1.       All pregnant patients should be screened with a non-treponemal reaginic test (RPR or VDRL) for syphilis:

         A.        At the initial visit.

B.       Again in the third trimester, 32-36 weeks.

C.       If and when the patient reports vulvar ulcers, sores, or unusual rashes.

D.       If the patient has ongoing drug use or is known to engage in prostitution,                      re-screen monthly.

 

2.       A positive RPR/VDRL should be confirmed with a specific treponemal test           (MHA-TP or FTA-ABS).

 

3.       For patients with a False - Positive VDRL (positive VDRL/RPR, negative FTA-ABS/MHA-TP), (discuss with MFM Attending regarding the need for referral to HROB Clinic).

 

4.       Confirmed Syphilis:  (For patients with both RPR and FTA-ABS tests positive)

 

A.       Contact patient immediately.

B.       Make appropriate health department notification for contact tracing.

C.       Consult with medical provider regarding need for transfer to HROB.   

D.       By history, attempt to identify possible timing of infection, specifically less than 1 year or greater than one year.

E.       Record any neuropsychiatric problems (hearing, visual problems, facial droops, peripheral weaknesses, psychotic behavior).

F.       Review records and confirm that testing for gonorrhea, Chlamydia, trichomonas, hepatitis B & C, and HIV infection has been performed or offered.  If not recently performed (less than 1-2 months) repeat STI testing.

G.       OB ultrasound should be ordered to rule out fetal hydrops.

H.       Drug screen should be ordered.

I.        Notify Pediatric Clinic of fetal exposure to syphilis to enhance follow-up of                       newborn.

J.        Discuss with patient how to prevent re-infection, specifically, the use of barrier methods.

k.       For patients with a known history of treated syphilis and positive testing discuss treatment with provider 

 

Treatment: Confirmed Syphilis (Positive RPR/positive FTA-ABS)

 

1.       Penicillin remains the main stay of syphilis treatment during pregnancy.  Erythromycin, doxycycline, and ceftriaxone are not adequate therapies during pregnancy, as they do not prevent congenital syphilis.

 

 General Guidelines for Outpatient Therapy.

 

1.       Less than 1 year duration - confirmed:  benzanthine, penicillin G, 2.4 million units x 1, intramuscular.

2.       Greater than 1 year duration or unknown:  benzanthine, penicillin G, 2.4 million units q wk x 3, intramuscular.

3.       Provide education and instruction regarding preterm labor.  Also instruct patient on assessing fetal movement.

 

 

1.       Allergic to penicillin (rash, hives or wheezing).  Patients with a history of nausea and vomiting may receive outpatient penicillin treatment.

2.       HIV positive.

3.       Have neuropsychiatric problems.

 

 

         1.        Patients treated for syphilis should have a repeat VDRL/RPR every month throughout pregnancy until negative.

2.        If the titer increases by fourfold or does not fall fourfold over a three month period, consult a physician regarding further testing and re-treatment

        3.        VDRL/RPR should be obtained at the 6 weeks postpartum visit. 

    

                                                         Prepared in conjunction with the

Division of Maternal-Fetal Medicine

Duke University Medical Center

                                                                                                                                  Director 

 

                                                                    Date

 

1. CDC. 2000 STD Treatment Guidelines, MMWR 51: RR06 1-80.May 10,2002

 

 

 

 

The Clinical Care Guidelines Development Committee of the Perinatal Improvement Board of Duke University Health System has developed a series of multi-disciplinary protocols to offer guidance to health care providers who are caring for pregnant women with high risk conditions.

 

These protocols are designed to assist health care providers in the management of a variety of problems that occur in pregnancy and the time of delivery. They should not be interpreted as standard of care, but instead represent only general guidelines for the care of pregnant women with high risk conditions.  We recognize that services offered by individual providers depend not only on their training, experience and institutional resources, but on the medical facts and circumstances of the specific care situation.

The protocols remain the intellectual property of the Duke University Health System.  They cannot be reproduced in whole or part without the expressed permission of the Health System.

 

These protocols are reviewed by the Department of Obstetrics and Gynecology Division of Maternal-Fetal Medicine, the Department of Pediatrics Division of Neonatology and the Department of Anesthesiology Division of Women’s Anesthesia.  Please contact Andra H. James (andra.james@duke.edu), Chair, Clinical Care Guidelines Development Committee of the Perinatal Improvement Board with ideas for additional protocols.