A Missed Opportunity for Early Maternal Syphilis Treatment

Introduction: 

Despite prenatal screening, serologic monitoring, and intervention by public health agencies, maternal syphilis treatment opportunities may be missed, resulting in congenital syphilis.

Case Description: 

This 32 year old woman came to STD clinic in 2009, three months after treatment with Bicillin (BIC) 7.4 million units (mu) for an RPR of 1:64.  She had a titer of 1:32 at first STD clinic visit and was not re-treated. Eleven months later, her titer was 1:2. In 2011 she returned to STD clinic with a titer of 1:8 (drawn at another facility) and was treated with BIC 2.4 mu. She stated that her husband had been diagnosed with syphilis and treated with three injections.  She had been sexually active with him before he completed treatment. 

By the beginning of 2012 titers dropped to 1:4 and remained the same six months later.

She became pregnant in 2013.  In the first trimester, titers ranged from 1:4 (Laboratory A/STD Clinic) to 1:16 on three subsequent samples at (Lab B/Ob-Clinic), dropping to 1:4 in the second trimester (Lab B/Ob-Clinic).  Titers rose to 1:16 (Lab B/Ob-Clinic) and 1:32 (Lab B/Ob-Clinic) at 33 and 37 weeks gestation, respectively.  In week 37 she was treated by her obstetrician with BIC 2.4 mu; she delivered one week later.

The baby’s titer at birth was 1:1, TP-PA positive.  Cerebrospinal fluid (CSF) VDRL was negative;  CSF protein normal.  The baby was treated per CDC Guidelines.

Discussion:  

Despite multiple titers indicating a need for treatment during pregnancy, treatment delay occurred. Contributing factors included:  1)a triage system in STD clinic that does not assess for  pregnancy, 2) an infectious disease consultant who advised  there was no need to treat at titers  <1:64,  3) laboratories reporting syphilis do not know patients’ pregnancy status, 4) errors in data entry which can result in failure to prioritize follow-up.