sMater | Dr Jill Parkes-Smith | Syphilis in Pregnancy

On this episode of sMater, Brisbane Infectious Diseases and Obstetric Medicine Physician Dr Jill Parkes-Smith warns the medical community of the rise in syphilis cases and the impacts of the disease on pregnant women and babies.

Reported cases of syphilis in Queensland have increased nine-fold over the past two decades resulting in the death or stillbirth of 17 babies. (Syphilis outbreak in Queensland | Queensland Health).

Jill explains the risks of fetal infection in untreated pregnant mothers, and screening and treatment regimes for GPs.

GP Education activity log:
  Podcast title - sMater: Syphilis in Pregnancy
  Provider - Mater Misericordiae Ltd
  Date published - August 30, 2024
  Certificate of completion - click here

To learn more about Mater, visit https://www.mater.org.au/

Transcript

Hello and welcome to this episode of sMater. A podcast by clinicians for clinicians brought to you by Mater, an Australian leader in healthcare for more than a century. My name is Jillian Whiting and we're coming to you from Meanjin the land on which this podcast is being recorded. Hello I'm Maggie Robin, Community GP rural GP obstetrician at Beaudesert Hospital and coordinator of Mater's GP shared care education program.

In this episode we're talking about syphilis in pregnancy with Dr Jill Parkes-Smith. Jill is an infectious diseases specialist and obstetric Medicine physician at the Mater Mothers' Hospital and Ipswich Hospital. Jill is joining us to talk about the rise of syphilis in Queensland its impact in the perinatal period and what we can do about it in primary care.

We are Mater, We are Mater, We are Mater, This is sMater.

Welcome to sMater. It's wonderful to be here thank you. Now this is a really interesting topic because some would consider syphilis as a disease of a bygone era but we are seeing a resurgence in Australia it's relatively recent. So within the past 15 years what we've noticed is over a 600% increase in the number of cases of syphilis and this is a change that we're seeing reflected worldwide so if we were to look to the statistics in the United States or Canada even the United Kingdom similarly they are having difficulty with an outbreak of syphilis and so I think part of the difficulty is that many medical practitioners and people in general think that it is a historical disease and so the impetus to go get checked. The impetus 
then to act on a positive result has a lot of stigma and shame associated with it so that just you know compounds the complexity of managing this this difficult condition that really is very easy to treat once diagnosed.

And those figures are reflected across Queensland as well that rise? Yeah so I mean there are slight differences within each area but in southeast Queensland we're seeing a particular increase and there are pockets within our community that are having higher numbers and these are people that often have some social economic disadvantage some barriers to healthcare so it's reflected in our indigenous Australian population and our Torres Straight Islander population as well as our people that are having some difficulty with substance use and just in general people that are presenting late in their pregnancy for care so that's some of the difficulties. We're also seeing an increase in the non-indigenous community in some remote and regional areas and so also a barrier there to accessing perhaps sexual health checks and care in general so those are the general numbers and the populations that we're seeing trouble in the Indigenous population is really that age group that are having children 15 to 34 for so that's why it's so important to reduce the risk of transmission in pregnancy that those age groups are screened. Why are we seeing this increase? So I think that there's lots of different hypothesized reasons why we might be seeing this increase and some of those

ideas relate to whether there was an interruption in Sexual Health Care during the COVID epidemic but I think if you look at the numbers it was increasing well before that and you'd note that we've been offering you know preventative measures for you know an oral tablet to prevent the acquisition of HIV in non-infected individuals and perhaps with that condom use may have fallen off a little bit also perhaps we're seeing some people that are having financial difficulties not accessing Medical Care and then I guess there's some theories that maybe there's more gender fluidity and some transmission from the MSM community across into the 
traditionally heterosexual community but really it's all just theories yeah but I think really social disadvantage is probably the big thing and that we're just not reaching those people and getting them tested.

Jill, what challenges are there in diagnosing syphilis given that its clinical presentation can be so variable and sometimes it's also asymptomatic? It's really, really hard because when people think of a sexual health screen patients aren't necessarily requesting a syphilis screen and so it really comes down to the clinician the Chancre that initially presents can be painless and then it can pass through what could seem like a viral like illness and they may or may not seek medical care and it can be quite non-specific so I think that that's part of the difficulty is really that wide range of atypical presentations that can happen.

Can you go through the stages a refresher of the stages from primary secondary and so on?

