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The problem of maternal syphilis after serologic surveillance during pregnancy
The problem of maternal syphilis after serologic surveillance GILLES
R.
BYRON
R.
G.
MONIF,
WILLIAMS,
STANFORD
T.
HERMANN
M.D. JR.,
A.B
SHULMAN
BAER,
Gainesville,
during pregnancy
M.D.
Florida
Because of an initial case of congenital syphilis occurring in the ofspring of a gravida who acquired infection in the interim between initial treponemal serologic testing and parturition, 1,000 maternal delivery serum specimens from gravida whose interim between the initial VDRL and parturition exceeded 90 days were screened using the rapid plasma reagin (RPR) card test. The specificity of a positive microflocculation reaction was confirmed by the fluorescent Treponema antibody absorption (FTA-Abs) test. Two additional cases of maternal syphilis prior to parturition were documented. While these cases may constitute isolated experiences, serious thought should be given to the screening of mothers prior to or at parturition for evidence of infection with Treponema pallidum until such time as the incidence of syphilis in the community is markedly reduced.
AT ONE TIME, it could be stated that congenital syphilis was primarily a reflection of inadequate prenatal care.ly 2 The institution of compulsory serologic analysis during pregnancy as an integral part of comprehensive prenatal care programs has markedly altered the natural history of congenital syphilis.?-” The
previous
peak
incidence
and secondary syphilis occurred in 1965 when over 25,000 cases were reported.? After 1965, and until 1970, there had been a gradual decline in the number of reported cases of infectious syphilis. Since 1970 the increase in the number of cases being reported has been such: that the previous peak incidence has now been surpassed. The increasing prevalence of syphilis among all socioeconomic groups has put new pressures on those aspects of preventive medicine involved with maternal-infant care and questioned their current adequacy. The recent admission to our institution of a g-week-old infant with congenital syphilis whose mother’s initial serologic test for syphilis at 3 months of pregnancy was negative, focused on a critical problem in the area of perinatal care, namely, maternal acquisition of infection in the interim between serologic testing and parturition. Recognition of this occurrence prompted us to analyze 1,000 maternal delivery specimens of gravida for whom the interim between initial VDRL and
of primary
From the Section on Infectious Diseases, The Departments of Obstetrics and Gynecology, Pediatrics, and Microbiology, University of Florida College of Medicine. Supported in part by National Institutes of Health Grant No. HL-14266-01 and the Florida Heart Association. f;;$ved Revised Accepted
for publication March March
December
15,
12, 1973. 19, 1973.
Reprint requests: Gilles R. G. Monif, M.D., Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, Florida 32601. 268
Volume Number
i17 2
Maternal
Table I. Summary interim
between Duration at time logic
-l----
of patient data on cases of maternal syphilis initial serologic surveillance and parturition of gestation of initial serosurveillance
76 days
VDRL/FTA at parturition Not
Fetal
Pilot
case
available
Case
1
117
days
VDRL
1:32/FTA
+ 4
Case
2
157 days
VDRL
1: 1 G/FTA
+ 4
parturition exceeded 90 days for possible fection with Treponema pallidurn. Material
and
in-
occurring
07
neonatal
syphilis
269
in the
outcome
Congenital syphilis : At age 9 weeks VDRL 1: 4, FTA + 4, long bone roentgenograms consistent with congenital syphilis-one week after initiation of penicillin therapy VDRL 1: 128 Fetal death in utero one week prior to parturition Congenital syphilis: IgM-FTA + 2 (cord)
the FTA-Abs test using an anti-human IgM conjugate developed by Scotti, Logan, and Caldwell and Alford and associates.lO, I1
methods
