Forum for Nordic Dermato-Venereology Nr 4, 2019 | Page 12

Lyudmyla Derevyanko – Progress Towards the Elimination of Mother to Child Transmission of Syphilis in Ukraine
Lyudmyla Derevyanko – Progress Towards the Elimination of Mother to Child Transmission of Syphilis in Ukraine
Statistical analysis Table I. Characteristics of newborns in general cohort (n = 102) Table II. Maternal characteristics in overall cohorts (n = 102)
The survey was statistically processed using STATISTICA 7.0
and MS Excel XP. The statistics presented in this study are
descriptive only. Characteristics Characteristics
In order to facilitate international contextualization of the
findings, we used the case definition of MTCT of syphilis
from European STI guidelines which distinguishes between
confirmed and presumed congenital infection (8), as follows:
• An infant was classified as a presumed case when: (i) it
was born to an inadequately treated or untreated mother
(regardless of signs in the infant); (ii) an infant had a posi­
tive serological test for syphilis and any of the following:
evidence of MTCT of syphilis on physical examination,
placental changes, confirmed necropsy;
• An infant was classified as a confirmed case when Treponema
pallidum was identified by darkfield microscopy of lesions,
placenta, umbilical cord, or necropsy (no such case was
reported).
Adequate treatment was defined according to the WHO as
the administration of parenteral penicillin (9). Whereas the
WHO and CDC treatment guidelines recommend treatment
with long-acting benzathine penicillin G (BPG) for primary,
secondary, and all forms of latent syphilis during pregnancy,
standard treatments in Ukraine include either long-acting or
daily doses of short-acting (aqueous or procaine) penicillin
G preparations. Therefore, we defined adequate treatment as
the administration of long-acting or short-acting penicillin G
regimens, completed at least 30 days before delivery.
R esults
Characteristics of infants with mother-to-child transmission of
syphilis
A total of 107 registered cases of MTCT of syphilis were iden-
tified from the 14 regions of Ukraine and Kyiv. Five infants
were excluded from the study because their diagnosis was not
consistent with the case definition of MTCT of syphilis. Syphi-
lis serology data were available for all the infants. All 102 cases
of registered MTCT of syphilis in the newborns were defined
as presumed, since Treponema pallidum was not identified by
darkfield microscopy in any skin lesions or discharge.
Table I shows the characteristics of infants with MTCT of
syphilis. The vast majority of these infants (85; 83.3%) had
symptoms, compared with 13 (12.7%) without symptoms.
Furthermore, 4 cases of stillbirth were registered with a range
of gestation ages of 26.5–37.5 weeks.
The following clinical abnormalities were found in symptomatic
cases of MTCT of syphilis: neurological symptoms, hepatosple-
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D ermatology A broad
Gestation age, weeks, mean ± SD/
range
Weight, g, mean ± SD/
range
Sex (female), n (%)
Symptomatic cases of MTCT of syphilis, total, n (%)
Neurological symptoms, n (%)
Hepatosplenomegaly, n (%)
Metaphyseal osteochondritis, n (%)
Diaphyseal periostitis, n (%)
Maculopapular skin rash, n (%)
Interstitial pneumonia, n (%)
Snuffles (sticky and bloody nasal discharge), n (%)
Anaemia (haemolytic and non-haemolytic), n (%)
Generalized non-tender lymphadenopathy, n (%)
35.6 ± 0.37/
26–40.5
2,458.81 ± 62.99/
903–3,850
51 ww(50.0)
85 (83.3)
74 (73.5)
62 (60.7)
36 (35.2)
23 (23.4)
28 (27.4)
10 (9.8)
7 (6.9)
44 (3.1)
8 (7.8)
SD: standard deviation; MTCTS: mother-to-child transmission of syphilis.
nomegaly, metaphyseal osteochondritis, diaphyseal periostitis,
interstitial pneumonia, generalized non-tender lymphadenop-
athy, characteristic mucocutaneous lesions, haemolytic and
non-haemolytic anaemia. Asymptomatic cases in newborns
with untreated or inadequately treated mothers had only
serological changes without clinical manifestations (Table I).
Infants with MTCT of syphilis were born at a mean±SD ges-
tational age of 35.6 ± 0.3 weeks and with a low birthweight of
2,459 ± 63 g. Despite extensive treatment, including penicillin,
7 children (4 of them in the postneonatal period) in the age
range 0.5–42 days died due to various severe complications
of MTCT of syphilis, including multisystem organ failure.
Furthermore, mothers of 11 babies (10.7% of all women)
abandoned their maternity rights. I.e. some women with
syphilis that gave birth to a child with CS, refuses to take the
child from the maternity home due to stimatization and later
on abandoned their maternity rights.
Characteristics of the mothers of infants with mother-to-child
transmission of syphilis
Table II shows the characteristics of the mothers of infants
with MTCT of syphilis. The mean age of mothers was 25.8±0.6
years, 50% were city residents, and 19.6% were non-residents
of the city or town in which they delivered, 28.4% of women
were living in the countryside. There were more single wom-
en (56.9%) than married or cohabitants (36.3%). More than
half of the women had a secondary (54.9%), and few had a
high er level of education (3.9%). However, almost 20% had
incomplete secondary education.