Yeah so in the first stage when a patient may present they could have a painless Chancre which is a shallow ulcer that presents on the skin surface where they were infected so that could be inside the vaginal vault, could be on the cervix 
or in the male patient on the penis and so I think that that's part of the difficulty is that you know it can be painless and maybe not visible to the patient in terms of the secondary stage it often presents with a rash that can be head to toe and it also involves the palms and soles of the feet and that can have a febrile 
like illness with that then you go on to the other stages really tertiary syphilis and you can have neurological syphilis at any stage in the disease so that can actually happen very early on so it is quite important to do a neurologic a basic neurological exam eyes and ears in that first instance because I think we classically thinks that neurological syphilis is quite far down the path pathway and it can be but it actually in about 5% of people can be quite early and it's really important that we treat those patients differently and that we're on to to those things and of what sort of signs would we see just in a neurological exam in I think that for some of them it could just be for the patient might report that they've had visual disturbances. And then we tend to do a cranial nerve exam looking for kind of any pses in that and then any kind of hearing deficit I I'm a physician too so I don't go into the to the nitty-gritty but if a patient reported to me that they had hearing loss then I would, in a in a young person, that had no other reason for it I'd be speaking to my infectious diseases team about whether that patient needed a lumber puncture and a CSF examination because really if we miss that that treatment is different and so that's why it matters that we actually find that difference so that we can treat them appropriately for that and then tertiary syphilis of course is far down the line and it can have many different manifestations cardiac disease but for the most part most of our patients that will be talking as that we'll be seeing in the pregnancy cohort a younger screening is critical and ideally it starts before pregnancy.

Given the rates of syphilis, should GPs be thinking about blanket testing for women and their Partners who are considering starting a family? I think it's you know a really good idea that in the context of sexual health screening which you a sexually active young person that we would be considering doing that yearly.

For most of our patients I think that would be a reasonable consideration depending on the patient's individual circumstances but certainly if I was doing an a preconception workout for a patient where I'm looking at their iron studies and their full blood count I would also include syphilis screening in that because it's a lot easier to just treat a patient before they conceive without all the anxiety and distress that it causes when we do have to make that diagnosis in pregnancy if screening detects latent syphilis before someone Falls pregnant and they've told you that they're planning a pregnancy what would the treatment be yeah so the treatment depends um and it's quite simple in the sense that if we have a negative result within 2 years for that individual patient then they only need a single dose of benzine penicillin and really important that it is benzine penicillin one injection and each buttock and that's the treatment that 
patient would require however if we have a patient that has positive syphilisology at this point and we have never done syphilis screening or it's greater than 2 years ago we have to give them three doses so each week for 3 weeks and ideally at the 7-Day mark, if it is one day before or one day later that's okay but anything beyond that we have to start that 3 week course again and it is you know an injection in each buttock which is quite painful for the patient.

A treatment of syphilis with Benzathine Penicillin is this something reasonable for GPs to do in a primary care setting?

I think that it is reasonable for some general practitioners that are comfortable giving the Benzathine Penicillin. I guess it depends on a few things. Firstly access can be problematic. There has been a shortage of Benzathine Penicillin and so for some general practitioners that's been problematic for them I guess then the other thing is how pregnant the patient is and whether they would require monitoring. I also think that I wouldn't necessarily delay treatment but it would be very reasonable to seek help from your local hospital infectious diseases service or sexual health because getting that stage of disease right is fundamental whether it really is latent or early syphilis and having that distinction because it really changes how many doses the patient requires and so often they'll need to be seen by ID or sexual health anyhow if they're pregnant.

And what do we do about penicillin allergy?

So with regards to penicillin allergy about you know there's reported 10% of patients that say that they have a penicillin allergy and studies have shown that approximately 90% of those patients don't actually have a true allergy and then in terms of anaphylaxis it really is a subset of that subset so it's actually not that prevalent so I think in the first instance you could refer them.  I wouldn't expect a general practitioner in the community to give a penicillin allergic patient a penicillin but referring them to the infectious diseases team to do an antibiotic history and then to decide whether it's appropriate because penicillin is the only medication that is recommended in pregnancy for the treatment of syphilis. Of course outside of pregnancy we have other options for treatment.

What are those options?

