Screening for Syphilis Infection in Pregnancy: U.S. Preventive Services Task Force Reaffirmation Recommendation Statement Free

The USPSTF recommends that clinicians screen all pregnant women for syphilis infection. This is a grade A recommendation.

See the Figure for a summary of the recommendation and suggestions for clinical practice.

Table 1 describes the USPSTF grades, and Table 2 describes the USPSTF classification of levels of certainty about net benefit. Both are also available at http://www.annals.org.

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

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

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

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.

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

This recommendation applies to pregnant women.

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.

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 or Treponema pallidum particle agglutination (TPPA) test.

The Centers for Disease Control and Prevention (CDC) has outlined appropriate treatment of syphilis in pregnancy (http://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 (http://www.cdc.gov/std/treatment/) to obtain the most up-to-date information.

All pregnant women should be tested at their first prenatal visit. For women in high-risk groups, many organizations recommend repeated 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).

The USPSTF has made recommendations on screening for other sexually transmitted diseases in pregnancy, including gonorrhea, chlamydial infection, hepatitis B, herpes, and HIV. Please see the USPSTF Web site (http://www.preventiveservices.ahrq.gov) for more information on these recommendations. The CDC guidelines on treatment for syphilis in pregnancy can be Accessed at http://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 http://www.preventiveservices.ahrq.gov.

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend (3) 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 advise (3) using a nontreponemal screening test initially (RPR or VDRL), followed by a confirmatory treponemal antibody test. The CDC recommends (4) 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 serologic test result 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 recommends (5) that all pregnant women be screened for syphilis. It advises screening with serologic testing at the first prenatal visit, with repeated 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 (Colorado Department of Public Health and Environment, Denver, CO); Diana B. Petitti, MD, MPH, Vice-Chair (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, 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 (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, 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 http://www.ahrq.gov/clinic/uspstfab.htm.