Communicable Disease Updates for Prenatal Care Providers/Obstetricians & Gynecologists (OB-GYNs)
Syphilis and Congenital Syphilis
In California and nationwide Syphilis rates are on the rise. The highest rates are among men who have sex with men; however, females are also affected. The underlying concern is for women who are pregnant or of childbearing age.
The CDC has responded with an urgent Syphilis Call To Action to identify interventions, treatment and prevention strategies. Providers have an increased role in controlling the rates of congenital syphilis by routine testing of risk groups.
In 2017[EC1] , there was a total of 918 reported cases of congenital syphilis, including 64 syphilitic stillbirths and 13 infant deaths. This represents a 153% increase relative to 2013. Unfortunately, substance use, poverty and homelessness have contributed to these rates. As efforts to address the opioid epidemic grow, providers and staff need to acquire skills to confidently discuss substance use issues, complete sexual histories and drug-related behaviors with patients to guide prevention efforts.
ACOG recommends testing every pregnant woman once in her first trimester prenatal labs. Women who are at risk or whose partners are at risk should be tested, or in areas where there is a high syphilis prevalence should be tested again in the beginning of 3rd trimester due to an increase likelihood of preterm delivery in congenital syphilis.
What is Syphilis?
Syphilis, a sexually transmitted infection caused by Treponema pallidum bacterium, can have very serious complications if left untreated yet simple to prevent and cure with the correct treatment. Congenital Syphilis occurs when there is vertical transmission from mother to baby during fetal development or at birth.
How is it spread?
Syphilis is spread through sexual contact with someone infected. Although signs and symptoms of syphilis in women can be missed or mistaken for another infection (e.g. herpes), syphilis can be diagnosed with a simple blood test and cured with antibiotics. Syphilis can also be spread from mother to unborn child.
What are the Symptoms?
Primary Stage: One or more chancres (usually firm, round, small and painless) appear at site of exposure ~3 weeks after infection. Chancres heal on own in a few days to weeks even without treatment. Patient is highly infections during primary phase.
Secondary Stage: Rash first appears on palms of hands or soles of feet, but typically then appears on trunk or other parts of body. 25% have wart-like lesions in genital area or mucous patches on tongue. Lymphadenopathy; patchy alopecia and neurologic symptoms.
Latent Stage: Patient has reactive nontreponemal and treponemal test >1 year after onset but no symptoms.
How is it diagnosed?
Presumptive diagnosis requires 2 serologic tests which are the VDRL or RPR, nontreponemal test and TP-PA or FTA-ABS, a specific treponemal test. Darkfield examination of lesion exudate or tissue are definitive in early syphilis.
How is it Treated?
Treatment regimen is based on stage with either one dose to three doses of Benzathine penicillin G IM. It is very important for patients to finish their treatment.
PCN allergic women will need desensitization.
Neurosyphilis can occur at any stage of syphilis. Neurologic, ophthalmologic or audiologic symptoms warrant a careful neurologic exam or may require CSF evaluation via lumbar puncture.
How can it be Prevented?
Screening should occur according to the recommendations. Women should be screening at pregnancy and according to risk. Men who have sex with men and people living with HIV should be screened at least annually. Increased risk for syphilis transmission occurs with men who have sex with men and women, a person with prior history of sexually transmitted infections, substance use, and/or sex partners who are non-monogamous. Additionally, any woman with minimal or no prenatal care or a series of missed prenatal visit should be considered for increased screening.
What are the Potential Complications?
Congenital Syphilis, if left undiagnosed, untreated or improperly treated in pregnant women, can lead to severe complications including miscarriage and stillbirth. Infants born to mothers infected with syphilis can suffer from bone deformities, jaundice, neurological problems including blindness and deafness. Congenital syphilis is completely preventable with appropriate prenatal screening and treatment.
Centers for Disease Control (CDC)
- Discordant Results from Reverse Sequence Syphilis Screening --- Five Laboratories, United States, 2006—2010 (MMWR)
- Syphilis Pocket Guide for Providers
- A Guide to Taking a Sexual History
Perinatal Hepatitis B Prevention Program PHPP)
PHPP is aims to prevent and control the spread of hepatitis B from mothers to newborn infants and household contacts by:
- Surveillance of childbearing-age HBsAg+ women in Marin County.
- Phone counseling and education to HBsAg+ pregnant women.
- Following HBsAg+ mothers and their newborn infants to ensure that:
- Children receive HBIG and their first dose of hepatitis B vaccine within 12 hours of birth.
- Subsequent hepatitis B vaccines are administered at age 1 month and 6 months.
- Post-vaccination serology is conducted to ensure seroconversion.
- Evaluating the hepatitis B status of household contacts and making referrals for screening and vaccination as needed.
Request of Providers:
- All cases of HBsAg+ women who reside in Marin County and are pregnant.
- All infants born to HBsAg+ women who reside in Marin County. Including date and time of birth, HBIG administration, and Hep B vaccination.
- Screen all pregnant women for hepatitis B surface antigen.
- Send a copy of the lab report documenting the woman’s HBsAg+ status to the birth hospital.
- Inform your patient about her HBsAg+ status and encourage HBsAg+ expectant mothers to talk to their household members about being protected against hepatitis B.
- Emphasize to the expecting mother the importance of having her newborn receive HBIG and the birth dose of hepatitis B to prevent perinatal hepatitis B transmission.
- Review mother’s HBsAg status at time of delivery. Order lab testing if status is unknown.
- Ensure appropriate administration of hepatitis B vaccine and HBIG to infants born to HBsAg+ women.
California Department of Public Health (CDPH)
- Preventing Perinatal Hep B: Guidelines for Prenatal Care Providers
- Perinatal Hepatitis B Post Exposure Prophylaxis Recommendations: Guidelines for Labor and Delivery Hospitals
- Perinatal Hepatitis B
Pertussis (aka whooping cough) has been on the rise in Marin and California in 2018 and 2019. The best strategy to prevent infant pertussis is to immunize pregnant women with Tdap between 27-36 weeks of gestation of every pregnancy, regardless of the mother’s Tdap history.
At least two weeks are needed for the development of enough maternal antibodies to be transferred to the infant through the placenta, so it is preferred that the immunization be administered at the beginning of the third trimester. Postpartum Tdap vaccination and cocooning do not provide direct protection to the infant. However, it is recommend that other close family members of a newborn get vaccinated as well.
Prevent infant pertussis by making a strong recommendation for Tdap vaccination. Prenatal patients seen by providers who stock vaccinations are much more likely to get vaccinated.
If your practice is currently unable to vaccinate on-site,
- Consider stocking Tdap vaccine at your site. Contact Marin Communicable Disease Prevention Control Immunization Program to find out about obtaining a free Tdap vaccine starter kit, which is only available to practices that do not currently stock Tdap.
- Assist patients in locating a local immunization provider/clinic that is covered by their insurance. Click here for a list of places to get vaccinated in Marin.
- Provide patients with a prescription. Although a prescription for Tdap is not needed, it may reinforce the importance of your recommendation. Order free copies of the pre-filled immunization RX-pad (IMM-1143) from Marin Communicable Disease Prevention and Control by calling 415-473-4163.
- Participate in the California Immunization Registry (CAIR). CAIR is a computerized information system that collects immunization data from public and private health care providers and combines it into one complete record for individuals in California. This helps health care providers, parents, and individuals to keep track of immunization status, even if those immunizations came from more than one provider. To learn more about CAIR or to join, visit the CAIR website.