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Testing for syphilis in pregnancy aims to detect women who have the infection so that they can be treated and transmission to babies prevented.

36.1 Background

Syphilis is a sexually acquired infection caused by Treponema pallidum. In pregnancy, it can result in spontaneous miscarriage or stillbirth or cause congenital syphilis infection. Syphilis in pregnancy can be safely treated with antibiotics, which can prevent these complications (Walker 2001).

36.1.1 Syphilis in Australia

  • Rates of diagnosis of syphilis: Between 2007 and 2014, notification rates for infectious syphilis among women were below 2.0 per 100,000. Rates rose to 2.5 per 100,000 in 2015 and 3.6 per 100,000 in 2016 (The Kirby Institute 2017b).[25] Rates among women in 2016 were highest in the 15–19 year (11.5 per 100,000), 20–24 year (9.5 per 100,000) and 25–29 year (9.9 per 100,000) age groups. The rate of notification for infectious syphilis among Aboriginal and Torres Strait Islander women was 39 times that among non-Indigenous women (57.1 vs 1.5 per 100,000) (The Kirby Institute 2017a).
  • Geographical distribution: In 2016, infectious syphilis notification rates were highest in remote and very remote areas of residence (49.4 per 100 000) (The Kirby Institute 2017b). Increases in notification rates occurred in all regions of residence between 2012 and 2017, with the sharpest increase in regional areas (209%) followed by remote areas (176%). Rates of notification among Aboriginal and Torres Strait Islander people were highest in the Northern Territory (229.6 per 100,000) and Queensland (99.3 per 100,000) (The Kirby Institute 2017a), corresponding with regions in which there has been an outbreak of infectious syphilis.
  • Congenital syphilis: Australia is a country of low prevalence for congenital syphilis. However, coinciding with peaks in infectious syphilis notifications, there have been peaks in cases of congenital syphilis, with four cases in 2015, declining from a high of eleven in 2006 (The Kirby Institute 2016). Three of the four cases were in Aboriginal and Torres Strait Islander babies.
  • Refugee background: An Australian cohort study found higher prevalence among women from humanitarian source countries than among women from non-humanitarian source countries in Africa (1.2-7.5% vs 0–0.3%) and Africa and Asia (2.5% vs 0.4 p < 0.001) (Gibson-Helm et al 2014; Gibson-Helm et al 2015).
  • Risk factors: Syphilis in Australia continues to be an infection primarily of men having male-to-male sex in urban settings, and of young heterosexual Aboriginal and Torres Strait Islander people in remote communities (The Kirby Institute 2016).

36.1.2 Risks associated with syphilis in pregnancy

Maternal syphilis infection results in congenital infection in at least two-thirds of cases (Zenker & Rolfs 1990; Chakraborty & Luck 2008; Woods 2009). Congenital infection can occur at any stage of maternal disease, including during incubation (Doroshenko et al 2006), as early as 9–10 weeks of pregnancy and at any subsequent time during pregnancy (Woods 2005).

Congenital syphilis is a serious condition that, if not fatal at a young age, can cause permanent impairment, debilitation and disfigurement (Chakraborty & Luck 2008; Richens & Mabey 2008). Pancreatitis and inflammation of the gastrointestinal tract are common (Woods 2005).

36.2 Syphilis testing

36.2.1 Effectiveness of universal testing

Universal syphilis testing programs have been shown to significantly increase the detection of pregnant women who have syphilis compared with selective testing of women considered to be a high-risk (Cameron et al 1997; Duthie et al 1990; Villar & Bergsjo 1997; Hurtig et al 1998). Based on convincing observational evidence, universal testing of pregnant women is recommended by the United States Preventive Services Task Force (USPSTF 2009; Wolff et al 2009), the World Health Organization (WHO 2004), the International Union against Sexually Transmitted Infections (IUSTI) (French et al 2009) and the United Kingdom national guidelines on the management of syphilis (Kingston et al 2008) as it decreases the proportion of babies with clinical symptoms of syphilis infection.

