A 22-year-old primigravid woman at 8 weeks gestation comes to the office for her initial prenatal visit. She has no symptoms except mild nausea. She smoked a pack of cigarettes a day and drank 7-8 beers each week but quit after learning she was pregnant. The patient has a history of an allergic reaction to penicillin; she developed a generalized rash with intense itching that responded to antihistamines and corticosteroid cream. Vital signs are within normal limits. Physical examination shows no abnormalities. The screening VDRL test is positive, as is the confirmatory fluorescent treponemal antibody absorption test. Her HIV test is negative. Which of the following is the best next step in management of this patient?

Question

A 22-year-old primigravid woman at 8 weeks gestation comes to the office for her initial prenatal visit.  She has no symptoms except mild nausea.  She smoked a pack of cigarettes a day and drank 7-8 beers each week but quit after learning she was pregnant.  The patient has a history of an allergic reaction to penicillin; she developed a generalized rash with intense itching that responded to antihistamines and corticosteroid cream.  Vital signs are within normal limits.  Physical examination shows no abnormalities.  The screening VDRL test is positive, as is the confirmatory fluorescent treponemal antibody absorption test.  Her HIV test is negative.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Treponema pallidum readily crosses the placenta and is associated with many adverse fetal outcomes, including intrauterine growth restriction, fetal death, and congenital infection. All pregnant women should be screened for syphilis at their first prenatal visit as treatment effectively reduces fetal risk. Screening may be done with either a nontreponemal test (eg, VDRL) or treponemal-specific test (eg, fluorescent treponemal antibody absorption), but a positive test result requires confirmation (with the other test type) as the rate of false positives is high. Pregnant patients with syphilis require treatment with penicillin as alternate antibiotic choices are ineffective, contraindicated, or have limited data in pregnancy. Patients with penicillin allergy should have a penicillin skin test to evaluate for the presence of an IgE-mediated response. If the test is positive, patients are desensitized to penicillin prior to receiving treatment with intramuscular penicillin G benzathine. (Choices A and D) Azithromycin and erythromycin do not reliably cure maternal or fetal infection as T pallidium is often macrolide-resistant. (Choice B) Ciprofloxacin is not an effective antibiotic for the treatment of syphilis. (Choice C) Nonpregnant patients with penicillin allergy are typically given doxycycline to treat early syphilis. However, doxycycline is contraindicated in pregnancy due to issues with fetal bone growth. (Choice E) Syphilis infection puts both the mother and fetus at great risk of complications. Delaying treatment is inadvisable. Educational objective: Treatment with penicillin is required for all pregnant patients with syphilis to prevent fetal complications. Patients with penicillin allergy should receive skin testing to confirm an IgE-mediated reaction. If the test is positive, patients are desensitized to penicillin prior to receiving treatment with intramuscular penicillin G benzathine.

A 22-Year-Old Primigravid Woman at 8 Weeks Gestation Comes to the Office