As of Sept. 1, 1969, every woman attending the prenatal facilities within a 13 county area for which the Department of Obstetrics and Gynecology has prime patient care responsibility, has had serum specimens registered within the serum bank of the Section of Infectious Diseases. Maternal and cord blood are obtained at the time of parturition on any gravida delivering at the Shands Teaching Hospital. This is a demographically stable, low socioeconomic, semirural population. One thousand gestations were identified in the se:rum bank population in which the interim between the initial VDRL and parturition exceeded 90 days. The maternal registration and delivery specimens were screented with the rapid plasma reagin sera from (RPR) card test. $,,y All maternal gravida who developed a positive microflocculation reaction in the delivery specimen were analyzed for specificity utilizing the fluorescent Treponema antibody absorption (FTA.-Abs) test. A VDRL test was done to obtain quantitative measurement of the degree of reactivity. The cord sera from the progeny of such serologically positive mothers were evaluated for evidence of stimulation of the immune process in utero. Documentation of fetal involvement was contingent upon the demonstration of specific IgM antibodies utilizing
Results
The results are summarized in Table I. Two cases of maternal syphilis occurred in the interim between initial serologic testing for syphilis and parturition. Because of its ease of performance and rapidity, low unit cost and sensitivity, the RPR card test was an ideal choice of a test to deal with large numbers of sera as would be engendered by an obstetric population on a daily basis. The major drawback in our hands has been its increased sensitivity over the VDRL and the resultant increased number of biologically false positive reactions. Comment
Congenital syphilis is now rarely diagnosed on clinical grounds primarily because of the serologic surveillance required by most states at the time pregnancy is diagnosed. This has eliminated much of the early fetal involvement which often manifested at birth. Even in the first year of life, less than 10 per cent of the cases are identified. The fact that organ pathology is not fully developed at birth emphasizes the necessity for early diagnosis and therapy.5 Both of these observations stress the need for the serologic diagnosis and early treatment of congenital infection with Treponema pallidurn. The cases reported here all focus on an important problem in the area of prenatal
270
Monif
September
et al. Am.
care, namely, the maternal acquisition of syphilis in the interim between initial serologic testing for syphilis and parturition. Confronted with a rising incidence of infection, a proportional increase can be anticipated in those in whom maternal infection will occur between the initial time of serologic surveillance and parturition. It may be that our experience is unique, and these cases may constitute isolated experiences and not real epidemiologic phenomena.
REFERENCES
1.
Fiumara,
2.
Sparling,
N.
Engl.
J. Med.
245:
634,
1951.
3. 4. 5. 6.
P. F.: N. Engl. J. Med. 284: 642, 1971. Woody, M. C., Sistrunk, W. G., and Platou, R. V.: J. Pediatr. 64: 63, 1964. Al-Salihi, F. L., Curran, J. P., and Shteir, 0. S.: J. Pediatr. 78: 121, 1971. Wilkinson, R. W., and Helles, R. M.: Pediatrics 47: 27, 1971. Saxoni, F., Lapatosanis, P., and Pantelakis, P.: Clin. Pediatr. 6: 687, 1967.
1.5, 19i3 Gynwd.
One fact which should not be overlooked is that these cases occurred in women who sought out prenatal care programs. In these instances, perinatal morbidity and mortality were not the ronsequence of a lack of good prenatal care. Serious thought should be given to screening mothers prior to or at parturition for evidence of infection with Treponema pallidurn until such time as the incidence of syphilis in the community is markedly reduced.
7.
N. J.:
J. Obstrt
8. 9. 10. 11.
Center for Disease Control: Summaries of reported cases of infectious syphilis. Morbidity and Morality Weekly Report, Vol. 20, No. 53, Atlanta, Georgia, The Center Annual Supplement, p. 66. Portnoy, J.: Am. J. Clin. Pathol. 40: 473, 1963. Reed, E. L.: Pub. Health Lab. 26: 123, 1968. Scotti, A. T., Logan, L., and Caldwell, J.: J. Pediatr. 73: 242, 1968. Alford, C. A., Pott, S. S., Cassady, G. E., Straumfjord, J. V., and Remington, J. S.: N. Engl. J. Med. 280: 1086, 1969.
