Skip directly to site content Skip directly to page options Skip directly to A-Z link


Centers for Disease Control and Prevention. CDC twenty four seven. Saving Lives, Protecting People
															Search

		Submit


Sexually Transmitted Infections Treatment Guidelines, 2021


Section Navigation
			
			CDC Home


Facebook
        Twitter
        LinkedIn
        Syndicate





Syphilis During Pregnancy										Related Pages
					All women should be screened serologically for syphilis at the first prenatal care visit (*174*), which is mandated by the majority of states (*142*). Among populations for whom receipt of prenatal care is not optimal, serologic screening and treatment (if serologic test is reactive) should be performed at the time of pregnancy testing (*632*). Antepartum screening can be performed by manual nontreponemal antibody testing (e.g., RPR) by using the traditional syphilis screening algorithm or by treponemal antibody testing (e.g., immunoassays) using the reverse sequence algorithm.
Pregnant women with positive treponemal screening tests (e.g., EIA, CIA, or immunoblot) should have additional quantitative nontreponemal testing because titers are essential for monitoring treatment response. Serologic testing should also be performed twice during the third trimester: at 28 weeks’ gestation and at delivery for pregnant women who live in communities with high rates of syphilis and for women who have been at risk for syphilis acquisition during pregnancy.
Maternal risk factors for syphilis during pregnancy include sex with multiple partners, sex in conjunction with drug use or transactional sex, late entry to prenatal care (i.e., first visit during the second trimester or later) or no prenatal care, methamphetamine or heroin use, incarceration of the woman or her partner, and unstable housing or homelessness (*174*,*633*–*636*). Moreover, as part of the management of pregnant women who have syphilis, providers should obtain information concerning ongoing risk behaviors and treatment of sex partners to assess the risk for reinfection.
Any woman who has a fetal death after 20 weeks’ gestation should be tested for syphilis. No mother or neonate should leave the hospital without maternal serologic status having been documented at least once during pregnancy. Any woman who at the time of delivery has no prenatal care history or has been at risk for syphilis acquisition during pregnancy (e.g., misuses drugs; has had another STI during pregnancy; or has had multiple sex partners, a new partner, or a partner with an STI) should have the results of a syphilis serologic test documented before discharge.
Diagnostic Considerations
Pregnant women seropositive for syphilis should be considered infected unless an adequate treatment history is clearly documented in the medical records and sequential serologic antibody titers have decreased as recommended for the syphilis stage. The risk for antepartum fetal infection or congenital syphilis at delivery is related to the syphilis stage during pregnancy, with the highest risk occurring during the primary and secondary stages. Quantitative maternal nontreponemal titer, especially if >1:8, might be a marker of early infection and bacteremia. However, risk for fetal infection is still substantial among pregnant women with late latent syphilis and low titers. Pregnant women with stable, serofast low nontreponemal titers who have previously been treated for syphilis might not require additional treatment; however, increasing or high antibody titers in a pregnant woman previously treated might indicate reinfection or treatment failure, and treatment should be offered.
If an automated treponemal test (e.g., EIA or CIA) is used for antepartum syphilis screening, all positive tests should be reflexed to a quantitative nontreponemal test (e.g., RPR or VDRL). If the nontreponemal test is negative, the results are considered discrepant and a second treponemal test (TP-PA is preferred) should be performed, preferably on the same specimen.
If the second treponemal test is positive (e.g., EIA positive, RPR negative, or TP-PA positive), current or previous syphilis infection can be confirmed. For women with a history of adequately treated syphilis who do not have ongoing risk, no further treatment is necessary. Women without a history of treatment should have the syphilis stage determined and should be treated accordingly with a recommended penicillin regimen.
If the second treponemal test is negative (e.g., EIA positive, RPR negative, or TP-PA negative), the positive EIA or CIA is more likely to represent a false-positive test result for women who are living in communities with low rates of syphilis, have a partner who is uninfected, and have no history of treated syphilis (*637*,*638*). If the woman is at low risk for syphilis, lacks signs or symptoms of primary syphilis, has a partner with no clinical or serologic evidence of syphilis, and is likely to follow up with clinical care, repeat serologic testing within 4 weeks can be considered to determine whether the EIA or CIA remains positive or if the RPR, VDRL, or TP-PA result becomes positive. If both the RPR and TP-PA remain negative, no further treatment is necessary. If follow-up is not likely, women with an isolated reactive treponemal test and without a history of treated syphilis should be treated according to the syphilis stage.