At the time of maternity leave, the vast majority of women
in all groups were unemployed or housewives. Syphilis was
found in only 19 (18.6%) of partners/husbands of the pregnant
women (data not shown).
Forum for Nord Derm Ven 2019, Vol. 24, No. 4
Age at delivery
≤19 years
≥20 years
Place of residence
City
Countryside
Non-resident
Education
High
Secondary
Incomplete secondary
Marital status
Married/cohabitant
Single
Unknown
Employment status
Unemployed
Employed
Housewife
Primigravida
Time of 1 st prenatal visit
1 st trimester
2 nd trimester
3rd trimester
No prenatal care
Time of the first syphilis test
1 st half of pregnancy
2 nd half of pregnancy
At delivery
After delivery
Stage of syphilis
Secondary
Early latent
Late latent
Unknown
Time of prenatal treatment
2 nd trimester
3 rd trimester
No treatment
Co-infections
HIV
Tuberculosis
Gonorrhoea
Trichomoniasis
n (%)
12 (11.8)
90 (88.2)
51 (50)
29 (28.4)
20 (19.6)
4 (3.9)
56 (54.9)
20 (19.6)
37 (36.3)
58 (56.9)
7 (6.9)
40 (39.2)
32 (31.3)
30 (29.4)
49 (48.0)
16 (15.7)
26 (25.5)
15 (14.7)
45 (44.1)
21 (20.6)
53 (51.9)
23 (22,5)
5 (4.9)
16 (15.7)
69 (67.6)
3 (2.9)
14 (13.7)
2 (2.0)
4 (3.9)
96 (94.1)
3 (3.8)
1 (0.9)
5 (4.9)
9 (8.8)
This study shows that 21.5% of women belonged to key groups
and vulnerable populations, including alcohol abuse, drug
abuse, or drug abuse of the partner, migrants, or immigrants.
In addition to syphilis, 13.7% of pregnant women had other
STIs (gonorrhoea, trichomoniasis), 3 women were co-infected
with HIV, and 1 woman with tuberculosis (Table II).
Of the pregnant women with active syphilis, 44.1% received
no prenatal care and 14.7% received care in the third trimes-
ter of pregnancy. Only 20.6% were tested during the first 20
weeks of pregnancy, 51.9% were tested in the second half of
pregnancy, and the rest during (22.5%) or after childbirth (5%).
Forum for Nord Derm Ven 2019, Vol. 24, No. 4
Among the 102 pregnant women who gave birth to infants
with presumed MTCT of syphilis, most of the women had early
syphilis; 69 (67.6%) had early latent syphilis, and 16 (15.7%)
had secondary syphilis. Of the remainder of the women, 3
(2.9%) had late latent syphilis, and 14 (13.7%) had syphilis
of unknown duration.
In addition to the main risk factors for MTCT of syphilis, such
as absence of prenatal care and treatment, a number of other
possible predictors were identified: delay in prenatal diagnosis
and prenatal treatment, late infection/low laboratory quality
assurance, iatrogenic mistakes, women refusing hospitalization
for treatment, delivery at home, and reinfection (Table III).
For 16 cases of pregnant women who were infected with
syphilis late in the third trimester, we conclude that their
first syphilis serology testing was negative due to incubating
syphilis. However, negative results could occur due to the
low sensitivity of the Wasserman test and cardiolipin-based
microprecipitation assay (MPR), which were used as a screen-
ing test assays.
D iscussion
This study revealed that an alarming proportion (94.1%) of
women with newborns diagnosed with MTCT of syphilis had
not received prenatal treatment, and that 28% of the women
had not had a syphilis test during pregnancy. Socio-demo-
graphic and behavioural characteristics revealed that most of
the pregnant women (78.5%) who gave birth to infants with
MTCT of syphilis did not belong to a risk group or vulnerable
population and had access to women’s facilities. These women
were young, and a significant proportion were single (56.9%),
although 36.3% were married or cohabiting. This indicates
the need to enhance the programme for primary prevention
of STI/HIV in the population of reproductive age in Ukraine.
The results of our study showed that approximately 57% of
pregnant women visited women’s facilities, but had not been
properly diagnosed and treated, resulting in a loss of opportu-
nity to prevent MTCT of syphilis in their babies. The study re-
vealed a delay in diagnosis and treatment of pregnant women
Table III. Risk factors for mother-to-child transmission of syphilis
Characteristics n (%)
Mothers without prenatal treatment
Mothers without prenatal care
Delay with prenatal diagnosis and treatment
Late infection/low laboratory quality assurance
Iatrogenic mistakes
Women refusing hospitalization for treatment
Reinfection 96 (94.1)*
45 (44.1)
14 (13.7)
18 (17.6)
6 (5.9)
4 (3.9)
1 (1.3)
*p < 0.05.
D ermatology A broad
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