So we can give doxycycline
outside of pregnancy and once again coming back to those stages so it's important that if it's early syphilis so under two years 

so they've had a negative result within the past two years then we can just give them a 14-day course of 100 milligrams BD of doxycycline. If we don't have that negative result or it's greater than 2 years then we would need to treat them as a late latent and that would be for 20 days of 100 100 milligrams BD appreciating that if they have neurosyphilis that is different and that would be the distinction that is required. It's clearly better to have treatment as soon as possible and screening is critical to that when your patient is already pregnant can you go through that detailed screening schedule?

So the Queensland guideline for syphilis in pregnancy has what's been identified as universal risk which is what we do for all women that are pregnant and then there's another group which we call the high-risk group. I'll talk first about the universal screening which we should be doing on all women so really with those that first lot of antenatal bloods at under 10 weeks gestation when they first come to you to confirm their pregnancy that would be a great time to do the first syphilis results so under 10 weeks for that one and then we do a follow-up test for that woman again at the 26 to 28 week mark when you're doing your oral glucose tolerance test so it's good to batch it with that and then again at 36 weeks so three time points. So antenatal, 26 to 28 and again at 36 weeks are time screens for the universal screening. With regards to the high-risk group how we make that determination it can be a little bit tricky because sometimes it's helpful to have taken a sexual history there's not always time for that but some of the simple things that we can look out for is substance use or someone that identifies as indigenous Australian or Torres Strait Islander or if they're partner does there are some declared outbreak areas but you're safe to you know have increased screening within those groups and also someone that has a partner that has sex with men would also be in that high-risk group and someone that has had contact with a positive syphilis patient would also be considered high- risk and for that group we would do the universal screening but in addition to that we would do an opportunistic test at approximately 20 weeks and then we would check them at 34 weeks rather than necessarily the 36 week mark and then we check them again at birth. So that is it is quite extensive the screening that has been recommended in those high-risk groups.

If a woman contracts syphilis while she's pregnant will it always be passed on to the baby?

No so you know what the studies have shown is that if we detect it under 20 weeks the risk of having congenital syphilis so that's when we talk about the baby having some abnormalities that are as a result of syphilis infection that risk really increases with the gestation so it's really important that we pick it up sooner and if we treat the woman quite early then the likelihood that will reduce the risk of an adverse pregnancy outcome is significantly increased and so what we get worried about is that syphilis increases the risk of pre-term birth stillbirth and also the abnormality that can be seen with congenital syphilis but treatment really significantly reduces those risks and so that's why treatment early is key.

Jill, can you tell us a bit more about the impacts of syphilis on the fetus and the neonate and how we treat congenital syphilis? Yeah absolutely. So look the impacts on the fetus really depend on when the infection is acquired in utero so if it's acquired after 20 weeks then what we might see is they can have differences from problems with their liver problems with their neurological system and then we can see more subtle things where they could have some bone changes which we might not even notice initially at the time of delivery in terms of treating the neonate. I'm not a pediatric physician but basically it depends on whether they're what their results are at birth and so and if there's a clinical suspicion if there is a clinical suspicion and that would really be depending on the mother's results and a few other factors. That baby would need intravenous therapy for 10 days with Penicillin and so that means a prolonged hospital stay, a canula and that can be quite you know concerning for the parents so it's better if we can treat the mother in utero and that treatment needs to have been completed 4 weeks prior to the mother delivering for us to consider that sufficient and we need to see a fall in that RPR by fourfold.

And what kind of clinical features would we expect to see in an infant that's affected by congenital syphilis?

We might see nothing in the neonate and that's what the difficulty is that it can be quite subtle and the changes could occur you know up to 2 years after they're born that we might see some changes so the things that we might see in the initial period could be a rash or skin scaling.

We could also see enlargement of the liver or spleen and then they could go on through to having neurological difficulties often unfortunately we will have a neonatal death or we could have a stillbirth and so that's sometimes the outcome of congenitally transmitted syphilis. 

Between 2001 and 2022, 44 congenital syphilis cases were notified in Queensland with 13 stillborn or dying after birth all first nation's infants. Last year alone Queensland Health recorded 5 cases of babies contracting syphilis in-utero, 4 of them died. It's the greatest number of Queensland deaths from congenital syphilis in a single year this century. 
Very concerning obviously the spike in syphilis and the potential risks that it holds. Why haven't we been able to eradicate syphilis?