Treatment
Penicillin G is the only known effective antimicrobial for treating fetal infection and preventing congenital syphilis (*639*). Evidence is insufficient to determine the optimal penicillin regimen during pregnancy (*640*).Recommended Regimen for Syphilis During PregnancyPregnant women should be treated with the recommended penicillin regimen for their stage of infection.Other Management Considerations
The following recommendations should be considered for pregnant women with syphilis infection:
Certain evidence indicates that additional therapy is beneficial for pregnant women to prevent congenital syphilis. For women who have primary, secondary, or early latent syphilis, a second dose of benzathine penicillin G 2.4 million units IM can be administered 1 week after the initial dose (*641*–*643*).
When syphilis is diagnosed during the second half of pregnancy, management should include a sonographic fetal evaluation for congenital syphilis. However, this evaluation should not delay therapy. Sonographic signs of fetal or placental syphilis (e.g., hepatomegaly, ascites, hydrops, fetal anemia, or a thickened placenta) indicate a greater risk for fetal treatment failure (*644*); cases accompanied by these signs should be managed in consultation with obstetric specialists. A second dose of benzathine penicillin G 2.4 million units IM after the initial dose might be beneficial for fetal treatment in these situations.
Women treated for syphilis during the second half of pregnancy are at risk for premature labor or fetal distress if the treatment precipitates the Jarisch-Herxheimer reaction (*590*). These women should be advised to seek obstetric attention after treatment if they notice any fever, contractions, or decrease in fetal movements. Stillbirth is a rare complication of treatment; however, concern for this complication should not delay necessary treatment. No data are available to support that corticosteroid treatment alters the risk for treatment-related complications during pregnancy.
Missed doses >9 days between doses are not acceptable for pregnant women receiving therapy for late latent syphilis (*613*). An optimal interval between doses is 7 days for pregnant women. If a pregnant woman does not return for the next dose on day 7, every effort should be made to contact her and link her to immediate treatment within 2 days to avoid retreatment. Pregnant women who miss a dose of therapy should repeat the full course of therapy.
All women who have syphilis should be offered testing for HIV at the time of diagnosis.Follow-Up
Coordinated prenatal care and treatment are vital because providers should document that women are adequately treated for the syphilis stage and ensure that the clinical and antibody responses are appropriate for the patient’s disease stage. If syphilis is diagnosed and treated at or before 24 weeks’ gestation, serologic titers should not be repeated before 8 weeks after treatment (e.g., at 32 weeks’ gestation) but should be repeated again at delivery. Titers should be repeated sooner if reinfection or treatment failure is suspected. For syphilis diagnosed and treated after 24 weeks’ gestation, serologic titers should be repeated at delivery.
A majority of women will not achieve a fourfold decrease in titers before delivery, although this does not indicate treatment failure (*645*). However, a fourfold increase in titer after treatment (e.g., from 1:8 to 1:32) that is sustained for >2 weeks is concerning for reinfection or treatment failure. Nontreponemal titers can increase immediately after treatment, presumably related to the treatment response. Therefore, unless symptoms and signs exist of primary or secondary syphilis, follow-up titer should not be repeated until approximately 8 weeks after treatment. Inadequate maternal treatment is likely if delivery occurs within 30 days of therapy, clinical signs of infection are present at delivery, or the maternal antibody titer at delivery is fourfold higher than the pretreatment titer.
Management of Sex Partners
See Syphilis, Management of Sex Partners.
Special Considerations
Penicillin Allergy
No proven alternatives to penicillin are available for treatment of syphilis during pregnancy. Pregnant women who have a history of penicillin allergy should be desensitized and treated with penicillin G. Skin testing or oral graded penicillin dose challenge might be helpful in identifying women at risk for acute allergic reactions (see Management of Persons Who Have a History of Penicillin Allergy).
Tetracycline and doxycycline are to be avoided in the second and third trimesters of pregnancy (*431*). Erythromycin and azithromycin should not be used because neither reliably cures maternal infection nor treats an infected fetus (*640*). Data are insufficient to recommend ceftriaxone or other cephalosporins for treatment of maternal infection and prevention of congenital syphilis (*646*,*647*).
HIV Infection
Placental inflammation from congenital syphilis infection might increase the risk for perinatal transmission of HIV. All women with HIV infection should be evaluated for syphilis and receive a penicillin regimen appropriate for the syphilis stage. Data are insufficient to recommend any alternative regimens for pregnant women with syphilis and HIV infection (see Syphilis Among Persons with HIV).Top of PageNext
							