Universal testing for syphilis has been shown to be cost-effective (Garland & Kelly 1989; Abyad 1995; Cameron et al 1997; Connor et al 2000; Walker 2001) even in areas of low prevalence.

Recommendation

  • Grade B
  • 38

Routinely offer and recommend syphilis testing at the first antenatal visit as treating syphilis benefits both mother and baby.

Approved by NHMRC in December 2011; expires December 2016 UNDER REVIEW

36.2.2 Type of test

There are two main classifications of serological tests for syphilis (NICE 2008):

  • non-treponemal tests, which detect non-specific treponemal antibodies and include the Venereal Diseases Research Laboratory (VDRL) and rapid plasma reagin (RPR) tests
  • treponemal tests, which detect specific treponemal antibodies and include EIAs, T. pallidum haemagglutination assay (TPHA) and the fluorescent treponemal antibody-absorbed test (FTA-abs).

The NICE guidelines reviewed the evidence on syphilis testing in pregnancy and found:

  • treponemal IgG EIA tests have high sensitivity (98%) and specificity (99%) at all stages of syphilis (except early primary syphilis), are useful for detecting syphilis antibodies in patients who are infected with HIV, and are comparable to the VDRL and TPHA combination in terms of sensitivity and specificity (Young et al 1989; 1992)
  • non-treponemal tests may result in false negatives, particularly in very early or late syphilis, in patients with reinfection or those who are HIV positive, and have poor positive predictive value when used alone in low prevalence populations
  • neither type of test will detect syphilis in its incubation stage (PHLS 1998).

The initial test is usually a test for antibodies of treponema (eg enzyme immunoassay), which identifies women with current untreated or incompletely treated infection or previous history of treated syphilis. If the test is positive, a non-treponemal test will be performed by the laboratory to confirm diagnosis and enable a quantitative value of disease activity to guide treatment.

36.2.3 Testing in rural and remote areas

On-site syphilis tests are being developed to allow results to be given and overcome the barrier to treating pregnant women who have to return to the clinic for tests results and treatments. The tests evaluated appear to have adequate sensitivity and specificity to be useful in remote areas or where equipment and lab equipment is not available (Mabey et al 2006; Marongoni et al 2005) and, in one study, reduced delays in treatment (Myer et al 2003).

36.3 Follow-up for women who test positive to syphilis

Not all women who test positive will have syphilis, as these serological tests cannot distinguish between different treponematoses (eg syphilis, yaws, pinta and bejel). Therefore, positive results should be interpreted with caution. Following confirmation of a reactive specimen, a second specimen should be tested to verify the results and ensure correct identification of the woman.

Recommendation

  • Practice point
  • YY

Because syphilis is a rare condition in most parts of Australia and a positive result does not necessarily mean that a woman has syphilis, expert advice regarding the care of women who test positive and their partners should be sought. Assessment/testing for other sexually transmitted infections in women with positive serology is advisable.

Approved by NHMRC in December 2011; expires December 2016 UNDER REVIEW

36.4 Outbreak management

In January 2011, an increase of infectious syphilis notifications among young Aboriginal and Torres Strait Islander people was identified in the North-West region of Queensland. Subsequent increases in notifications were reported in the Northern Territory and Western Australia in July 2013 and June 2014 respectively, following sustained periods of low notification rates (Bright & Dups 2016).

The disease control interventions that have been implemented include: opportunistic and community testing, particularly among young sexually active people aged less than 35 years; immediate treatment of people who are symptomatic (eg genital ulceration), have tested positive for syphilis or are sexual contacts of cases; and antenatal testing for syphilis (Bright & Dups 2016). Public health alerts, health protection and education and campaigns, and active follow-up of cases are also being conducted.

Over the course of the recent outbreak (January 2011 to December 2015), the rate of congenital syphilis (including both confirmed and probable cases) in the Aboriginal and Torres Strait Islander populations for all of Queensland, the Northern Territory and Western Australia averaged 23.0 cases per 100,000 live births, which was lower than that recorded in the 5 years prior to the outbreak (2006 to 2010) at 38.2 cases per 100,000 live births (Bright & Dups 2016).