I think there's a lot of stigma associated with sexually transmitted infections and that remains problematic in our community and also I think access to medication and to testing particularly in some of the remote and rural areas that can be problematic and then in some of our community members that don't have regular health care so I think it's that you know all that lack of ability to test and then the treatment is an injection and that can also be problematic. I think that we really also have like dropped the ball somewhat thinking that it was a condition that is historical and now we're really having to restart.

How about reinfection, Jill? Is that something that we need to think about in pregnant patients who we may have already treated?

Absolutely and this is part of the problem that we need not only our patient that we're seeing face to face to be treated but we also need their partner to be treated and depending on how long ago it was that they acquired the infection which can be quite difficult to ascertain we need to contact trace back some time so we need to find their sexual partners there are some apps and sorry web platforms that can notify patients anonymously of the fact that the patient has been diagnosed with syphilis and they can do that anonymously so it's that contact tracing that is key because reinfection can happen again and again and again there is no immunity and so the same patient that we're seeing and treating for syphilis we need to follow their serology and so in pregnancy we would be doing that as per the high-risk protocol and making sure that we see that fall because if we don't more often than not it's not that the antibiotics didn't work it is that they've been reinfected and so that's important in your pregnant patients but it's also important in your non- pregnant patients because chances are they could have contact with someone that could be of childbearing um years but also it has implications outside of pregnancy in terms of you know costs and morbidity and so it is important in the pregnant cohort but also in the non pregnant cohort that we test retest and call a friend if we're not sure then phone a friend because interpreting RPRs and syphilis serology no one likes doing it apart from ID Physicians. We like it but no one likes doing it so you can phone a friend or you can call the Queensland syphilis surveillance service and they have a 18 100 number and they're a great source of reference in terms of where the patients have been tested in the past whether they've been treated in the past and they can give you that full history and then you can submit your data on what you've done for that patient and complete that picture for them. They're a wonderful service so the Queensland syphilis surveillance service do they get their data from the public health notifications when syphilis is diagnosed yeah they do and then they rely on the clinicians filling out a form as to what treatment the patients have received and they keep that on a database and then it allows them in the future to give that information back to the next clinician trying to interpret that syphilis serology again in the future determining whether it is a new infection or it's a previously old infection and we can use that to interpret.
Jill, do you think we can turn around these numbers and what if we don't?

So I think that there is hope but if we don't I dread to think of how many cases of congenital syphilis we are going to see in Queensland with the five cases of congenital syphilis in the past year with multiple deaths from that that is more than I want to see in my lifetime um and I think that in you know practitioners gone by they wouldn't have seen one and I'm a pretty young practitioner and I've seen more than those practitioners and I think that's really significantly concerning and so I think this is the time to act as now.

It is concerning and thank you so much for joining us today to share your knowledge on sMater. Before you go though we have a little segment we'd like to introduce you to and it's called The Checkup so Maggie is going to ask you 5 quick questions and this is just about getting to know Jill as a medical professional and as a person as well. Are you ready? I am. Jill where were you born and where did you grow up? I'm a complicated one. You can probably hear from my mixed of accents I was born in the United States and I grew up in the Philippines and then I moved to Sydney and then I married a Queenslander so here I am.

Do you listen to podcasts and if so what are your favorites? I'm pretty nerdy and I listen to a podcast called This Podcast Will Kill You.

It's all about infectious diseases that can kill you they also go through a variety of other medical conditions but it's done by two fantastic female presenters that kind of go through the nitty-gritty of bugs and then I otherwise just like to listen to scamfluences. Excellent. Tell

me about your first pet?

Oh I had a cat that was golden in colored called champagne and a boxer called Sally as a child and I used to dress them both up as little dolls and push them around in a pram.

Would you have a single piece of advice that you would impart to a medical student?

Two things: first do what you're passionate about whatever that is in medicine and then secondly remember that along your journey you need to be kind and considerate and make good contacts because you never know when you'll need that information from another specialist or a colleague and if you've been kind it will more likely mean you'll get the information and that can achieve a better outcome for your patient.

And finally what is the best outfit that you've ever worn to a costume party?

I recently went to a costume party and my husband went in Baywatch. No one else dressed up he hasn't forgiven me yet and I went as Sarah Connor from the Terminator and we got in the Uber and the lady asked me if I had a gun and I had to reassure her that it was an empty holster and that I was not hostile. Excellent. Perfect, I love it. Thank you Jill so much again 
for joining us on sMater. Thank you very much for having me. For our listeners at home or in the car or having a well-deserved break between patients, thanks for tuning in. See you next time on sMater.