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Congenital syphilis cases increase due to missed opportunities to treat pregnant women

January 1, 2021

Congenital syphilis is infection with Treponema pallidum in a fetus or neonate acquired from the mother during pregnancy. Poor birth outcomes such as miscarriage, stillbirth or early neonatal death as well as lifelong morbidity due to physical and neurologic impact can result from congenital syphilis.

The number of congenital syphilis cases rose by 261% from 2013-’18, despite the fact that it can be prevented with adequate penicillin-based treatment regimens targeted to the stage of maternal syphilis and initiated at least 30 days prior to delivery. Rates of primary and secondary syphilis among women of child-bearing age doubled from 2014-’18, in line with the rise in congenital syphilis cases.

Opportunities to prevent congenital syphilis include timely diagnosis and treatment of syphilis in women of child-bearing age and access to prenatal care.

Researchers from the Centers for Disease Control and Prevention identified missed opportunities to prevent congenital syphilis in 2018 using case report data from the National Notifiable Disease Surveillance System from all 50 states and the District of Columbia. Each case was put into one of four mutually exclusive categories of missed opportunities.


The percent of missed opportunities for prevention of congenital syphilis by category were as follows:

  • lack of adequate maternal treatment despite the timely diagnosis of syphilis during pregnancy (30.7%),
  • lack of timely prenatal care and syphilis testing (28.2%),
  • late identification of seroconversion during pregnancy (11.2%), and
  • lack of syphilis testing despite receipt of timely prenatal care (8.9%).

The remainder of cases did not fall into one of the four categories. Nearly 4% of congenital syphilis cases occurred despite maternal treatment completion, and 17.5% of cases had insufficient information.

Missed prevention opportunities varied by race/ethnicity in the highest morbidity regions in the South and West (see figure).

Additionally, demographic and clinical characteristics of infants with congenital syphilis and their mothers varied. Most cases of congenital syphilis occurred in the southern U.S. (52.5%) and the western U.S. (35.6%).

Other common demographic and clinical factors associated with congenital syphilis included:

  • race/ethnicity of the mother (39.1% non-Hispanic black, 31.5% Hispanic, 21.9% non-Hispanic white),
  • maternal stage of syphilis (unknown duration or late, 50.8%; early non-primary non-secondary, 30.6%) and
  • infant outcomes (live-born with no documented signs or symptoms of congenital syphilis, 60.3%; live-born with signs or symptoms of congenital syphilis, 33.2%; stillborn, 6%).


These results suggest that ensuring adequate maternal treatment of syphilis during pregnancy represents a high-yield intervention to decrease rates of congenital syphilis. Lack of adequate maternal treatment despite the timely diagnosis of syphilis during pregnancy was the most common missed opportunity nationally and was especially prominent in distinct geographic regions, including the South.

While timely access to prenatal care and diagnosis of syphilis during pregnancy represent additional areas to target, the heterogeneity in missed prevention opportunities by geographic region and race/ethnicity suggest different populations may benefit from distinct preventive measures. In addition, social vulnerabilities likely contribute to missed prevention opportunities and should be considered when designing targeted interventions.

The results of this study should be taken into consideration when designing prevention efforts, and key clinical and public health stakeholders across the health sector should be involved.


Which of these areas offer opportunity for targeted interventions to decrease rates of congenital syphilis in the United States?

A) Improve women’s access to prenatal care.

B) Ensure timely diagnosis of syphilis among pregnant women.

C)  Treat maternal syphilis with appropriate penicillin-based regimens.

D)  Ensure appropriate treatment for maternal syphilis occurs 30 or more days prior to delivery.

E)  All of the above

Answer: E

Dr. Quincer is a post-residency training fellow in pediatric infectious diseases at Emory University School of Medicine and Children’s Healthcare of Atlanta (CHOA). Dr. Pickering is adjunct professor of pediatrics at Emory University School of Medicine and CHOA.

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