Guidance

Managing syphilis infection in pregnancy

Published 3 April 2023

Applies to England

The information below describes in detail the steps outlined in the flowchart above for managing syphilis infection in pregnancy.

This guideline applies to anyone with a confirmed syphilis screen positive result during pregnancy. Whilst we use the words woman and women throughout the guideline, this information and advice applies equally to trans men and non-binary people who may be pregnant and also diagnosed with syphilis.

1. Laboratory informs the antenatal screening team of a confirmed screen positive syphilis result

There must be a locally agreed process in place to ensure the screening laboratory informs the screening team of all confirmed screen positive syphilis results. The screening team must acknowledge receipt of this notification.

1.1 Urgent screening results

Urgent screening results are results from tests on those presenting labour, where labour is imminent, or for those who have recently given birth. This includes those who are either unbooked or where there is no evidence of screening results from a UKAS accredited laboratory.

See the IDPS programme and laboratory handbooks for guidance on urgent screening and communication of confirmed and unconfirmed positive syphilis results.

2. Screening team informs the woman of the result, makes a referral to sexual health services (SHS) and adds details to the Maternity Infectious Diseases Multidisciplinary Team (MID MDT) caseload

Antenatal screening teams must inform women of their confirmed screen positive result in equal to or less than 5 working days of receipt of the result from the laboratory. The screening team should then refer every woman to SHS and add her details to the MID MDT caseload.

2.1 Give result

A face-to-face appointment must be offered, or appointments can be virtual if that is the woman’s choice and it meets her individual needs. Interpretation services should be provided if required. People who have a disability, impairment or sensory loss should be provided with information they can easily read or understand in line with the Accessible Information Standard.

Discussion between the screening team member and the woman should include:

• up to date information about syphilis infection in pregnancy using the IDPS ‘Syphilis: explaining the screening result’ resource which is available in English and 12 other languages
• an easy guide to syphilis screening and management in pregnancy if required
• the need for referral to sexual health services (SHS) for assessment and possible treatment
• asking for any relevant information to aid referral, for example the timing and location of any past treatment
• explanation that testing of partner(s)/sexual contact(s) may be required

2.2 Refer to SHS

All women with a confirmed screen positive result must be assessed by SHS. The screening team must refer anyone with a confirmed screen positive syphilis result to SHS for assessment regardless of any past results or treatment. It’s not the responsibility of screening teams to make an assessment about the requirement for treatment. Locally agreed pathways for referral from maternity services must ensure:

• referrals are made promptly to enable timely assessment
• SHS confirm receipt of referrals

SHS should be encouraged to provide a named link clinician for maternity referrals to aid referral and ongoing management.

2.3 Add details to MID MDT caseload

The screening team must add all women with a confirmed positive syphilis result to the MID MDT caseload to enable them to be managed collaboratively.

Where the prevalence of syphilis is low, and it may not be feasible to hold regular face-to-face MDT meetings, other options to consider include:

• virtual meetings
• merging with existing forums, such as HIV or neonatal MDTs within which members will have well established working relationships
• creating joint or regional MDTs with other providers, enabling shared expertise and support

Regardless of the number of cases, each referral should be discussed and managed collaboratively to ensure the provision of high quality, personalised care.

3. SHS carry out assessment in less than or equal to 10 working days of receipt of referral from screening team

SHS assessment should take place as early as possible and in less than or equal to 10 working days of receipt of the referral from the screening team.

Assessment will include a review of the blood results and any relevant clinical history or documented evidence of past treatment. The woman may require an appointment, either face-to-face or virtually. This will be determined by SHS, based on individual history, and the woman’s needs and choice.

The outcome of the SHS assessment should be documented using the British Association for Sexual Health and HIV (BASHH) syphilis birth plan or local equivalent. A birth plan should be completed for all women including those who do not require treatment in this pregnancy.

The screening team must request an urgent assessment of those who book after 20 weeks gestation due to the increased risk of premature delivery in women who screen positive for syphilis.

4. Has SHS completed the assessment?

Yes: There must be a process in place to ensure the screening team are informed by SHS that the assessment has taken place and the outcome of the assessment.

