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.