Point-of-care rapid syphilis testing has been used with good effect in recent outbreaks in remote Australia, both in the context of community-wide testing and to increase opportunistic testing within primary care services (CDNA 2015). Guidance on responding to a notifiable disease event is included in Section 36.6.

36.4.1 Notification of congenital syphilis

One study found that 95% of babies in the Northern Territory meeting Communicable Disease Network Australia (CDNA) criteria for probable congenital syphilis were not notified between 2009 and 2014 and that improved education regarding CDNA criteria for notification of congenital syphilis is necessary for clinicians and public health staff.

36.5 Practice summary: syphilis

When

Early in antenatal care.

Who

  • Midwife
  • GP
  • obstetrician
  • Aboriginal and Torres Strait Islander health worker
  • multicultural health worker.

What

  • Discuss the reasons for syphilis testing
    Explain that it is important to find out whether a woman has syphilis because of the effects that infection can have on the pregnancy and the baby.
  • Document and follow-up
    Note the results of syphilis testing in the woman’s record, including whether the syphilis is newly diagnosed or was previously treated. Have a follow-up system in place so that infected women receive timely treatment or referral.
  • Take a holistic approach
    If a woman is found to be infected with syphilis, important considerations include counselling, contact tracing, partner testing, testing for other sexually transmitted infections and follow-up.

