What is the treatment for pregnant women with syphilis (Sexually Transmitted Infection)?

From the Guidelines

Pregnant women with syphilis should be treated with penicillin G, which is the only recommended therapy during pregnancy. The specific regimen depends on the stage of syphilis. For early syphilis (primary, secondary, or early latent), a single dose of benzathine penicillin G 2.4 million units intramuscularly is recommended 1. For late latent syphilis or syphilis of unknown duration, the regimen is benzathine penicillin G 2.4 million units intramuscularly once weekly for three consecutive weeks. Patients with neurosyphilis require aqueous crystalline penicillin G 18-24 million units daily, administered as 3-4 million units IV every 4 hours for 10-14 days. For penicillin-allergic patients, desensitization is necessary as there are no proven alternatives during pregnancy 1. Treatment should begin immediately after diagnosis to prevent congenital syphilis. The Jarisch-Herxheimer reaction (fever, chills, headache) may occur within 24 hours of treatment and can trigger preterm labor, so pregnant women should be monitored closely. Follow-up serologic testing is essential at 1,3,6, and 12 months after treatment to ensure adequate response. Penicillin is effective because it crosses the placenta and treats both the mother and the developing fetus, preventing congenital syphilis which can cause severe birth defects or fetal death.

Some key considerations in the treatment of pregnant women with syphilis include:

• The importance of prompt treatment to prevent congenital syphilis 1
• The need for desensitization in penicillin-allergic patients, as there are no proven alternative therapies during pregnancy 1
• The potential for the Jarisch-Herxheimer reaction to trigger preterm labor, and the need for close monitoring of pregnant women after treatment 1
• The importance of follow-up serologic testing to ensure adequate response to treatment 1

Overall, the treatment of pregnant women with syphilis requires careful consideration of the stage of syphilis, the potential for penicillin allergy, and the need for prompt and effective treatment to prevent congenital syphilis. Penicillin G remains the only recommended therapy for syphilis during pregnancy, and treatment should be guided by the most recent and highest-quality evidence available 1.

From the Research

Treatment of Pregnant Women with Syphilis

• The recommended treatment for pregnant women with syphilis is benzathine penicillin G, administered according to the maternal stage of infection per Centers for Disease Control and Prevention guidelines 2.
• Women with a penicillin allergy should be desensitized and then treated with penicillin appropriate for their stage of syphilis 2.
• A single dose of 2.4 million units of benzathine penicillin G is the drug of choice for managing early syphilis 3.
• The effectiveness of benzathine penicillin regimen in the treatment of syphilis in pregnancy has been confirmed, with a regimen of 2.4 million units weekly for 3 consecutive weeks being clinically effective for prevention of congenital syphilis 4.

Diagnosis and Screening

• Testing for syphilis should be performed at initiation of prenatal care and twice during the third trimester in high-risk patients 2.
• Women testing positive for syphilis should undergo a history and physical exam as well as testing for other sexually transmitted infections, including HIV 2.
• Cerebrospinal fluid (CSF) examination should be performed in all persons with serologic evidence of syphilis infection and neurologic symptoms 3.

Prevention of Congenital Syphilis

• Congenital syphilis continues to be a preventable cause of global stillbirth and neonatal morbidity and mortality 5.
• Estimating benzathine penicillin need for the treatment of pregnant women diagnosed with syphilis during antenatal care in high-morbidity countries is crucial for prevention of congenital syphilis 5.
• Initiatives to ensure a stable and adequate supply of benzathine penicillin for treatment of maternal syphilis are important for congenital syphilis prevention 5.

Resistance and Treatment Failures

• The emergence of clinically significant azithromycin resistance in Treponema pallidum subsp. pallidum has resulted in treatment failures, thus precluding the routine use of this second-line drug 6.
• Macrolide-resistant T. pallidum is a challenge for syphilis treatment, and information on the diagnosis and recommended antibiotic treatment of syphilis is essential 6.