This recommendation statement was first published in Annals of Internal Medicine n May 2009 (Ann Intern Med 2009;150:705-709. https://www.annals.org). Select for copyright and source information.

Importance

Untreated syphilis during pregnancy is associated with stillbirth, neonatal death, bone deformities, and neurologic impairment.

Detection

There is adequate evidence that screening tests can accurately detect syphilis infection.

Benefits of Detection and Early Treatment

The USPSTF found convincing observational evidence that the universal screening of pregnant women decreases the proportion of infants with clinical manifestations of syphilis infection.

Harms of Detection and Early Treatment

Screening and treatment may result in potential harms, including false-positive results that require clinical evaluation, unnecessary anxiety to the patient, and harms of antibiotic use. However, the USPSTF concluded that the harm from screening is no greater than small.

USPSTF Assessment

The USPSTF concludes with high certainty that the net benefit of screening is substantial for pregnant women.

Patient Population Under Consideration

This recommendation applies to pregnant women.

Assessment of Risk

Pregnant women who are at increased risk for syphilis infection include uninsured women, women living in poverty, sex workers, illicit drug users, and women in communities with high syphilis morbidity.¹ The prevalence of syphilis infection differs by region (it is higher in the southern United States and in some metropolitan areas than it is in the United States as a whole) and by ethnicity (it is higher in Hispanic and African-American populations than in the white population). Persons in whom sexually transmitted diseases have been diagnosed may be more likely than others to engage in high-risk behavior, which places them at increased risk for syphilis.

Screening Tests

Nontreponemal tests commonly used for initial screening are the Venereal Disease Research Laboratory (VDRL) test or the Rapid Plasma Reagin (RPR) test. These are typically followed by a confirmatory fluorescent treponemal antibody absorbed test orbTreponema pallidumparticle agglutination test (TPPA).

Treatment

The Centers for Disease Control and Prevention (CDC) has outlined appropriate treatment of syphilis in pregnancy (https://www.cdc.gov/std/treatment/). In its 2006 sexually transmitted disease treatment guidelines, the CDC recommends parenteral benzathine penicillin G for the treatment of syphilis in pregnancy. Evidence on the efficacy or safety of alternative antibiotics in pregnancy is limited; therefore, women who report penicillin allergies should be evaluated for penicillin allergies and, if present, desensitized and treated with penicillin. Because the CDC updates these recommendations regularly, clinicians are encouraged to access the CDC Web site (https://www.cdc.gov/std/treatment/) to obtain the most up-to-date information.

Screening Intervals

All pregnant women should be tested at their first prenatal visit. For women in high-risk groups, many organizations recommend repeat serologic testing in the third trimester and at delivery. Most states mandate that all pregnant women be screened at some point during pregnancy, and many mandate screening at the time of delivery. Follow-up serologic tests should be obtained after treatment to document decline in titers. To ensure that results are comparable, follow-up tests should be performed by using the same nontreponemal test that was used initially to document the infection (for example, VDRL or RPR).

Useful Resources

The USPSTF has made recommendations on screening for other sexually transmitted diseases in pregnancy, including gonorrhea, chlamydial infection, hepatitis B, herpes, and HIV. Please go to the USPSTF Web site (https://www.uspreventiveservicestaskforce.org) for more information on these recommendations. The CDC guidelines on treatment for syphilis in pregnancy can be accessed at https://www.cdc.gov/std/treatment/.

In 2004, the USPSTF reviewed the evidence on screening for syphilis in pregnant women. In 2008, the USPSTF performed a targeted literature review and determined that the net benefit of screening pregnant women continues to be well established.² This literature update included a search for new and substantial evidence on the benefits of screening, harms of screening, and harms of treatment with penicillin. The USPSTF found no new substantial evidence that could change its recommendation, and therefore reaffirms its recommendation to screen all pregnant women. The previous recommendation statement and evidence report, as well as the 2008 summary of the updated literature search, can be found at https://www.uspreventiveservicestaskforce.org.

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend³ that all pregnant women be screened for syphilis with serologic testing at the first prenatal visit, after exposure to an infected partner, and at the time of delivery. They recommend that pregnant women who are considered at high risk for acquiring syphilis should also be tested at the beginning of the third trimester. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists advise³ using a nontreponemal screening test initially (RPR or VDRL), followed by a confirmatory treponemal antibody test. The CDC recommends⁴ that all pregnant women be screened for syphilis with serologic testing at the first prenatal visit. Pregnant women who are at high risk, live in areas with a high prevalence of syphilis, have not been previously tested, or have had a positive serology test for syphilis during the first trimester should be screened again early in the third trimester (28 weeks) and at the time of delivery. The American Academy of Family Physicians strongly recommends⁵ that all pregnant women be screened for syphilis. It advises screening with serologic testing at the first prenatal visit, with repeat serologic testing at 28 weeks and at the time of delivery for pregnant women who are at high risk.

Members of the U.S. Preventive Services Task Force* are Ned Calonge, MD, MPH, Chair, USPSTF (Colorado Department of Public Health and Environment, Denver, CO); Diana B. Petitti, MD, MPH, Vice-chair, USPSTF (Arizona State University, Phoenix, AZ); Thomas G. DeWitt, MD (Children's Hospital Medical Center, Cincinnati, OH); Allen Dietrich, MD (Dartmouth Medical School, Lebanon, NH): Kimberly D. Gregory, MD, MPH (Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA); David Grossman, MD, MPH (Group Health Cooperative, Seattle, WA); George Isham, MD, MS (Health Partners, Inc., Minneapolis, MN); Michael L. LeFevre, MD, MSPH (University of Missouri School of Medicine, Columbia, MO); Rosanne Leipzig, MD, PhD (Mount Sinai School of Medicine, New York, NY); Lucy N. Marion, PhD, RN (School of Nursing, Medical College of Georgia, Augusta, GA); Bernadette Melnyk, PhD, RN, CPNP/NPP, FAAN, FNAP (Arizona State University College of Nursing and Healthcare Innovation, Phoenix, AZ); Virginia A. Moyer, MD, MPH (Baylor College of Medicine, Houston, TX); Judith K. Ockene, PhD (University of Massachusetts Medical School, Worcester, MA); George F. Sawaya, MD (University of California, San Francisco, CA); J. Sanford Schwartz, MD (University of Pennsylvania School of Medicine and The Wharton School, Philadelphia PA); and Timothy Wilt, MD, MPH (Minneapolis Veterans Affairs Medical Center for Chronic Disease Outcomes Research, Minneapolis MN).

*Members of the Task Force at the time this recommendation was finalized. For a list of current Task Force members, go to https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/current-members.

Disclaimer: Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

This document is in the public domain within the United States.

Requests for linking or to incorporate content in electronic resources should be sent via the USPSTF contact form.

Source: U.S. Preventive Services Task Force. Screening for syphilis infection in pregnancy: U.S. Preventive Services Task Force Reaffirmation Recommendation Statement. Ann Intern Med 2009;150:705-9.