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Queensland Clinical Guideline – Syphilis in Pregnancy

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Queensland Clinical Guideline – Syphilis in Pregnancy Queensland Health Clinical Excellence Queensland Maternity and Neonatal Clinical Guideline Syphilis in pregnancy Queensland Clinical Guideline: Syphilis in pregnancy Document title: Syphilis in pregnancy Publication date: December 2018 Document number: MN18.44-V4-R23 The document supplement is integral to and should be read in conjunction with Document supplement: this guideline. Amendments: Full version history is supplied in the document supplement. Amendment date: June 2021 Replaces document: MN18.44-V3-R23 Author: Queensland Clinical Guidelines Health professionals in Queensland public and private maternity and neonatal Audience: services Review date: December 2023 Queensland Clinical Guidelines Steering Committee Endorsed by: Statewide Maternity and Neonatal Clinical Network (Queensland) Email: [email protected] Contact: URL: www.health.qld.gov.au/qcg Cultural acknowledgement We acknowledge the Traditional Custodians of the land on which we work and pay our respect to the Aboriginal and Torres Strait Islander Elders past, present and emerging. Disclaimer This guideline is intended as a guide and provided for information purposes only. The information has been prepared using a multidisciplinary approach with reference to the best information and evidence available at the time of preparation. No assurance is given that the information is entirely complete, current, or accurate in every respect. The guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice. Variation from the guideline, taking into account individual circumstances, may be appropriate. This guideline does not address all elements of standard practice and accepts that individual clinicians are responsible for: • Providing care within the context of locally available resources, expertise, and scope of practice • Supporting consumer rights and informed decision making, including the right to decline intervention or ongoing management • Advising consumers of their choices in an environment that is culturally appropriate and which enables comfortable and confidential discussion. This includes the use of interpreter services where necessary • Ensuring informed consent is obtained prior to delivering care • Meeting all legislative requirements and professional standards • Applying standard precautions, and additional precautions as necessary, when delivering care • Documenting all care in accordance with mandatory and local requirements Queensland Health disclaims, to the maximum extent permitted by law, all responsibility and all liability (including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred for any reason associated with the use of this guideline, including the materials within or referred to throughout this document being in any way inaccurate, out of context, incomplete or unavailable. Recommended citation: Queensland Clinical Guidelines. Syphilis in pregnancy. Guideline No. MN18.44- V4-R23. Queensland Health. 2018. Available from: http://www.health.qld.gov.au/qcg © State of Queensland (Queensland Health) 2021 This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives V4.0 International licence. In essence, you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute Queensland Clinical Guidelines, Queensland Health and abide by the licence terms. You may not alter or adapt the work in any way. To view a copy of this licence, visit https://creativecommons.org/licenses/by-nc-nd/4.0/deed.en For further information, contact Queensland Clinical Guidelines, RBWH Post Office, Herston Qld 4029, email [email protected]. For permissions beyond the scope of this licence, contact: Intellectual Property Officer, Queensland Health, GPO Box 48, Brisbane Qld 4001, email [email protected] phone (07) 3234 1479. Refer to online version, destroy printed copies after use Page 2 of 31 Queensland Clinical Guideline: Syphilis in pregnancy Flow Chart: Antenatal care Syphilis Risk assess all women No serology Universal risk reactive? • All pregnant women Increased risk Yes • Woman or her partner identify as Aboriginal Discuss case with QSSS and expert and/or Torres Strait Islander practitioner • Adolescent pregnancy Assessment • STI in current pregnancy or last 12 months • Obstetric history • Ongoing sexual links in high prevalence • Sexual history countries (woman or partner) • Previous diagnosis of syphilis High risk • History of previous treatment • Sexual contact with infectious syphilis case • Symptoms of syphilis • Woman or partner identify as Aboriginal • Clinical examination and/or Torres Strait Islander AND reside in o PCR swab of lesions an outbreak declared area • Substance use – particularly methamphetamine (‘ice’) • Woman’s partner is MSM • Late, limited or no antenatal care Treatment • Engages in high risk sexual activity required? No Yes Antenatal screening Develop and document plan of care with QSSS and expert practitioner to: All pregnant women • Serology at first antenatal visit (preferably • Identify treatment appropriate for stage of < 10 weeks gestation) syphilis and history • Dry swab (PCR) if lesions/chancre present • Facilitate contact tracing/treatment • Repeat if change in risk status • Promote maternal and neonatal serological follow-up If increased risk • Monitor effect of maternal treatment • Repeat serology at 26–28 weeks gestation Treatment If high risk • Infectious syphilis • Repeat serology at: o Benzathine penicillin 1.8 g (2.4 million o Around 20 weeks gestation units) IM once (opportunistically between 16–24 weeks) • Late latent or unknown duration 26–28 weeks gestation o o Benzathine penicillin 1.8 g (2.4 million o 34–36 weeks gestation units) IM weekly for three weeks* Test at birth if (any of the following) o Optimal interval is one dose every 7 days* • Woman is high risk If penicillin allergy • Woman is increased risk AND: • Seek expert advice o No serology after 26 weeks Ongoing antenatal care o Preterm birth with most recent serology > 4 weeks before birth • Retest as per high risk women • Indicated following risk assessment • Perinatal assessment as indicated • Discuss: o Risk of reinfection and prevention * If dose is missed or there is an interval of greater Symptoms of syphilis than 7 days considering restarting entire course in o consultation with an expert practitioner o Importance of follow-up • At birth, syphilis serology, placental histopathology and PCR Expert practitioner: clinician with specialist knowledge and experience in the testing, result interpretation, management and treatment of syphilis in the pregnant woman and/or her baby Routine care IM: intramuscular injection, MSM: Men who have sex with men, PCR: Polymerase Chain Reaction QSSS: Queensland Syphilis Surveillance Service, STI: sexually transmitted infection, <: less than ≤ less than or equal to Queensland Clinical Guidelines: Syphilis in pregnancy. Flowchart version: F18.44.1-V3-R23 Refer to online version, destroy printed copies after use Page 3 of 31 Queensland Clinical Guideline: Syphilis in pregnancy Flow Chart: Baby care At risk baby • Mother had syphilis requiring treatment in this pregnancy (irrespective of *adequacy Plan and document all care, investigations and treatment in conjunction with an of treatment) AND/OR expert practitioner • Baby with clinical suspicion of syphilis: o Rash, hepatomegaly, rhinitis, lymphadenopathy and/or other signs and Additional investigations symptoms Consider • FBC, ELFT • Initial assessments Chest x-ray • If *inadequate maternal treatment, or • Long bone radiographs suspicion of syphilis • CSF • Neuroimaging o Treat (do not wait for results) • Perform all of the following: • Ophthalmologic exam • Auditory brain stem response o Parallel ‘syphilis serology’ testing of mother’s and baby’s serum (a non- treponemal titre that is four-fold the Treatment for congenital syphilis maternal titre is diagnostic of CS) 0–7 days of age o IgM of baby’s serum (positive IgM • Benzyl penicillin 30 mg/kg IV 12 hourly for strongly indicative of CS) 10 days Clinical examination of the baby o 8–30 days of age o Placental histopathology and PCR • Benzyl penicillin 30 mg/kg IV 8 hourly for o Review *adequacy of maternal treatment 10 days > 30 days of age • Benzyl penicillin 30 mg/kg IV 4–6 hourly for All initial No 10 days assessments normal? Follow-up Yes Communication • Document need for follow-up • Communication Advise local services of follow-up needs • Document need for follow-up Clinical assessment • Advise local services of follow-up needs • At each opportunity Follow-up Serology • Clinical assessment at each opportunity • At 3, 6 and 12 months of age • Serology at 3 and 6 months of age o If follow-up difficult, aim for 2 tests by 6 o If possible co-ordinate with other health months of age (> 4 weeks apart) check opportunities • If serology persistently reactive at 12 o If follow-up difficult, aim for 2 tests by 6 months seek advice from expert months of age, (> 4 weeks apart) practitioner • If serology remains non-reactive, no further • If at birth CNS or CSF abnormal, repeat action CSF at 6 months for VDRL, cell count and protein Precautionary single dose at discharge *Adequate treatment: treatment may be considered • Expert practitioner may consider single adequate if a stage-appropriate penicillin regimen was precautionary dose of antibiotic if completed 30 days or more prior to birth and all serological follow-up is uncertain
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