Your Pregnancy Matters

Congenital syphilis is on the rise: What pregnant women need to know

Your Pregnancy Matters

Pregnant woman holding her belly looking concerned.
Syphilis can cause serious complications for a baby if it goes undetected.

Despite what you might have heard, syphilis is not a thing of the past.

In fact, congenital syphilis infections, which fell 92% between 1999 and 2005, are back with a vengeance, increasing 80% in the U.S. from 2018 to 2022. Those are the highest numbers since the 1950s.

Congenital syphilis occurs when the infection in a mother passes to the fetus during pregnancy. The problem is particularly significant in Texas, which has the fourth highest rate of congenital syphilis in the U.S., according to the Texas Department of State Health Services.

And here’s the most troubling part: the bacterial infection, which starts when a mother contracts syphilis, a sexually transmitted infection (STI), is fatal for up to 40% of infants who are infected. It is the second leading cause of preventable stillbirth globally.

Syphilis testing is part of routine prenatal check-ups in Texas. In fact, we screen for it three times during pregnancy, and it can be treated when detected early in the mother. So, it is very preventable. But left untreated, congenital syphilis can cause serious complications for the baby, such as:

  • Bone abnormalities
  • Vision and hearing loss
  • Jaundice, or a yellowing of the skin due to liver dysfunction
  • Pneumonia
  • Anemia or low platelets
  • Skin rashes
  • Miscarriage or stillbirth

While babies who survive may recover, few studies have been done on the long-term effects of congenital syphilis infection.

Why is congenital syphilis on the rise?

Reasons for this exponential rise are complex. Limited access to preventive and prenatal care are factors driving the surge in congenital syphilis cases, along with other social determinants of health and substance use disorders as well as public awareness and public health funding gaps. The pandemic took a dramatic toll on public health, and many patients who lost jobs and income were left without health insurance and a direct link to health education.

For example, some patients delayed STI screenings or prenatal care due to financial costs.

But there are options – Medicaid offers free health care coverage during pregnancy and now up to the first 12 months after birth for patients who qualify, and the Children’s Health Insurance Program (CHIP) Perinatal program provides care for uninsured women who don’t qualify for Medicaid. But these programs do not cover pre-pregnancy preventive care for all females of childbearing age. For those who do become pregnant, knowing how coverage options change can be confusing.

Limited access to preventive and prenatal care are factors driving the surge in congenital syphilis cases, along with other social determinants of health and public health funding gaps.

– Emily Adhikari, M.D.

Persistent stigmas around “who gets STIs” also contribute to the problem. Racial and ethnic minority groups account for seven out of 10 infants born with congenital syphilis in Texas. However, syphilis doesn’t discriminate. Anyone can contract the infection and pass it to their child, even without typical risk factors such as:

  • Late entry to prenatal care (or none at all)
  • Incarceration of an expectant person or their partner
  • Sex with more than one partner
  • Sex associated with drug use
  • Housing insecurity

Discussing STIs can be uncomfortable for patients and their partners. But getting screened regularly – particularly with a new sexual partner and after unprotected sex – and seeking prenatal care as soon as pregnancy is suspected offers the best chance of healthier outcomes for the mother and baby. Screening for sexually transmitted infections is often free and can be accessed through primary care, prenatal care, or through sexual health clinics.

How is congenital syphilis diagnosed?

Congenital syphilis is a consequence of maternal syphilis, which is an infection that comes from sexual contact with an infected partner. Syphilis is often called “the great imitator” because its symptoms often mimic those of other diseases, although most infections do not cause noticeable symptoms at all. The only way to know for sure is to get a syphilis test, which involves a simple blood draw. Some signs the mother or her partner may be infected include:

  • Firm, round, sores on mucosal surfaces like genital area or mouth
  • Skin rashes over the torso, hands, or feet
  • Bumps or growths in the genital area
  • Swollen lymph nodes
  • Fever, malaise, and fatigue
  • Hair loss in patches

If a pregnant woman is diagnosed with syphilis in the second or third trimester, we will use ultrasound to examine the fetus for signs of congenital syphilis, such as:

  • Enlarged liver
  • Enlarged placenta
  • Signs of anemia
  • Signs of heart failure
  • Fluid in the abdominal cavity

After birth, pediatric specialists make a diagnosis of congenital syphilis after a thorough evaluation of the baby. This evaluation may include physical examination, laboratory tests, radiologic studies (X-rays), and sometimes more invasive tests like lumbar puncture (spinal tap).

How is congenital syphilis treated?

The goal is to prevent congenital syphilis by detecting and treating it early in pregnancy, preferably in the first trimester.

If you are diagnosed with syphilis during pregnancy, the only treatment that has been shown to treat the fetus exposed to maternal syphilis is long-acting penicillin. Treatment must occur at least 30 days before delivery for the best chance at preventing congenital syphilis in your baby. While non-pregnant individuals with penicillin allergies have alternative options (like doxycycline) for treatment, there are no other options currently available to treat syphilis in pregnancy. Patients who report an allergy to penicillin in pregnancy must undergo evaluation to determine whether the allergy is high risk, and they may have to undergo a special procedure called desensitization in order to receive appropriate treatment for syphilis.

After birth, depending on the results of the evaluation by pediatric specialists and timing of syphilis treatment during pregnancy, babies may receive a single injection of penicillin or need to be treated in the neonatal intensive care unit (NICU) with IV penicillin for 10 to 14 days. The later syphilis is diagnosed in pregnancy, the more likely it is that a baby will have to stay in the NICU for longer treatment.

Getting early, consistent prenatal care is the best way to prevent complications from congenital syphilis. Prior to pregnancy, routine STI testing can help decrease your chances of getting a syphilis infection. It’s also important that any sexual partners get tested and treated. Otherwise, you run the risk of reinfection and your baby still has a risk of congenital syphilis.

We’ve gained ground against congenital syphilis before, and with dedicated patient education and improved access to care, we can do so again. It all begins with awareness that syphilis is still a very real and potentially dangerous problem for babies.

Talk with a doctor if you suspect you may be pregnant, and especially if you think you may be at risk of syphilis infection. The sooner you seek care, the better the outcomes can be for you and your baby.

To make a prenatal appointment, call 214-645-8300 or request an appointment online.