Pregnancy with a Reactive VDRL Test — Syphilis: Diagnosis, Treatment & Newborn Care
Syphilis (Treponema pallidum) crosses the placenta at any stage; untreated, it causes miscarriage, stillbirth, preterm birth, neonatal death, or congenital syphilis in up to half or more of pregnancies in early disease
A reactive VDRL (Venereal Disease Research Laboratory) or RPR (Rapid Plasma Reagin) test is a non-treponemal screening test: it may be a true infection or a biological false positive
Penicillin treats both mother and fetus; treatment started at least 4 weeks before delivery prevents almost all congenital infection
Congenital syphilis is entirely preventable by screening at the first antenatal visit and treating the same day
| Result | Interpretation | Action |
|---|---|---|
| Non-treponemal reactive (VDRL or RPR) + treponemal reactive (TPHA, TPPA, FTA-ABS, or rapid test) | Syphilis (current or past, treated or untreated) | Stage the disease; treat unless there is proof of adequate past treatment; use the titre as the baseline |
| Non-treponemal reactive + treponemal non-reactive | Biological false positive — or very early primary syphilis | Repeat both tests in 2–4 weeks; look for the causes below; treat if high risk or if a lesion is present |
| Non-treponemal non-reactive + treponemal reactive | Past treated syphilis, very early or late untreated disease, or false positive | Ask about past treatment; examine; repeat testing; treat if no history of treatment |
| Very high titre, negative at low dilution | Prozone phenomenon | Ask the laboratory to dilute the serum and retest |
| Point-of-care test reactive (no laboratory available) | Treat as syphilis under the national protocol | Treat immediately, then send RPR (qualitative and quantitative) and treat the partner |
All pregnant women are tested at the first antenatal visit, as early as possible, whatever their previous syphilis status
Re-screen in the third trimester or at delivery: past or current STI, more than one partner, sex workers, injecting drug users, repeated abortions, stillbirths, preterm or neonatal deaths, high-prevalence areas, or no earlier test
Women arriving in labour without a test: point-of-care (POC) treponemal rapid test at once
Where RPR is available, use RPR (qualitative and quantitative); otherwise the POC treponemal rapid test (at sub-district level and below)
HIV and syphilis are tested together by the ANM from a single finger prick, with consent and an opt-out option
| HIV | Syphilis | Action |
|---|---|---|
| Non-reactive | Reactive | Medical Officer at the PHC treats the woman and the partner; plan institutional delivery |
| Reactive | Reactive | Refer to the ICTC (Integrated Counselling and Testing Centre) for HIV; syphilis treated by the PHC Medical Officer |
| Reactive | Non-reactive | Refer to the ICTC; ensure institutional delivery |
| Non-reactive | Non-reactive | No referral; repeat in the third trimester if high risk |
| Role | Task |
|---|---|
| ASHA (Accredited Social Health Activist) | Awareness, mobilising women, ensuring treatment, partner testing, and planning delivery at a first referral unit |
| ANM (Auxiliary Nurse Midwife) | Register, POC test at the first visit, record in the MCP card and RCH register, refer reactive women, follow up mother and baby |
| Medical Officer | Treat all reactive women and partners, manage anaphylaxis, follow up after treatment, and refer for delivery |
| Laboratory technician | RPR (qualitative and quantitative) on mother and newborn |
| Stage | Features | Regimen (national protocol) |
|---|---|---|
| Early syphilis (primary, secondary, or under 2 years) | Chancre, rash, condylomata lata; RPR often below 1:8 | Benzathine benzylpenicillin 2.4 million units IM, once |
| Late or unknown duration (over 2 years) | No signs; RPR often above 1:8 | 2.4 million units IM, once a week for 3 weeks (3 doses) |
| Neurosyphilis or ocular syphilis | Headache, visual loss, hearing loss, cranial nerve palsy | Refer: IV aqueous penicillin G for 10–14 days in hospital |
| Partner | Same stage as the woman, or unknown | Same regimen as the woman; test for HIV and other STIs |
| Issue | What to do |
|---|---|
| Penicillin allergy (severe) | Preferred: penicillin desensitisation, then full treatment (CDC, WHO, RCOG). The national protocol notes that no alternative is proven and advises penicillin whenever possible |
| If desensitisation is impossible | National protocol: erythromycin base 500 mg four times a day for 15 days (early) or 30 days (late); azithromycin 2 g once for a primary chancre. Never erythromycin estolate; doxycycline and tetracycline are contraindicated |
| Non-penicillin regimens | They cross the placenta poorly — treat the newborn as inadequately treated |
| Jarisch-Herxheimer reaction | Fever, chills, uterine contractions, and fetal heart decelerations within 24 hours; treat in a facility, give paracetamol, monitor the fetus, and counsel; do not stop treatment |
| Monitoring the titre | Repeat RPR or VDRL monthly (international advice) and at delivery; a fourfold fall (two dilutions) means success; a rise means treatment failure or reinfection |
| Follow-up | After delivery, then at 6 months and 24 months (national protocol); test for reinfection if the partner was not treated |
Ultrasound after 20 weeks: look for hepatomegaly, thick placenta, ascites, hydrops, polyhydramnios, fetal anaemia (raised middle cerebral artery Doppler)
Treatment before 20 weeks prevents most fetal damage; fetal signs predict treatment failure and need specialist care
Deliver at a first referral unit with an obstetrician and a paediatrician; syphilis alone does not require caesarean section — use usual obstetric indications
Fetal monitoring during labour; check for stillbirth risk and Jarisch-Herxheimer reaction if treatment is given close to delivery
Breastfeeding is safe unless there is a lesion on the breast or nipple
Counsel on safer sex, and offer HIV, hepatitis B, gonorrhoea, and chlamydia tests; repeat HIV and syphilis tests in the third trimester in high-risk couples
| Situation | Plan |
|---|---|
| All newborns | RPR test (and compare with the mother's titre); examine fully for signs of congenital syphilis |
| Regimen 1 — prophylaxis: no signs, no serological evidence, and the mother was adequately treated at least 4 weeks before delivery | Benzathine penicillin G 50,000 units/kg as a single IM dose |
| Regimen 2 — treatment: any symptomatic baby, or mother treated less than 4 weeks before delivery, with a non-penicillin regimen, with unknown treatment, or an incomplete course; or infant RPR at least 4-fold above the mother's | Aqueous crystalline penicillin G 50,000 units/kg per dose IV every 12 hours for 7 days, then every 8 hours to complete 10 days; or procaine penicillin 50,000 units/kg IM daily for 10 days |
| Missed doses | If more than one day of treatment is missed, restart the full course |
| Follow-up | Examine and test at postnatal visits and at 6 and 24 months; titres should fall and become non-reactive |
Snuffles (blood-stained nasal discharge)
Rash on palms and soles, peeling skin
Hepatosplenomegaly, jaundice, anaemia
Pseudoparalysis from bone inflammation
Hydrops, low birth weight, or stillbirth
Hutchinson's teeth and saddle nose
Interstitial keratitis and sensorineural deafness
Saber shins, frontal bossing, and rhagades
Intellectual disability, hydrocephalus, or seizures
Prevent by treating the mother early
Waiting for confirmation before treating a reactive POC test — the delay can cost the baby
Dismissing a reactive VDRL as a false positive without a treponemal test and clinical review
Using doxycycline or erythromycin as a routine alternative — these are not reliable for the fetus
Forgetting the partner, the HIV test, and the re-screening of high-risk women late in pregnancy
Not telling the paediatrician or treating the newborn on the maternal history alone; no follow-up at 6 and 24 months
No comments:
Post a Comment