Congenital Syphilis - Medical Provider Resources

Increasing Cases

Congenital syphilis cases have increased dramatically in Washington and across the United States. Washington had 1 reported case of congenital syphilis in 2014. That has since risen to 81 reported cases in 2024. Congenital syphilis can cause extreme health impacts such as miscarriage, neonatal death, preterm delivery and long-term developmental problems. This increase in congenital syphilis is associated with a rise in rates of syphilis among heterosexual men and women, and subsequent increase in diagnoses during pregnancy. Congenital syphilis is preventable.

Prevention

While anyone who is sexually active can acquire a syphilis infection, there are interventions that can reduce the likelihood of congenital syphilis.

As detailed in a Health Advisory (PDF) from Public Health Seattle and King County (PHSKC) and the Washington Department of Health (WA DOH), health care providers should:

  • Treat all patients with signs or symptoms consistent with primary or secondary syphilis when they present to care. Do not delay treatment when syphilis is suspected.
  • Be aware of the signs and symptoms of primary and secondary syphilis.
  • Follow ACOG guidance on testing all pregnant people for syphilis during their first prenatal visit, with third trimester labs at 24-28 weeks gestation, and again at delivery.
  • Screen all pregnant people who present late for prenatal care, have fragmented care, or who lack a syphilis screening result during pregnancy.
  • Offer and discuss contraception with those of childbearing age who do not desire pregnancy and are diagnosed with syphilis.
  • Test sexually active persons experiencing homelessness or persons who use substances such as methamphetamine, non-prescription opiates, or cocaine when they present to care.
  • Follow MMR guidelines on treating people who report sexual exposure to someone with syphilis even in the absence of laboratory evidence, signs, or symptoms of infection.
  • Be familiar with current STI treatment guidelines for syphilis infection.
  • Understand and follow the syphilis testing algorithm that is available and used by your organization to guide which tests to order for patients.
  • Call your local health jurisdiction if you have any syphilis related questions or if you need assistance with ascertaining serologic history.
  • Report all cases of syphilis to your local health jurisdiction. Be aware that your local health jurisdiction will follow-up on congenital syphilis reporting. See STI Case Reports by County. 

Testing and Screening Guidelines

Syphilis Screening Guidelines (PDF)

Pregnant persons should be tested at the following times:

  • First prenatal care visit.
  • During the third trimester along with routine laboratory testing at 24-28 weeks gestation.
  • At delivery.
  • At any time within any clinical setting if not engaged in prenatal care.
  • Whenever a fetal demise occurs at ≥ 20 weeks of gestation.

All babies born to pregnant people with a reactive nontreponemal and treponemal test should be evaluated with a quantitative nontreponemal serologic test (RPR or VDRL). Pathologic examination of the placenta or umbilical cord using specific staining or a T. pallidum PCR test should be considered. Darkfield microscopic examination or PCR testing of suspicious lesions or bodily fluids should also be performed.

It is not recommended to conduct serologic testing on umbilical cord blood as it could contain maternal blood, which could yield a false positive result. It is not recommended to conduct a treponemal test (TP-PA, immunoassay-EIA, CIA, or microbead immunoassay) on neonatal serum as maternal antibodies could be transferred to the baby.

Treatment Guidelines

Congenital Syphilis Treatment Guidelines, CDC

All babies born to pregnant people with a reactive nontreponemal and treponemal test should be evaluated for congenital syphilis. Treatment and evaluation guidelines are based on:

  • Whether the pregnant person was adequately treated for their syphilis infection before delivery.
  • Comparing the baby’s serologic titer to the pregnant person’s serologic titer at delivery.
  • Abnormal physical evaluation consistent with congenital syphilis.
  • Positive darkfield test, PCR of placenta, cord, lesions or bodily fluids, or positive silver stain of the placenta or cord.

Four possible scenarios with evaluation and treatment guidelines are in the Congenital Syphilis Treatment Guidelines, CDC.

  • Scenario 1: Confirmed Proven or Highly Probable Congenital Syphilis
  • Scenario 2: Possible Congenital Syphilis
  • Scenario 3: Congenital Syphilis Less Likely
  • Scenario 4: Congenital Syphilis Unlikely

Treatment for congenital syphilis can look like:

  • Aqueous crystalline penicillin G 100,000-150,000 units/kg body weight/day, administered as 50,000 units/kg body weight/dose by IV every 12 hours during the first 7 days of life and every 8 hours thereafter for a total of 10 days.
    OR
  • Procaine penicillin G 50,000 units/kg body weight/dose IM in a single daily dose for 10 days.
    OR
  • Benzathine penicillin G 50,000 units/kg body weight/dose IM in a single dose.

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