R.
BYRON
R.
G.
MONIF,
WILLIAMS,
STANFORD
T.
HERMANN
M.D. JR.,
A.B
SHULMAN
BAER,
Gainesville,
during pregnancy
M.D.
Florida
Because of an initial case of congenital syphilis occurring in the ofspring of a gravida who acquired infection in the interim between initial treponemal serologic testing and parturition, 1,000 maternal delivery serum specimens from gravida whose interim between the initial VDRL and parturition exceeded 90 days were screened using the rapid plasma reagin (RPR) card test. The specificity of a positive microflocculation reaction was confirmed by the fluorescent Treponema antibody absorption (FTA-Abs) test. Two additional cases of maternal syphilis prior to parturition were documented. While these cases may constitute isolated experiences, serious thought should be given to the screening of mothers prior to or at parturition for evidence of infection with Treponema pallidum until such time as the incidence of syphilis in the community is markedly reduced.
AT ONE TIME, it could be stated that congenital syphilis was primarily a reflection of inadequate prenatal care.ly 2 The institution of compulsory serologic analysis during pregnancy as an integral part of comprehensive prenatal care programs has markedly altered the natural history of congenital syphilis.?-” The
previous
peak
incidence
and secondary syphilis occurred in 1965 when over 25,000 cases were reported.? After 1965, and until 1970, there had been a gradual decline in the number of reported cases of infectious syphilis. Since 1970 the increase in the number of cases being reported has been such: that the previous peak incidence has now been surpassed. The increasing prevalence of syphilis among all socioeconomic groups has put new pressures on those aspects of preventive medicine involved with maternal-infant care and questioned their current adequacy. The recent admission to our institution of a g-week-old infant with congenital syphilis whose mother’s initial serologic test for syphilis at 3 months of pregnancy was negative, focused on a critical problem in the area of perinatal care, namely, maternal acquisition of infection in the interim between serologic testing and parturition. Recognition of this occurrence prompted us to analyze 1,000 maternal delivery specimens of gravida for whom the interim between initial VDRL and
of primary
From the Section on Infectious Diseases, The Departments of Obstetrics and Gynecology, Pediatrics, and Microbiology, University of Florida College of Medicine. Supported in part by National Institutes of Health Grant No. HL-14266-01 and the Florida Heart Association. f;;$ved Revised Accepted
for publication March March
December
15,
12, 1973. 19, 1973.
Reprint requests: Gilles R. G. Monif, M.D., Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, Florida 32601. 268
Volume Number
i17 2
Maternal
Table I. Summary interim
between Duration at time logic
-l----
of patient data on cases of maternal syphilis initial serologic surveillance and parturition of gestation of initial serosurveillance
76 days
VDRL/FTA at parturition Not
Fetal
Pilot
case
available
Case
1
117
days
VDRL
1:32/FTA
+ 4
Case
2
157 days
VDRL
1: 1 G/FTA
+ 4
parturition exceeded 90 days for possible fection with Treponema pallidurn. Material
and
in-
occurring
07
neonatal
syphilis
269
in the
outcome
Congenital syphilis : At age 9 weeks VDRL 1: 4, FTA + 4, long bone roentgenograms consistent with congenital syphilis-one week after initiation of penicillin therapy VDRL 1: 128 Fetal death in utero one week prior to parturition Congenital syphilis: IgM-FTA + 2 (cord)
the FTA-Abs test using an anti-human IgM conjugate developed by Scotti, Logan, and Caldwell and Alford and associates.lO, I1
methods
