Case Report

Syphilis in Pregnancy: Resurgent Preventable Disease

Solwayo Ngwenya1,2,3*
1Department of Obstetrics and Gynaecology, Mpilo Central Hospital, Zimbabwe
2Department of Obstetrics and Gynaecology, Royal Women’s Clinic, Zimbabwe
3Department of Obstetrics and Gynaecology, National University of Science and Technology Medical School, Zimbabwe

*Corresponding author: Solwayo Ngwenya, Department of Obstetrics and Gynaecology, Clinical Director, Mpilo Central Hospital, Vera Road, Mzilikazi, Zimbabwe

Published: 20 Dec, 2016
Cite this article as: Ngwenya S. Syphilis in Pregnancy: Resurgent Preventable Disease. Ann Clin Case Rep. 2016; 1: 1216.


Syphilis in pregnancy can cause considerable fetal and neonatal morbidity and mortality. It is endemic in the developing world but it is now resurgent in the developed world. Maternal syphilis can result in fetal infection leading to fetal and neonatal harm. Mid-trimester miscarriages, stillbirths, low birth weight, prematurity, congenital syphilis and neonatal deaths are all the results of syphilis infection in pregnancy. Universal antenatal screening of all pregnant women by serological testing is the cornerstone in detecting and treating the mother and her partner, and preventing congenital syphilis. Penicillin remains the drug of choice in pregnancy. Congenital syphilis is a preventable disease hence fetal morbidity and mortality is avoidable.

Keywords: Syphilis; Screening; Complications; Congenital syphilis; Perinatal morbidity; Perinatal mortality; Penicillin


Despite widespread antenatal screening and treatment, syphilis remains a disease of global concern with recent indications that it is a resurgent disease, mostly so in the developed world. Each year about 2 million pregnant women are infected with syphilis infection, mostly in developing [1] countries where it remains endemic [2]. As of 2012, an estimated 930 000 maternal syphilis infections caused 350 000 adverse pregnancy outcomes [3].
These are staggering figures considering the public awareness efforts associated with the HIV/ AIDS pandemic and other sexually transmitted infections. The disease appears to be resurgent hence public awareness campaign efforts must be re-doubled. Combating the spread of HIV and other sexually transmitted infections like syphilis must be intensified.
Due to increasing rates of congenital syphilis, efforts to decrease and treat infection in pregnancy are necessary. The world must tackle both old and emerging diseases without neglecting the old ones that still take human lives.

Microbiology and Pathology

Treponema pallidum is the causative spirochete bacterium [4] agent. This fastidious organism is difficult to isolate in microbiological culture, making its identification difficult and research into antimicrobial therapies challenging [5]. Treponema pallidum is a spiral-shaped gram-negative highly mobile bacterium. Humans are the only known natural reservoir. Syphilis is a sexually transmitted infection. The spirochete is able to pass through intact mucous membranes or compromised skin. Mother-to-child transmission occurs via transplacental transmission during pregnancy or by direct contact at birth resulting in congenital syphilis.


The clinical diagnosis of syphilis is difficult to make in early stages. Dark field microscopy of wet samples obtained from suspected syphilitic lesions that can reveal spirochetes. Serologic tests are more commonly used to detect infection. The diagnosis is confirmed with treponemal tests such as treponemal pallidum particle agglutination or florescent treponemal antibody absorption test.


Screening is the cornerstone of congenital syphilis prevention [6,7]. Adverse outcomes of motherto- child transmission of syphilis can be prevented with antenatal screening and penicillin therapy [8]. Every pregnant woman should undergo screening for syphilis as part of the routine obstetric care. Re-screening in the third-trimester is recommended for women at increased risk of syphilis. Re-screening later in pregnancy can potentially reduce adverse fetal and neonatal outcomes [9] but this approach is limited by the costs involved and the fact that to prevent one adverse outcome large numbers of patients have to be screened. Governments in the world must be encouraged to provide universal screening for syphilis by making healthcare facilities accessible even to poor rural areas, in the remotest regions of the world.


Up to two-thirds of pregnant women with untreated syphilis may develop unwanted complications including second-trimester miscarriages, stillbirths [10], premature births, congenital syphilis and neonatal deaths [11,12]. In 2012, there were 143 000 early fetal deaths and stillbirths, 62 000 neonatal deaths, 44 000 preterm or low birth weights and 102 000 infected infants worldwide [3].
Fetal mortality can be six times higher in congenital syphilis [13]. Prenatal ultra sounographic examination may sometimes reveal abnormal features suggesting congenital syphilis [14]. Congenital syphilis may manifest in the late neonatal and infant stages hence continued paediatric specialists follow-up is important.
Therefore these complications of syphilis infection and the staggering statistics must be a wake-up call to all health care workers looking after pregnant women to seek for the condition, adequately treat the patient and her partner and prevent serious fetal and neonatal adverse outcomes.


