy MUST undergo desensitization followed by penicillin treatment—no exceptions 6, 1, 2
• Tetracycline, doxycycline, erythromycin, azithromycin, and ceftriaxone are completely inadequate in pregnancy 6, 1
• Erythromycin does not reliably cure fetal infection 6
• Skin testing may be helpful before desensitization 6

Critical Warnings About Treatment During Pregnancy

• Women treated during the second half of pregnancy are at risk for premature labor and/or fetal distress from Jarisch-Herxheimer reaction 6, 1
• The Jarisch-Herxheimer reaction is an acute febrile reaction that may occur within 24 hours after treatment 1, 5
• Women should seek immediate obstetric attention if they notice any contractions or decrease in fetal movements after treatment 6, 1
• Stillbirth is a rare complication of treatment, but concern about this should not delay necessary treatment 6

Follow-Up Protocol

• Repeat serologic titers in the third trimester and at delivery 6
• Check titers monthly in women at high risk for reinfection or in geographic areas with high syphilis prevalence 6
• Most women will deliver before their serologic response to treatment can be assessed definitively 6
• Expect a fourfold decline in nontreponemal titer within 6 months for primary/secondary syphilis 1, 5

Management of the Husband (Sex Partner)

• Treat presumptively if exposed within 90 days of diagnosis, even if seronegative 1
• Time periods for at-risk partners: 3 months plus duration of symptoms for primary syphilis, 6 months plus duration of symptoms for secondary syphilis 1
• Obtain information about partner treatment to assess risk for maternal reinfection 6

Prevention of Congenital Syphilis

• Effective prevention depends on identification and treatment of syphilis in pregnant women 6
• No infant or mother should leave the hospital unless maternal serologic status has been documented at least once during pregnancy and preferably again at delivery 6
• Coordinated prenatal care, treatment follow-up, and syphilis case management are essential 6

Common Pitfalls to Avoid

• Never substitute alternatives for penicillin in pregnancy—only penicillin prevents congenital syphilis 1
• Never delay treatment due to concerns about Jarisch-Herxheimer reaction—the benefits far outweigh the risks 6
• Never skip partner evaluation and treatment—reinfection will compromise maternal and fetal outcomes 6
• Do not rely on umbilical cord blood for serologic testing—it can be contaminated with maternal blood and yield false-positive results 6