As of Sept. 1, 1969, every woman attending the prenatal facilities within a 13 county area for which the Department of Obstetrics and Gynecology has prime patient care responsibility, has had serum specimens registered within the serum bank of the Section of Infectious Diseases. Maternal and cord blood are obtained at the time of parturition on any gravida delivering at the Shands Teaching Hospital. This is a demographically stable, low socioeconomic, semirural population. One thousand gestations were identified in the se:rum bank population in which the interim between the initial VDRL and parturition exceeded 90 days. The maternal registration and delivery specimens were screented with the rapid plasma reagin sera from (RPR) card test. $,,y All maternal gravida who developed a positive microflocculation reaction in the delivery specimen were analyzed for specificity utilizing the fluorescent Treponema antibody absorption (FTA.-Abs) test. A VDRL test was done to obtain quantitative measurement of the degree of reactivity. The cord sera from the progeny of such serologically positive mothers were evaluated for evidence of stimulation of the immune process in utero. Documentation of fetal involvement was contingent upon the demonstration of specific IgM antibodies utilizing
Results
The results are summarized in Table I. Two cases of maternal syphilis occurred in the interim between initial serologic testing for syphilis and parturition. Because of its ease of performance and rapidity, low unit cost and sensitivity, the RPR card test was an ideal choice of a test to deal with large numbers of sera as would be engendered by an obstetric population on a daily basis. The major drawback in our hands has been its increased sensitivity over the VDRL and the resultant increased number of biologically false positive reactions. Comment
Congenital syphilis is now rarely diagnosed on clinical grounds primarily because of the serologic surveillance required by most states at the time pregnancy is diagnosed. This has eliminated much of the early fetal involvement which often manifested at birth. Even in the first year of life, less than 10 per cent of the cases are identified. The fact that organ pathology is not fully developed at birth emphasizes the necessity for early diagnosis and therapy.5 Both of these observations stress the need for the serologic diagnosis and early treatment of congenital infection with Treponema pallidurn. The cases reported here all focus on an important problem in the area of prenatal
270
Monif
September
et al. Am.
care, namely, the maternal acquisition of syphilis in the interim between initial serologic testing for syphilis and parturition. Confronted with a rising incidence of infection, a proportional increase can be anticipated in those in whom maternal infection will occur between the initial time of serologic surveillance and parturition. It may be that our experience is unique, and these cases may constitute isolated experiences and not real epidemiologic phenomena.
REFERENCES
1.
Fiumara,
2.
Sparling,
N.
Engl.
J. Med.
245:
634,
1951.
3. 4. 5. 6.
P. F.: N. Engl. J. Med. 284: 642, 1971. Woody, M. C., Sistrunk, W. G., and Platou, R. V.: J. Pediatr. 64: 63, 1964. Al-Salihi, F. L., Curran, J. P., and Shteir, 0. S.: J. Pediatr. 78: 121, 1971. Wilkinson, R. W., and Helles, R. M.: Pediatrics 47: 27, 1971. Saxoni, F., Lapatosanis, P., and Pantelakis, P.: Clin. Pediatr. 6: 687, 1967.
1.5, 19i3 Gynwd.
One fact which should not be overlooked is that these cases occurred in women who sought out prenatal care programs. In these instances, perinatal morbidity and mortality were not the ronsequence of a lack of good prenatal care. Serious thought should be given to screening mothers prior to or at parturition for evidence of infection with Treponema pallidurn until such time as the incidence of syphilis in the community is markedly reduced.
7.
N. J.:
J. Obstrt
8. 9. 10. 11.
Center for Disease Control: Summaries of reported cases of infectious syphilis. Morbidity and Morality Weekly Report, Vol. 20, No. 53, Atlanta, Georgia, The Center Annual Supplement, p. 66. Portnoy, J.: Am. J. Clin. Pathol. 40: 473, 1963. Reed, E. L.: Pub. Health Lab. 26: 123, 1968. Scotti, A. T., Logan, L., and Caldwell, J.: J. Pediatr. 73: 242, 1968. Alford, C. A., Pott, S. S., Cassady, G. E., Straumfjord, J. V., and Remington, J. S.: N. Engl. J. Med. 280: 1086, 1969.