The first-line treatment for all stages of syphilis during pregnancy is penicillin G [2]. Penicillin is the only known effective treatment for congenital syphilis [5]. Those penicillin sensitive patients should be desensitized and treated with penicillin. Early and adequate treatment could improve the adverse pregnancy outcomes among women with syphilis [15].
Penicillin therapy for maternal syphilis is important in preventing congenital syphilis [16]. The treatment must be adequate. In a Chinese study, only 68% were found to have received adequate treatment [15]. Contact tracing for partners of infected patients is important [17] to treat them and prevent long-term syphilis sequalea and protect the mother and her unborn child from re-infection. Babies born to treated mothers should be evaluated by a specialist. In a UK study, follow up of infants born to treated women was found to be poor [7].


Syphilis in pregnancy remains a global threat to human health. Further interventions to reduce vertical transmission should include universal screening [18]. There should be integrated HIV and services during pregnancy including the use of dual rapid HIV and syphilis testing. Congenital syphilis remains an important preventable cause of perinatal morbidity and mortality [19]. Rigorous antenatal screening, detection and adequate treatment of syphilis during pregnancy remain critical in reducing congenital syphilis and its complications.


  1. Shahrook S, Mori R, Ochirbat T, Gomi H. Strategies of testing for syphilis during pregnancy. Cochrane Database Syst Rev. 2014; 29: CD010385.
  2. Stamm LV. Syphilis: antibiotic treatment and resistance. Epidemiol Infect. 2015; 143: 1567-1574.
  3. Wijesooriya NS, Roger W Rochat, Mary L Kamb, Prasad Turlapati, Marleen Temmerman, Nathalie Broutet, et al. Global burden of maternal and congenital syphilis in 2008 and 2012: a health systems modelling study. Lancet Glob Health. 2016; 4: e525-533.
  4. Osbak KK, Houston S, Lithgow KV, Meehan CJ, Strouhal M, Šmajs D, et al. Characterizing the Syphilis-Causing Treponema pallidum ssp. Pallidum Proteome Using Complementary Mass Spectrometry. PLoS Negl Trop Dis. 2016; 10: e0004988.
  5. Moline HR, Smith JF. The continuing threat of syphilis in pregnancy. Curr Opin Obstet Gynecol. 2016; 28: 101-104.
  6. Charlier C, Benhaddou N, Dupin N. Syphilis and pregnancy. Presse Med. 2015; 44: 631-638.
  7. Townsend CL, Francis K, Peckham CS, Tookey PA. Syphilis screening in pregnancy in the United Kingdom. 2010-2011: a national surveillance study. BJOG. 2016.
  8. Lago EG. Current Perspectives on Prevention of Mother-to Child Transmission of Syphilis. Cureus. 2016; 8: e525.
  9. Albright CM, Emerson JB, Werner EF, Hughes BL. Third-Trimester Prenatal Syphilis Screening: A Cost-Effectiveness Analysis. Obstet Gynecol. 2015; 126: 479-485.
  10. Wallace HE, Isitt CE, Broomhall HM, Perry AE, Wilson JD. Adverse pregnancy outcomes following syphilis treatment in pregnancy in the UK. Int J Std Aids. 2015.
  11. Braccio S, Sharland M, Ladhani SN. Prevention and treatment of motherto- child transmission of syphilis. Curr Opin Infect Dis. 2016; 29: 268-274.
  12. Bowen V, Su J, Torrone E, Kidd S, Weinstock H. Increase in incidence of congenital syphilis- United States, 2012-2014. MMWR Morb Mortal Wkly Rep. 2015; 64: 1241-1245.
  13. Domingues RM, Leal Mdo C. Incidence of congenital syphilis and factors associated with vertical transmission: data from the Birth in Brazil study. Cad Saude Publica. 2016; 32.
  14. Park JY, Han GH, Kwon DY, Hong HR, Seol HJ. Prenatal diagnosis of congenital syphilis presenting with transient pleural effusion in the fetus: a case report and rising incidence of congenital syphilis in South Korea. Clin Exp Obstet Gynecol. 2015; 42: 822-824.
  15. Zhang XH, Xu J, Chen DQ, Guo LF, Qiu LQ. Effectiveness of treatment to improve pregnancy outcomes among women with syphilis in Zhejiang Province, China. Sex Transm Infect. 2016.
  16. Taylor MM, Nurse-Findlay S, Zhang X, Hedman L, Kamb ML, Broutet N, et al. Estimating Benzathine Penicillin Need for the Treatment of Pregnant Women Diagnosed with Syphilis during Antenatal Care in High- Morbidity Countries. PLoS One. 2016; 11: e0159483.
  17. Wu X, Hong F, Zhang C, Feng T, Lan L, Yang Y, et al. Contact tracing of pregnant women infected with syphilis and the associated factors. Zhonghua Yu Fang Yi Xue Za Zhi. 2015; 49: 1067-1072.
  18. Dionne-Odom J, Mbah R, Rembert NJ, Tancho S, Halle-Ekane GE, Enah C, et al. Hepatitis B, HIV, and Syphilis Seroprevalence in Pregnant Women and Blood Donors in Cameroon. Infect Dis Obstet Gynecol. 2016; 2016: 4359401.
  19. Su JR, Brooks LC, Davis DW, Torrone EA, Weinstock HS, Kamb ML. Congenital syphilis: trends in mortality and morbidity in the United States, 1999 through 2013. Am J Obstet Gynecol. 2016; 214: 381.e1-9.