The USPSTF reaffirms its recommendation for screening of all pregnant women for syphilis

The US Preventive Services Task Force (USPSTF) today reaffirmed its 2009 recommendation for early screening of all pregnant women for syphilis following a massive surge of cases of congenital syphilis. The statement was published September 4 in the JAMA with an accompanying editorial in JAMA Dermatology.

The newest guidance is a class ‘A’ recommendation which means that there exists substantial evidence in favor of the benefits of early screening for mother and fetus. 

Vertical transmission of syphilis can occur any time and at any stage during pregnancy, and congenital syphilis is associated with adverse outcomes such as preterm birth, low birth weight, stillbirth, congenital anomalies, active syphilis in the newborn (NB) and long-term health sequelae such bone deformities and neurologic impairment.

In the US, the incidence of congenital syphilis has increased by nearly 87% between 2012 to 2016, after a steady decline during the previous 4 years.  The rise coincides with rising national rates of syphilis among women of reproductive age – from 0.9 cases of primary and secondary syphilis infection per 100,000 women in 2012 to 1.9 cases in 2016.

The USPSTF recommends that all pregnant women should be screened for syphilis as early as possible when they present at the healthcare provider’s office. If a woman presents directly in labor and has not received any testing earlier, she should be immediately tested.

The screening test for syphilis is a two-step process– initially a “nontreponemal” antibody test (i.e., Venereal Disease Research Laboratory test or rapid plasma reagin [RPR] test) is done to detect biomarkers released from damage caused by syphilis infection, followed by a confirmatory “treponemal” antibody detection test (i.e., fluorescent treponemal antibody absorption or T pallidum particle agglutination test).

A newer alternative is a reverse sequence screening algorithm that involves an automated treponemal test (such as an enzyme-linked, chemiluminescence, or multiplex flow immunoassay first, followed by a nontreponemal test.

The CDC has recommended parenteral benzathine penicillin G for the treatment of syphilis in pregnant women. Evidence in favor of the safety of alternative treatment is limited; therefore, women who present with an allergy to penicillin should be evaluated and desensitized first and treated with the drug.

One way to decrease the incidence of congenital syphilis is to bring down the rates of primary and secondary syphilis infection among all women. Lower rates of syphilis in women prevent the sexual transmission and subsequent vertical transmission of congenital syphilis. Hence, the USPSTF recommends screening for syphilis in nonpregnant adolescents and adults at increased risk for infection.

The current recommendations are in accordance with those issued by other professional organizations. The CDC recommends screening for syphilis infection in all pregnant women at their first contact with the provider. The CDC, AAP, and ACOG also recommend repeat screening at 28 weeks of gestation and again at delivery in women who are at high risk for syphilis infection.

High-risk women include those with HIV or a history of incarceration or commercial sex worker. ACOG and AAP also recommend repeat screening after encountering an infected partner.

JAMA Full article

JAMA Dermatology editorial

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Migraine linked to increase in pregnancy, labor and neonatal complications!

The occurrence and frequency of migraine attacks in women is influenced by hormonal changes throughout the lifecycle. More than 50% of women report an improvement in attacks, especially during the second and third trimester irrespective of the type of migraine.

If migraines do occur, they do so most often during the first three months of pregnancy due to the rise in estrogen level. The other triggers for attacks in pregnancy are possibly from lack of sleep, additional stresses, or other headache causes.

Women who have migraine during pregnancy end up having higher rates of preeclampsia, preterm delivery, and low-birthweight babies that far exceed national statistics, a new study suggests.  In Women older than 35years of age, it is an independent risk factor for adverse pregnancy outcome.

The study was presented on April 17, 2016 at the American Academy of Neurology (AAN) 68th Annual Meeting in Vancouver, Canada.

"Over half the patients experienced some type of adverse birth outcome, which suggests that pregnancies in such patients should be considered high risk, especially in older women," said lead author Matthew S. Robbins, MD, associate professor, clinical neurology, Albert Einstein College of Medicine, chief of neurology, Jack D. Weiler Hospital, Montefiore Medical Center, and director of inpatient services, Montefiore Headache Center, Bronx, New York.

Researchers at Montefiore Medical Center reviewed 5 years of data between July 1, 2009, to June 30, 2014 and identified 90 women, who had severe attack during pregnancy.

The findings included:

• About 38.8% of women were African American, 76.7% were obese with body mass index of 30 kg/m² or more and a third of the group (30%) was nulliparous.
• More than half of these women (54 percent) had at least one complication.  
• About 30 percent of the women had a preterm delivery, as compared to nearly 10 percent in general population.
• About 20 percent of the women with migraine had preeclampsia, compared to between 5 and 8 percent in the general population.
• 19 percent of the women with migraine delivered babies with low birthweight, compared to 8 percent in the general population.
• Researchers do not know the cause for these increased incidences of co-morbidities, but is possibly linked to increased cardiovascular complications in these women, or changes in   the endothelium leading to preecclampsia.

Dr. Robbins caution against generalizing these findings to other population, as the study involved a small inner city population but does suggest a close follow up of women with migraine and treating them as high risk.

The study had many limitations, notable lack of control group of women who had migraine but did not report to physician for care. Also, Sixty-two percent of the women in the study received treatment for their migraine, which also could have played a part in the pregnancy and birth complications.

David J. Dickoff, MD, a general community neurologist in Yonkers, New York summed it well saying "The importance of the migraine study is to alert all doctors, especially obstetricians, that history of migraine headaches is a risk factor for pre-eclampsia," Dr Dickoff said. "These patients may need to be considered high risk and followed more closely for BP [blood pressure] elevations and proteinuria."

References :

http://www.prnewswire.com/news-releases/pregnant-women-with-severe-migraine-may-be-at-increased-risk-for-labor-and-delivery-complications-300230520.html

http://www.ncbi.nlm.nih.gov/pubmed/9825951