Discussion:
There is insufficient literature on delivery of pregnant women with syphilis. No specific guidelines have been established regarding treatment methods or modes of delivery in syphilis patients. Consequently, treatment policies and modes of delivery vary from one medical facility to another. We reviewed the literature on management of pregnancies complicated by syphilis that occurred in the third trimester of pregnancy.
Syphilis Treponema is a bacillus of the genus Treponema , with a width of approximately 100-200 nm and a length of 10-20 μm (6). It is a sexually transmitted disease that can be transmitted via contact with mucous membranes and skin (6). It is also known that untreated syphilis infection during pregnancy can lead to vertical infection and congenital syphilis in the child (6,7). Clinical manifestations result from a local inflammatory reaction caused by proliferating spirochetes in the tissues. In general, early syphilis refers to infections that can be sexually transmitted and is synonymous with infectious syphilis. The WHO defines early syphilis as infections of less than 2 years duration (8). Patients with first episode of syphilis present with a single chancre or multiple lesions at the site of genital or sexual contact and regional lymphadenopathy, approximately three weeks after infection (6). Secondary symptoms such as fever, headache, and maculopapular rash on the flanks, shoulders, arms, chest, and back appear. The rashes often involve the palms of the hands and the soles of the feet (6). Mother-to-child transmission primarily occurs during the primary and secondary infection periods, followed by the early incubation period (5,6,9). Infants born to infected mothers are often born premature, have low birth weight, and clinical signs that mimic neonatal sepsis (such as poor feeding, lethargy, rash, jaundice, hepatosplenomegaly, and anaemia)(10,11).
Majority of syphilis cases in infants occur due to in utero transmission, although mother-to-infant transmission of syphilis may occur at the time of delivery. Spirochetes have reportedly been detected in placental or umbilical cord samples as early as 9–10 weeks of gestation, which substantiates transplacental transmission to the foetus (12).
Syphilis often presents with diverse symptoms and is difficult to diagnose clinically. Painless lesions in hidden exposed sites, such as the cervix and rectum, are often missed. In addition, secondary syphilis eruptions and other lesions may appear hazy or could be mistaken for other diseases. Diagnosis of syphilis is often based on the medical history and the results of blood and other laboratory investigations. Serology is the most common method for diagnosing syphilis in both symptomatic and non-symptomatic individuals who are screened.
Screening for syphilis is universally recommended for pregnant women, regardless of previous exposure, because it is a highly effective preventive intervention against vertical transmission during pregnancy(5). Most national guidelines recommend screening for syphilis during the first antenatal visit, ideally during the first trimester. Some countries recommend that high-risk women should be screened again in the third trimester of pregnancy and at the time of delivery to identify new infections.
In the present case, syphilis screening test in the first trimester of pregnancy was negative, but symptoms such as hard chancre confirmed syphilis infection in the third trimester of pregnancy. A detailed history after the onset of the disease suggested that she had sexually transmitted syphilis from her husband immediately before or after conceiving. Therefore, it was assumed that the initial screening test result was negative because of pre-infection or early infection. She was in full-term labour when the infection was discovered. Penicillin G infusion to prevent congenital syphilis was administered for 10 days, as per the package insert. The vulvar and skin lesions were confirmed to have disappeared. However, lesions on the vaginal wall and cervix were difficult to identify with the naked eye, and the possibility of trans natal vaginal infection could not be ruled out. Therefore, we elected to perform a caesarean section. There is no clear description of the mode of delivery for syphilis cases in late pregnancy in the guidelines, and this may be considered controversial. We also believe that screening for syphilis during the second trimester of pregnancy should be considered in the future.
In conclusion, we encountered a case of a pregnant woman with second-stage syphilis complication that developed in the third trimester of pregnancy. Incidence of syphilis has been on the increase among young people in the recent years, and we anticipate that similar cases may increase in the future. Therefore, it is desirable to establish guidelines for management and mode of delivery of patients with syphilis in the second and trimesters of pregnancy.
Acknowledgements: Informed consent for publication of this report was obtained from the patient in our hospital. We appreciate Editage (www.editage.com) for English language editing.