Syphilis passed from mother to baby (congenital syphilis) is one of the leading preventable causes of stillbirth worldwide. WHO estimates hundreds of thousands of adverse birth outcomes each year are due to syphilis in pregnancy. Cases have been rising in many countries, including high-income ones such as the United States. Yet the solution is simple and cheap: test every pregnant woman early, and treat with penicillin. Nurses and midwives are central to making that happen.
What syphilis does in pregnancy
- Miscarriage and stillbirth.
- Preterm birth and low birth weight.
- Newborn death.
- Congenital syphilis in surviving babies: rash, enlarged liver and spleen, bone problems, anaemia, and later complications affecting eyes, ears, teeth and the nervous system.
Many women with syphilis have no symptoms, so screening is essential.
Screening
- WHO recommends that all pregnant women are tested at their first antenatal visit, ideally in the first trimester.
- Some countries recommend repeat testing in the third trimester and at delivery, especially in high-prevalence areas or for women at ongoing risk.
- Rapid point-of-care tests give results in minutes, so women can be treated the same day.
- Dual HIV/syphilis rapid tests are recommended by WHO as the first test in antenatal care, supporting the “triple elimination” of mother-to-child transmission of HIV, syphilis and hepatitis B.
- Rapid treponemal tests can stay positive after treatment, so history is important; a non-treponemal test (such as RPR) helps assess active infection where available.
Treatment
- Benzathine penicillin G by deep intramuscular injection is the treatment of choice and the only treatment proven to prevent congenital syphilis reliably.
- For early syphilis, a single dose of 2.4 million units is typical; for late latent or unknown duration, three doses at weekly intervals. Follow national guidelines.
- Treatment should ideally be given at least 30 days before delivery to protect the baby.
- Don’t delay treatment while waiting for confirmatory tests if a rapid test is positive and there’s no record of previous adequate treatment.
- Ask about penicillin allergy. Many reported allergies aren’t true allergies; desensitisation may be needed for genuinely allergic pregnant women, because alternatives are less effective in preventing congenital infection.
- Warn about the Jarisch-Herxheimer reaction: fever, headache and muscle aches within 24 hours. In pregnancy, it can trigger contractions or fetal distress; advise her to return if she feels contractions or reduced fetal movement.
Partner notification
Reinfection from an untreated partner is common. Encourage and support partner testing and treatment, offer partner notification slips or assisted notification, and advise condom use until both are treated. Approach sensitively: disclosure can raise fears of blame or violence.
The newborn
- Babies born to mothers with syphilis need assessment, especially if the mother was untreated, inadequately treated, or treated less than 30 days before birth.
- Follow national protocols for testing and treating the baby (often with penicillin).
- Arrange follow-up.
Barriers nurses can address
- Late antenatal booking: encourage early attendance.
- Test kit and penicillin stockouts: report and escalate. Global shortages of benzathine penicillin have occurred.
- Stigma: present testing as routine for everyone.
- Missed follow-up doses: use reminders and track women.
Related: HIV care and adherence · Hepatitis B birth dose · Premarital health checks
Based on WHO guidelines on syphilis screening and treatment for pregnant women, WHO antenatal care recommendations, and WHO guidance on triple elimination. Educational content: follow national guidelines.