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Syphilis during pregnancy
Last reviewed: 07.07.2025
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All women should be screened for syphilis early in pregnancy. In populations where optimal prenatal care is not available, screening with the RPR test and treatment (if positive) should be performed at the time of pregnancy diagnosis. In communities and populations with a high incidence of syphilis or in high-risk patients, serologic testing should be repeated in the third trimester and before delivery. All stillbirths after 20 weeks of gestation should be tested for syphilis. No child should be discharged from the hospital without documented serologic status at least once during pregnancy.
How to examine?
What tests are needed?
Treatment of syphilis during pregnancy
Penicillin is effective in preventing transmission to the fetus or in treating established fetal infection. However, there are insufficient data to determine whether specific recommended penicillin regimens are optimal.
Recommended treatment regimens for syphilis during pregnancy
Treatment during pregnancy should be carried out with penicillin according to the regimen corresponding to the stage of syphilis detected in the woman.
Other notes on pregnancy care
Some experts recommend additional treatment in certain circumstances. A second dose of benzathine penicillin 2.4 million units intramuscularly may be given one week after the initial dose for women with primary, secondary, or early latent syphilis. Ultrasound evidence of fetal syphilis (ie, hepatomegaly and edema) indicates treatment failure; obstetricians should be consulted in such cases.
Women treated for syphilis during the second half of pregnancy are at risk for preterm birth or fetal abnormalities, or both if the Jarisch-Herxheimer reaction is associated with treatment. These women should be advised to report any changes in fetal movement or uterine contractions to the treating physician. Stillbirth is a rare complication of treatment; however, since treatment is necessary to prevent further damage to the fetus, this should not delay treatment. All patients with syphilis should be offered HIV testing and the possibility of drug dependence should be considered.
Follow-up observation
Coordinated prenatal care and follow-up can facilitate identification and treatment of pregnant women with syphilis. Serologic testing should be repeated in the third trimester and at delivery. Serologic titers can be checked monthly in women at high risk of reinfection or in areas with high syphilis prevalence. Clinical manifestations and antibody levels should be consistent with the stage of disease. Many women will deliver before serologic response can reliably assess treatment response.
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Special Notes
Allergy to penicillin
There are no alternatives to penicillin for the treatment of syphilis in pregnant women. Pregnant women with a penicillin allergy should be treated with penicillin after desensitization. Skin testing may be necessary.
Tetracycline and doxycycline are not usually used during pregnancy. Erythromycin should not be prescribed because it is not guaranteed to cure an infected fetus. There are insufficient data on the use of azithromycin or ceftriaxone to recommend their use during pregnancy.
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