Approach to evaluation and management of newborns born to mothers who tested positive for syphilis during pregnancy

This figure summarizes our suggested approach to evaluating and treating infants with suspected congenital syphilis infection based upon maternal and infant serologies, adequacy of maternal treatment, clinical findings in the infant, and other findings. Evaluation for congenital syphilis is warranted in all infants born to mothers who have reactive nontreponemal and treponemal tests for syphilis during pregnancy. For mothers screened with the traditional approach, the treponemal test is necessary to exclude a false-positive nontreponemal result. When reverse sequencing is used, the nontreponemal test is still necessary for comparison with the mother's result and for monitoring of treatment success (two nontreponemal tests are needed when there is discordance between syphilis antibody and nontreponemal test during reverse sequencing). Refer to UpToDate's topics on syphilis during pregnancy and congenital syphilis for additional details.

VDRL: venereal disease research laboratory; RPR: rapid plasma regain; DFA: direct fluorescent antibody; PCR: polymerase chain reaction; LP: lumbar puncture; CBC: complete blood count; LFTs: liver function tests; ABR: auditory brainstem response; CDC: Centers for Disease Control and Prevention; CSF: cerebrospinal fluid; IM: intramuscular; IV: intravascular.

* Findings of congenital syphilis may include hepatosplenomegaly, rash, condyloma lata, snuffles, jaundice (nonviral hepatitis), pseudoparalysis, pallor (anemia), or edema (nephrotic syndrome and/or malnutrition). Refer to UpToDate topic on congenital syphilis for additional details.

¶ A 4-fold titer is equivalent to two dilutions (eg, infant's titer 1:32 if maternal titer is 1:8).

Δ These tests are not available in most clinical settings.

◊ Additional testing may include neuroimaging if there are concerning neurologic findings, chest radiograph if there are pulmonary findings, or abdominal imaging if there is significant organomegaly.

§ Adequate treatment is defined as completion of a penicillin-based regimen, in accordance with CDC treatment guidelines, appropriate for stage of infection and initiated ≥4 weeks before delivery. Relapse or reinfection after treatment is suggested by a 4-fold increase maternal VDRL or RPR titers after treatment. Inadequate/suboptimal therapy includes any of the following:

Treatment with a nonpenicillin antibiotic
Treatment given <4 weeks before delivery
Inappropriate dose for stage of disease
Inadequate documentation of maternal treatment
Inadequate response to therapy (ie, maternal VDRL or RPR titers did not decline at least 4-fold after treatment)

¥ The CDC guidelines include a caveat that additional evaluation may not be necessary for neonates in the "possible" category if a 10-day treatment course is planned. Nevertheless, we suggest performing the evaluation in higher-risk neonates (as defined above) since the evaluation may inform decisions regarding treatment and follow-up.

‡ All neonates with reactive nontreponemal serologies should be monitored with follow-up examinations and serial serologic testing with VDRL or RPR (use same test as for initial testing) at 1, 2, 4, 6, and 12 months or until nonreactive. If nontreponemal tests are still positive at 6-12 months, the infant should be re-evaluated (including LP) and treated with an extended course of parenteral penicillin. Infants with nonreactive nontreponemal serologies at birth should be retested at 3 months to confirm that the infant remains seronegative.

† For infants in the "less likely" category, some specialists opt not to treat and instead provide close (ie, monthly) serologic follow-up. If this approach is chosen, treatment should be provided if the infant's titers do not decline as expected over the first few months after birth.

** If follow-up is uncertain, some specialists would provide a single dose of IM penicillin G benzathine (long-acting IM penicillin) to protect the infant in the unlikely event that the mother was reinfected.

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Approach to evaluation and management of newborns born to mothers who tested positive for syphilis during pregnancy