					
						Page last reviewed:  July 22, 2021					Content source: 	Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention homeSTI Treatment Guidelines, 2021
Provider Resourcesplus icon
Customizable Announcement
Screening Recommendations
Tables of Evidence
Table of Contents
Summary and Introduction
Methods
Clinical Prevention Guidanceplus icon
STI and HIV Infection Risk Assessment
Primary Prevention Methods
Partner Servicesplus icon
Expedited Partner Therapy (EPT)
Reporting and Confidentiality
Retesting After Treatment to Detect Repeat Infections
Detection of STIs in Special Populationsplus icon
Pregnant Women
Adolescents
Children
MSM
WSW and WSWM
Transgender and Gender Diverse Persons
Persons in Correctional Facilities
HIV Infection: Detection, Counseling, and Referral
Diseases Characterized by Genital, Anal, or Perianal Ulcersplus icon
Chancroid
Genital Herpes
Granuloma Inguinale (Donovanosis)
Lymphogranuloma Venereum (LGV)
Syphilisplus icon
Primary and Secondary Syphilis
Latent Syphilis
Tertiary Syphilis
Neurosyphilis, Ocular Syphilis, and Otosyphilis
Syphilis Among Persons with HIV Infection
Syphilis During Pregnancy
Congenital Syphilis
Managing Persons Who Have a History of Penicillin Allergy
Diseases Characterized by Urethritis and Cervicitis
Chlamydial Infections
Gonococcal Infectionsplus icon
Gonococcal Infections Among Adolescents and Adults
Gonococcal Infections Among Neonates
Gonococcal Infections Among Infants and Children
*Mycoplasma genitalium*
Vulvovaginal Itching, Burning, Irritation, Odor or Dischargeplus icon
Bacterial Vaginosis
Trichomoniasis
Vulvovaginal Candidiasis
Pelvic Inflammatory Disease (PID)
Epididymitis
Human Papillomavirus (HPV) Infectionplus icon
Anogenital Warts
HPV-Associated Cancers and Precancers
Viral Hepatitisplus icon
HAV
HBV
HCV
Proctitis, Proctocolitis, and Enteritis
Ectoparasitic Infections
Sexual Assault and Abuse and STIsplus icon
Adolescents and Adults
Sexual Assault or Abuse of Children
References
Terms and Abbreviations Used in This Report
Workgroup Members
Timeline of STI Treatment Guidelines STDs Home Page
 Treatment
 Social_round_twitterSTD on Twitter
Social_round_facebookSTD on Facebook


About CDC
					Contact Us
					800-232-4636
 Facebook Twitter Instagram LinkedIn Youtube Pinterest Snapchat
 CONTACT CDC
				Contact Us
							Call 800-232-4636
							Email Us
			ABOUT CDC
				About CDC
							Jobs
							Funding
			POLICIES
				Accessibility
							External Links
							Privacy
							Policies
							No Fear Act
							FOIA
							OIG
							Nondiscrimination
							Vulnerability Disclosure Policy
			CONNECT WITH US
				Facebook
								Twitter
								Instagram
								LinkedIn
							Youtube
								Pinterest
								Snapchat
								Email
			LANGUAGES
				Español
							繁體中文
							Tiếng Việt
							한국어
							Tagalog
							Русский
							العربية
							Kreyòl Ayisyen
							Français
							Polski
							Português
							Italiano
							Deutsch
							日本語
							فارسی
							English


U.S. Department of Health & Human Services
			Accessibility
			External Links
			Privacy
			Policies
			No Fear Act
			FOIA
			Nondiscrimination
			OIG
			Vulnerability Disclosure Policy
			USA.gov


Exit Notification / Disclaimer Policy Close
 Links with this icon  indicate that you are leaving the CDC website. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website.
				Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website.
				You will be subject to the destination website's privacy policy when you follow the link.
				CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. Website Disclaimers
 Cancel Continue