Changes to syphilis testing during pregnancy

What is the issue?

Cases of congenital syphilis represent a serious and preventable public health problem which has re-emerged in Victoria since 2017 with a total of 19 cases of congenital syphilis, including 10 deaths. Prior to 2017, only 2 congenital cases were notified in the preceding 25 years. This has occurred along with an increase in infectious syphilis among women and men of reproductive age (15 to 49 years of age) over the past 8 years with the highest number of notifications in Victoria occurring in 2023 (2,778 cases).

Syphilis occurring in pregnancy requires prompt treatment and follow-up to prevent serious adverse consequences in the baby.

Eliminating congenital syphilis requires active screening of all pregnant people, early case detection, timely and appropriate treatment, and adequate follow-up of pregnant people, their babies, and their sexual partners.

National guidelines have recently been updated to recommend a minimum of 3 syphilis tests for every pregnant person during each pregnancy: at the first antenatal visit, at 26 to 28 weeks, and at 36 weeks or birth (whichever is earlier). See Syphilis – CDNA National Guidelines for Public Health Units, updated 5 November 2024, for further information.

Who is at risk?

All sexually active people are at risk of syphilis. The following groups are at increased risk of syphilis during pregnancy:

• those who have multiple sexual partners
• sexual partners of gay, bisexual and other men who have sex with men
• those who use drugs
• Aboriginal and Torres Strait Islander peoples
• those presenting with any other STIs during pregnancy.

Symptoms and transmission

Congenital syphilis occurs as a result of transplacental transmission during pregnancy or from mother to baby during birth. A person with syphilis can remain infectious during the primary, secondary and early latent periods of the clinical course, usually for up to 2 years from the time of infection acquisition if left untreated.

Primary syphilis is typically characterised by an ulcerative and painless lesion (chancre) located at the site of inoculation. A headache, fatigue, lymphadenopathy, fever, sore throat, rash, mucocutaneous lesions and condylomata lata (raised, whitish or grey, flat-topped lesions found in warm moist areas like the mouth, genitals or anus) may occur in secondary syphilis, while early latent syphilis is no longer symptomatic.

Congenital syphilis can result in stillbirth, prematurity, low birth weight or neonatal death. Babies born with congenital syphilis can appear normal at birth but develop a wide range of clinical manifestations by 2 months of age.

Late manifestations of congenital syphilis can appear from 2 years after birth and include central nervous system abnormalities, eye and hearing problems, and bone or teeth abnormalities.

Recommendations

For health professionals

Testing during pregnancy

• The recommendations for universal syphilis testing during pregnancy have changed in Victoria. It is recommended that clinicians test all pregnant people a minimum of 3 times:
  • at the first antenatal visit
  • at 26 to 28 weeks and
  • at 36 weeks or birth (whichever is earlier).
• Indicate pregnancy status on the requesting pathology slip clinical notes.
• Repeat syphilis testing in all pregnant people presenting with signs or symptoms of any other STIs.
• Neonates must not be discharged without confirming that the mother's syphilis status has been documented at least once during pregnancy. If in doubt, maternal syphilis serology should be ordered at birth.
• Primary laboratories are requested to forward to VIDRL all specimens from pregnant people with positive syphilis serology, for reference testing. This enables VIDRL to perform parallel testing of samples throughout the entire pregnancy and at birth, thus addressing intra and inter-laboratory variability and better informing risk assessment and treatment decisions.

Management of pregnant people and their contacts

• Notify all cases of syphilis to the Department of Health.
• All cases of syphilis in pregnancy require close cooperation between GPs, laboratories, and specialist clinics to ensure the pregnant woman and their baby are treated appropriately.
• Actively follow up pregnant people who do not attend for testing. Ensure pregnant people are not lost to follow-up. Local Public Health Units and the Department's Partner Notification Officers (see below) can assist with cases lost to follow-up.
• Any pregnant person diagnosed with syphilis requires prompt and appropriate treatment with long acting (benzathine) penicillin. Short acting formulations such as benzylpenicillin are ineffective and should not be used.
• Advice on appropriate management in pregnancy is available from Infectious Diseases physicians, or from the Melbourne Sexual Health Centre doctors' information line. Call 1800 009 903.
• Sexual partners of people diagnosed with syphilis during pregnancy should be tested and treated without waiting for test results, to prevent reinfection during pregnancy.
• All babies born to mothers diagnosed with syphilis in pregnancy will require follow-up and testing overseen by a specialist paediatric clinic such as those at the Royal Children's Hospital or the Monash Children's hospital.

Partner notification

• Ensure timely testing and treatment of partners to prevent reinfection. Refer to another service if required.
• Local Public Health Units and the Partner Notification Officers from the Department of Health are available to assist in contacting the sexual partners of any patient diagnosed with an STI, including syphilis. This is a confidential service. Parter Notification Officers can be reached on (03) 9096 3367 or by email at contact.tracers@dhhs.vic.gov.au.
• Partner notification tools are available to contact partners anonymously at Let Them Know.

Education

• Advise all people diagnosed with syphilis in pregnancy of the importance of adequate treatment and appropriate follow-up of mother and baby to prevent adverse health consequences in the baby.
• Advise all pregnant people at risk of STIs of the importance of being tested for syphilis in both early and late pregnancy and of the importance of safer sex in preventing syphilis in pregnancy.
• Advise all people diagnosed with syphilis on the importance of partner notification, testing, and treatment to prevent further infections. Offer active support with partner notification.
• All pregnant people diagnosed with syphilis are at risk of reinfection if their current partners remain untested and untreated for syphilis.