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

Management of Postpartum Patient with Positive VDRL and TPHA

Immediate Treatment Required

A postpartum patient with both positive VDRL and TPHA requires immediate treatment with benzathine penicillin G, as this confirms active or past syphilis infection that demands urgent intervention to prevent transmission to the infant and protect maternal health. 1

Critical First Steps

Determine Treatment History and Stage

• Review prenatal records immediately to establish if the mother received adequate penicillin treatment during pregnancy, when it was administered, and what her VDRL titers were throughout pregnancy 2
• Document the quantitative VDRL titer now and compare to any previous titers to assess disease activity 1, 3
• A fourfold change in VDRL titer is clinically significant for determining active infection versus treated disease 1

Assess the Infant's Risk

The infant's management depends entirely on the mother's treatment status:

Scenario 1: Mother was untreated or inadequately treated during pregnancy

• The infant requires full evaluation including CSF examination, long-bone radiographs, CBC with platelets, and other tests as clinically indicated 2
• Treat the infant with aqueous crystalline penicillin G 100,000-150,000 units/kg/day IV for 10 days OR procaine penicillin G 50,000 units/kg/dose IM daily for 10 days 2

Scenario 2: Mother received treatment but less than 4 weeks before delivery

• The infant still requires full evaluation and 10-day parenteral penicillin therapy 2
• Treatment administered <4 weeks before delivery is considered inadequate to prevent congenital syphilis 2

Scenario 3: Mother received adequate treatment >4 weeks before delivery with appropriate serologic response

• If the infant's physical examination is normal and nontreponemal titer is ≤4-fold the maternal titer, treat with single-dose benzathine penicillin G 50,000 units/kg IM 2
• Some experts recommend close serologic follow-up without treatment if maternal titers decreased fourfold after early syphilis treatment 2

Maternal Treatment Protocol

If Previously Untreated or Inadequately Treated

For early syphilis (primary, secondary, or early latent <1 year):

• Benzathine penicillin G 2.4 million units IM as a single dose 2, 1

For late latent syphilis or unknown duration:

• Benzathine penicillin G 2.4 million units IM once weekly for 3 consecutive weeks (total 7.2 million units) 1, 3

Critical caveat: Parenteral penicillin G is the only therapy with documented efficacy for syphilis during pregnancy and the postpartum period if breastfeeding 2

Penicillin Allergy Management

• Penicillin desensitization is mandatory for postpartum women who need treatment and report penicillin allergy, as no alternative has proven efficacy for preventing congenital syphilis 2
• Skin testing may be useful but minor determinants are not commercially available 2

Essential Concurrent Actions

HIV Testing

• Test for HIV infection immediately if not already done, as HIV coinfection significantly affects monitoring frequency and neurosyphilis risk 1, 3
• HIV-infected patients require CSF examination for late latent syphilis and follow-up every 3 months instead of 6 months 1, 3

Neurosyphilis Screening

• Perform lumbar puncture with CSF examination if any of the following are present: neurologic symptoms, ocular symptoms, VDRL titer ≥1:32, or HIV infection with late latent disease 1, 3
• If neurosyphilis is confirmed, treat with aqueous crystalline penicillin G 18-24 million units per day IV for 10-14 days 1, 3

Partner Notification

• Identify and notify sexual partners from the past 3 months plus duration of symptoms for primary syphilis, 6 months for secondary syphilis, or 1 year for early latent syphilis 2
• Partners should receive presumptive treatment if exposed within 90 days of diagnosis 2

Follow-Up Monitoring

Maternal Serologic Monitoring

• Recheck quantitative VDRL/RPR at 6,12, and 24 months after treatment 1, 3
• Treatment success is defined as a fourfold decline in titer within 6-12 months for early syphilis or 12-24 months for late latent syphilis 1, 3
• Use the same nontreponemal test method (VDRL or RPR) at the same laboratory for all follow-up testing, as titers are not interchangeable 1, 3

Infant Serologic Monitoring

• Infants should have nontreponemal testing at 3,6,12, and 15 months of age 2
• Infant titers should decline and become nonreactive by 6 months if only passively transferred maternal antibodies are present 2
• A reactive nontreponemal test at 18 months is diagnostic of congenital syphilis and requires full evaluation and treatment 2

Critical Pitfalls to Avoid

• Never use treponemal tests (TPHA) to monitor treatment response - they remain positive for life regardless of cure and do not correlate with disease activity 1
• Do not delay treatment waiting for staging workup - initiate appropriate therapy immediately based on available information 1
• Do not assume low VDRL titers mean inactive disease - titers <1:8 can still represent active infection requiring treatment 4, 5
• Do not use non-penicillin regimens in postpartum women who may breastfeed - only penicillin has documented safety and efficacy 2

Jarisch-Herxheimer Reaction Warning

• Advise the patient that an acute febrile reaction with headache and myalgia may occur within 24 hours after penicillin therapy 2
• Antipyretics may be recommended, though no proven prevention methods exist 2
• This reaction is common with early syphilis but should not prevent or delay necessary treatment 2