No: The screening team must contact SHS to follow up the referral. Where a woman does not attend (DNAs) a scheduled face-to-face appointment, or cannot be reached by telephone, this should be managed collaboratively by the screening team and SHS in line with local maternity provider and SHS DNA guidelines. Ongoing failure to engage someone should be discussed with the MID MDT to agree a plan.

Where a woman is admitted in labour before a SHS assessment/treatment has been completed, SHS must be contacted urgently to inform them of the admission and to request a review.

5. Is treatment for syphilis required during pregnancy?

Treatment not required: SHS should complete the British Association for Sexual Health and HIV (BASHH) syphilis birth plan or local equivalent and send a copy to the antenatal screening team without delay following assessment to inform them that no further action is necessary.

After sending the birth plan the woman will be discharged by SHS.

It is the responsibility of screening teams to make birth plans available to obstetric and neonatal teams on delivery suite/IT system as per local arrangement as soon as they receive them from SHS. The birth plan informs colleagues that despite a confirmed positive syphilis result on the IT system, the woman has been assessed, maternal treatment was not required and the infant does not require follow-up at birth.

The screening team must complete notification(s) to the Integrated Screening Outcomes Surveillance Service (ISOSS).

Treatment required: If treatment is required, please see the following step.

6. SHS informs screening team and screening team adds neonatal alert

An agreed process must be in place to ensure SHS inform the screening team of their plan to give treatment.

Where treatment for the woman is required, the infant(s) will require a review following delivery. A neonatal alert must be put in place by the screening team (electronic or paper as per local arrangement) to make sure the neonatal team are aware of the woman’s admission to the delivery suite.

The screening team must complete notification(s) to the Integrated Screening Outcomes Surveillance Service (ISOSS).

7. SHS sends birth plan for screening team to circulate when treatment is complete

When treatment is complete SHS should complete the BASHH syphilis birth plan or local equivalent, detailing maternal treatment and follow-up needs of the infant. A copy should be sent to the screening team who are responsible for its circulation and to make sure it is available at delivery to obstetric and neonatal teams.

8. Screening team completes Syphilis Management Checklist

The syphilis management check list is to ensure all necessary actions have been undertaken and contact has been made with women to discuss follow up for their baby. The checklist should be completed on completion of treatment and no later than 28 weeks gestation.

For those diagnosed after 28 weeks of pregnancy, the checklist should be undertaken as soon as treatment is complete.

9. Has treatment and follow-up by SHS been completed?

No: The screening team must refer the woman back to SHS urgently for treatment. When SHS confirm that treatment is complete, the screening team must circulate the birth plan and ensure it is available at delivery to obstetric and neonatal teams.

Yes: The screening team must contact the woman to discuss what to expect following delivery including infant examination, serology and outpatient follow-up.

There should also be a discussion to identify any risk factors for reinfection. The main risk factor is where the woman’s partner is untreated, partially treated or has been lost to follow-up.

10. Is there a risk of reinfection?

Yes: The screening team must refer the woman back to SHS urgently for assessment.

The SHS should confirm if further treatment was required and update the birth plan if necessary. The screening team must then circulate the birth plan and ensure it is available at delivery to obstetric and neonatal teams.

No: No further action is required.

11. Neonatal team reviews infant following delivery

All infants born to women who required treatment for syphilis in pregnancy must have a neonatal review following delivery for a physical examination and syphilis serology. The neonatal team should then arrange an outpatient follow-up appointment at 3 months of age before the mother and infant are discharged home. See BASHH guidelines for further guidance.

The screening team must complete the ISOSS outcome notification(s).

12. Further resources

Detailed information about syphilis infection in pregnancy and its management can be found in the NHS IDPS eLearning resource.

IDPS ‘Syphilis: explaining the screening result resource for women’.

Infectious diseases in pregnancy screening: ISOSS syphilis report 2022 - Report showing the outcomes for the NHS Infectious Diseases in Pregnancy Screening (IDPS) programme for women who screen positive for syphilis and vertical transmissions.

Clinical guidance for healthcare professionals providing the NHS infectious diseases in pregnancy screening (IDPS) programme can be found here.