What is the management plan for a pregnant female patient with a positive Venereal Disease Research Laboratory (VDRL) test and Treponema Pallidum Haemagglutination Assay (TPHA) test indicating syphilis infection?

Management of Pregnant Female with Positive VDRL and TPHA

Immediate Treatment Required

Treat immediately with benzathine penicillin G 2.4 million units IM as a single dose if this represents primary, secondary, or early latent syphilis (infection within the past year), or benzathine penicillin G 2.4 million units IM once weekly for 3 consecutive weeks if this represents late latent or unknown duration syphilis. 1, 2

The positive VDRL and TPHA confirm active syphilis infection requiring urgent treatment to prevent congenital syphilis and fetal complications. 1

Critical First Steps

Determine Stage of Infection

• Obtain detailed sexual history including timing of last unprotected exposure, presence of any chancre or rash, and duration of known infection to classify as early (≤1 year) versus late latent (>1 year or unknown duration). 1

• Perform thorough physical examination specifically looking for primary chancre, secondary syphilis rash, mucocutaneous lesions, lymphadenopathy, or any neurologic/ocular symptoms. 1

• Obtain quantitative VDRL titer on maternal serum (not cord blood) to establish baseline for monitoring treatment response. 1

Assess Treatment Urgency

• Calculate gestational age as women in the second half of pregnancy are at higher risk for Jarisch-Herxheimer reaction precipitating premature labor or fetal distress. 1

• Consider additional therapy with a second dose of benzathine penicillin 2.4 million units IM one week after the initial dose, particularly for women in the third trimester or those with secondary syphilis. 1, 2

Penicillin Administration Protocol

Standard Treatment Regimens

• For primary, secondary, or early latent syphilis: Benzathine penicillin G 2.4 million units IM as a single dose. 1, 2

• For late latent or unknown duration syphilis: Benzathine penicillin G 2.4 million units IM once weekly for 3 consecutive weeks (total 7.2 million units). 1, 2

Management of Penicillin Allergy

No alternatives to penicillin are acceptable for treating syphilis during pregnancy. 1

• Perform penicillin skin testing if available to confirm true allergy versus historical report. 1

• Desensitize and treat with penicillin regardless of allergy history, as this is the only proven effective treatment to prevent congenital syphilis. 1, 2

• Do not use tetracycline, doxycycline, erythromycin, azithromycin, or ceftriaxone as these do not reliably cure fetal infection or are contraindicated in pregnancy. 1, 2

Monitoring and Follow-Up

Jarisch-Herxheimer Reaction Counseling

• Advise patient to seek immediate obstetric attention if she notices any contractions or decrease in fetal movements within 24 hours after treatment. 1

• Explain that stillbirth is a rare complication but this concern should never delay necessary treatment, as untreated syphilis causes far greater fetal harm. 1, 2

Serologic Monitoring Schedule

• Repeat quantitative VDRL titers in the third trimester and at delivery to assess treatment response. 1, 2

• Check titers monthly in women at high risk for reinfection or in geographic areas with high syphilis prevalence. 1, 2

• Expect fourfold decline in titer within 6-12 months for early syphilis and 12-24 months for late latent syphilis as evidence of adequate treatment. 3, 4

Coordinated Prenatal Care

• Establish coordinated prenatal care, treatment follow-up, and syphilis case management as most women will deliver before serologic response can be definitively assessed. 1

• Obtain information about treatment of sex partners to assess risk for maternal reinfection. 1

Partner Management

• Identify and treat all sexual contacts from the past 90 days presumptively, even if seronegative, as they may be in the incubation period. 1, 3

• For secondary syphilis, extend contact tracing to 6 months plus duration of symptoms. 1

• For early latent syphilis, extend contact tracing to 1 year. 1

Additional Testing

• Test for HIV infection as all patients with syphilis should be offered HIV testing, and HIV status affects monitoring frequency and neurosyphilis risk. 1, 2

• Perform CSF examination if neurologic or ocular symptoms are present, or if HIV-infected with late latent syphilis. 1, 5

Infant Evaluation Planning

• Ensure maternal serologic status is documented at least once during pregnancy and preferably again at delivery before any infant leaves the hospital. 1

• Plan for infant evaluation at birth including quantitative nontreponemal test on infant serum (not cord blood), physical examination for congenital syphilis signs, and comparison of maternal and infant titers. 1

Critical Pitfalls to Avoid

• Never delay treatment due to concerns about Jarisch-Herxheimer reaction or stillbirth risk, as untreated syphilis causes far greater fetal harm than treatment complications. 1, 2

• Never use non-penicillin regimens including erythromycin, tetracyclines, azithromycin, or ceftriaxone, as these do not prevent congenital syphilis. 1, 2

• Never allow infant discharge without documented maternal syphilis screening during pregnancy. 1, 2

• Never use treponemal test titers to monitor treatment response, as these remain positive for life regardless of treatment success. 3, 5