There are a number of clinical challenges that are specific to managing syphilis in pregnancy: Which women have the highest risk of adverse pregnancy outcome and is there anything extra we should do for them? What effect does the timing of treatment have on the pregnancy? What is the best treatment and should this be modified in the presence of HIV? What effect does the Jarisch-Herxheimer reaction have on pregnancy? What rate of adverse pregnancy outcome can be expected following successful treatment? Should all babies be treated at birth and how should the baby be monitored?

Early stage maternal infection and higher RPR increase the risk of adverse pregnancy outcome. Treatment in the third trimester is also associated with poorer outcomes. Parenteral penicillin G is the only recommended therapy for treatment of syphilis during pregnancy, and the lack of effective alternatives is why desensitisation is recommended in those who report a penicillin allergy. However, a meta-analysis concluded there is insufficient evidence to determine an optimal penicillin regimen. Adequate treatment in pregnancy significantly reduces adverse pregnancy outcomes (APOs) and congenital syphilis but APOs are still reported probably due to placental damage and effects of the fetal immune response. Some guidelines recommend treating all infants born to positive women whether or not the mother was adequately treated in pregnancy whereas others suggest this is probably not necessary. All recommend examination and serological testing of the babies every 3 months until the test/s become nonreactive.

This presentation will look at the evidence base, and the recommendations in different national guidelines, to try to provide answers to these questions.