Primary Syphilis In the Third Trimester
- Describe the fetal symptoms that occur secondary to syphilis exposure during pregnancy.
- Identify the treatment options for syphilis during pregnancy.
- Associate the Jarisch-Herxheimer reaction with treatment during pregnancy.
Background:
Congenital syphilis is a devastating systemic infection that can cause permanent impairment, debilitation and disfigurement. Although the number of cases of syphilis is on the decline the number of cases of congenital syphilis increased 3.7% between 2005 and 2006. Two-thirds of neonates born to mothers with untreated syphilis have congenital syphilis and 45% will die shortly after birth.
Case:
C.B. is a 28 year-old G1 P0 at 30 weeks gestation with no significant medical, surgical, or obstetrical history. She arrived in triage complaining of abdominal pain. The patient reported flu-like symptoms "a few weeks" ago, which included fever, lethargy, headache and joint pain. Vital signs were BP 120/78, temperature 99.8°F, respirations 22,and heart rate 88. Cervical examination revealed 3/80/-1. Fetal monitoring showed normal baseline, moderate variability, and no periodic or episodic changes. Contraction frequency was every 2-3 minutes, duration 50-60 seconds and strength moderate by palpation.
Initial treatment included IV hydration, magnesium sulfate and betamethasone. Prenatal labs revealed blood type A+, HepBsAg negative, RPR negative, Rubella immune, and hemoglobin 11, hematocrit 32, and WBC 8,000. Fetal ultrasound revealed ventriculomegaly, hepatomegaly, and splenomegaly. Admission labs were remarkable for WBC 18,000 and RPR positive.
Conclusion:
The patient was diagnosed with early syphilis and treated with benzathine penicillin G 2.4 million units IM. Thirteen hours later the patient complained of fever, lethargy, tachycardia and hypotension. The fetal monitor showed tachycardia, late decelerations, and minimal variability. She also reported uterine contractions. The nurse recognized the Jarisch-Herxheimer reaction, which occurs in 45% of patients receiving treatment for primary syphilis. Hydration, increased magnesium sulfate dosage, and one dose of terbutaline 0.25mg subcutaneously were given. Despite treatment she delivered a preterm neonate at 30.2 weeks gestation by primary cesarean section. The neonate was transferred to the NICU in critical condition and despite intensive therapy the neonate died at 48 hours of age secondary to congenital syphilis.
Recognition of symptoms of early syphilis is essential for optimizing outcomes. The bedside nurse must be aware of treatment modalities and the possibility of a potentially serious reaction to treatment. These women are also at-risk for preterm labor and birth and continuous fetal monitoring in the hospital during treatment should be considered over outpatient therapy.
Keywords: primary early syphilis, Jarisch-Herxheimer, syphilis