36.6 Resources

References

  • Abyad A (1995) Cost-effectiveness of antenatal screening for syphilis. Health Care Women Int 16(4): 323–28.
  • Bright A & Dups J (2016) Infectious and congenital syphilis notifications associated with an ongoing outbreak in northern Australia. Commun Dis Intell Q Rep 40(1): E7-10.
  • Cameron ST, Thong KJ, Young H et al (1997) Routine antenatal screening for syphilis in Lothian: a study of the results 1988 to 1994. Brit J Obstet Gynaecol 104(6): 734-7.
  • CDNA (2015) Syphilis CDNA National Guidelines for Public Health Units. Canberra: Communicable Diseases Network Australia.
  • Chakraborty R & Luck S (2008) Syphilis is on the increase: the implications for child health. Arch Dis Childhood 93(2): 105–09.
  • Connor N, Roberts J, Nicoll A (2000) Strategic options for antenatal screening for syphilis in the United Kingdom: a cost effectiveness analysis. J Med Screen 7(1): 7-13.
  • Doroshenko A, Sherrard J, Pollard AJ (2006) Syphilis in pregnancy and the neonatal period. Int J STD AIDS 17(4): 221–27.
  • Duthie SJ, King PA, Yung GL et al (1990) Routine serological screening for syphilis during pregnancy- disposable anachronism or fundamental necessity? Aust NZ J Obstet Gynaecol 30(1): 29–31.
  • French P, Gomberg M, Janier M et al (2009) IUSTI: 2008 European Guidelines on the Management of Syphilis. Int J STD AIDS 20(5): 300–09.
  • Garland SM & Kelly VN (1989) Is antenatal screening for syphilis worth while? Med J Aust 151(7): 368, 370, 372.
  • Gibson-Helm M, Teede H, Block A et al (2014) Maternal health and pregnancy outcomes among women of refugee background from African countries: a retrospective, observational study in Australia. BMC Pregnancy Childbirth 14: 392.
  • Gibson-Helm ME, Teede HJ, Cheng IH et al (2015) Maternal health and pregnancy outcomes comparing migrant women born in humanitarian and nonhumanitarian source countries: a retrospective, observational study. Birth 42(2): 116-24.
  • Hurtig AK, Nicoll A, Carne C et al (1998) Syphilis in pregnant women and their children in the United Kingdom: results from national clinician reporting surveys 1994-7. Brit Med J 317(7173): 1617–19.
  • Kingston M, French P, Goh Bet al (2008) UK National Guidelines on the Management of Syphilis 2008. Int J STD AIDS 19(11): 729–40.
  • Mabey D, Peeling RW, Ballard R et al (2006) Prospective, multicentre clinic-based evaluation of four rapid diagnostic tests for syphilis. STI 82(Suppl 5): v13–v16.
  • Marangoni A, Sambri V, Accardo S et al (2005) Evaluation of LIAISON Treponema Screen, a novel recombinant antigen-based chemiluminescence immunoassay for laboratory diagnosis of syphilis. Clin Diag Lab Immunol 12(10): 1231–34.
  • Myer L, Wilkinson D, Lombard C et al (2003) Impact of on-site testing for maternal syphilis on treatment delays, treatment rates, and perinatal mortality in rural South Africa: a randomised controlled trial. STI 79(3): 208–13.
  • NICE (2008) Antenatal Care. Routine Care for the Healthy Pregnant Woman. National Collaborating Centre for Women’s and Children’s Health. Commissioned by the National Institute for Health and Clinical Excellence. London: RCOG Press.
  • PHLS (1998) Report to the National Screening Committee. Antenatal Syphilis Screening in the UK: A Systematic Review and National Options Appraisal with Recommendations. STD Section, HIV and STD Division, PHLS Communicable Disease Surveillance Centre, with the PHLS Syphilis Working Group. London: Public Health Laboratory Service.
  • Richens J & Mabey CW (2008) Sexually transmitted infections (excluding HIV). In: Cook G, Zumla A (eds) Manson’s Tropical Diseases. 22nd Edition. London: Saunders Elsevier.
  • The Kirby Institute (2016) HIV, viral hepatitis and sexually transmissible infections in Australia. Annual Surveillance Report 2016. Sydney: University of New South Wales.
  • The Kirby Institute (2017a) Bloodborne viral and sexually transmissible infections in Aboriginal and Torres Strait Islander people: Annual surveillance report 2017. Sydney: The Kirby Institute, UNSW Australia.
  • The Kirby Institute (2017b) HIV, viral hepatitis and sexually transmissible infections in Australia. Annual Surveillance Report 2017. Sydney: The Kirby Institute, UNSW.
  • USPSTF (2009) Screening for syphilis infection in pregnancy: US Preventive Services Task Force reaffirmation recommendation statement. Annals Int Med 150(10): 705–09.
  • Villar J & Bergsjo P (1997) Scientific basis for the content of routine antenatal care. I. Philosophy, recent studies, and power to eliminate or alleviate adverse maternal outcomes. Acta Obstet Gynecol Scand 76(1): 1–14.
  • Walker GJA (2001) Antibiotics for syphilis diagnosed during pregnancy. Cochrane Database of Systematic Reviews 2001, Issue 3. Art. No.: CD001143. DOI: 10.1002/14651858.CD001143.
  • Wolff T, Shelton E, Sessions C et al 2009 Wolff T, Shelton E, Sessions C et al (2009) Screening for syphilis infection in pregnant women: evidence for the US Preventive Services Task Force reaffirmation recommendation statement. Annals Int Med 150(10): 710–16.
  • Woods CR (2009) Congenital syphilis? Persisting pestilence. Pediatr Infect Dis J 28(6):536–37.
  • Woods CR (2005) Syphilis in children: congenital and acquired. Sem Pediatr Infect Dis 16(4): 245–57.
  • WHO (2004) Sexually Transmitted Infections Management Guidelines. 2004.
  • Young H, Moyes A, McMillan A et al (1992) Enzyme immunoassay for anti-treponemal IgG: Screening of confirmatory test? J Clin Pathol 45: 37–41.
  • Young H, Moyes A, McMillan A et al (1989) Screening for treponemal infection by a new enzyme immunoassay. Genitourin Med 65: 72–78.
  • Zenker PN & Rolfs RT (1990) Treatment of syphilis, 1989. Rev Infect Dis 12 (Suppl 6): S590–S609.
  • 25 An expanded infectious syphilis national case definition was implemented in July 2015 in all jurisdictions except for New South Wales, where it was implemented in July 2016. The new case definition includes a new subcategory of ‘probable’ infectious syphilis to capture infectious syphilis cases in people without a prior testing history, particularly young people aged 15–19 years. The probable infectious syphilis cases are included in the number of infectious syphilis notifications in 2015 and 2016.
Last updated: 
20 November 2018