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In 2008, the World Health Organization (WHO) estimated that 1.86 million cases of syphilis occur globally among pregnant women each year and that a large proportion of them are untreated or inadequately treated.
Existing barriers to scaling up these programmes can only be overcome through active involvement from policy-makers.
We systematically searched the published literature without date or language restrictions to identify studies assessing pregnancy outcomes in the presence of maternal syphilis. Because our goal was to estimate the range of possible birth outcomes associated with untreated syphilis during pregnancy, our population of interest was pregnant women who had untreated syphilis. We calculated crude proportion estimates and standard errors (SEs) for all adverse pregnancy outcomes in women with untreated syphilis and women without syphilis. We performed group-specific analyses for all adverse outcomes and for specific adverse outcomes to explore the sources of heterogeneity. In this article, we quantified the proportion of all adverse pregnancy outcomes and specific adverse pregnancy outcomes among untreated women with syphilis and women without syphilis using data from six articles that met eligibility criteria for inclusion in our systematic review and meta-analysis.
Early investigations evaluating syphilis testing and treatment preceded the use of experimental study designs; later studies have been limited by moral restrictions on the use of randomized controlled designs that withhold an effective intervention from a control group. Owing to the inherent differences between experimental and observational study designs and to biases commonly seen in observational data,11 appropriate caution should be taken in interpreting our results. Finally, group 3 studies occurred in settings in which pregnant women might not have attended an ANC clinic, might have attended an ANC clinic but not been tested for syphilis, or were tested for syphilis but did not receive treatment before delivery.
Our study suggests that, unless testing and treatment of syphilis in pregnancy are universally available, over half of pregnancies in women with syphilis will result in an adverse outcome.
Terris-Prestholt F, Watson-Jones D, Mugeye K, Kumaranayake L, Ndeki L, Weiss H, et al., et al. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al., Meta-analysis of Observational Studies in Epidemiology (MOOSE) group, et al.
Amsterdam Institute for Global Health and Development, Trinity Buildings, Building C, Pietersbergweg 17, PO Box 22700, 1100 DE Amsterdam, Netherlands.b. Up to one third of the women attending antenatal care (ANC) clinics are not tested for syphilis.1 If syphilis is left untreated during pregnancy, it can lead to fetal loss or stillbirth or, in a liveborn infant, neonatal death, prematurity, low birth weight or congenital syphilis. Evidence-based estimates of the burden of congenital syphilis at the global, national and subnational levels help make the case for allocating resources to these effective programmes, increasing access to interventions and making progress towards elimination.
We included studies that described pregnancy outcomes among women presumed to have syphilis (i.e.
We then calculated crude proportion estimates and SEs for the following select adverse pregnancy outcomes: fetal loss or stillbirth (combined), neonatal death (defined as a death occurring from birth up to the age of 28 days), prematurity or low birth weight (combined) and clinical evidence of syphilis. Among women without syphilis, the summary statistic was highest for group 1 and lowest for group 3 (Appendix A).
On average, pooled estimates of fetal loss or stillbirth, neonatal death and prematurity or low birth weight showed significantly higher rates among the offspring of women with syphilis than among the offspring of women without syphilis. It showed that infants delivered by untreated mothers with syphilis had 10% more deaths than those delivered by mothers without syphilis.
We relied on the outcome definitions used in the original papers, many of which were published before a consensus definition was available. This study probably underestimated the proportion of adverse pregnancy outcomes: some pregnancies included in the study may have occurred before women were infected and others may have occurred years after exposure, when syphilis was inactive and less likely to be transmitted to the fetus.


These studies probably underestimated the frequency of adverse pregnancy outcomes for several reasons. This is a preventable burden on mothers, families and health systems that highlights the need to prioritize global efforts to eliminate the mother-to-child transmission of syphilis.
Lives Saved Tool supplement detection and treatment of syphilis in pregnancy to reduce syphilis related stillbirths and neonatal mortality.
Effectiveness of interventions to improve screening for syphilis in pregnancy: a systematic review and meta-analysis.
Syphilis control in pregnancy: decentralization of screening facilities to primary care level, a demonstration project in Nairobi, Kenya.
Syphilis control during pregnancy: effectiveness and sustainability of a decentralized program.
Penicillin therapy of the syphilitic pregnant woman: its practical application to a large urban obstetrical service. The prevention of congenital syphilis in the large urban hospital: a study of clinic administration.
Province of residence and active syphilis infection among Zambian men and women: new evidence from population-based data.
Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, United States of America.c. Calculating the burden relies on precise estimates of the local prevalence of syphilis and adverse pregnancy outcomes among untreated women with syphilis.
We separately calculated crude proportion estimates of infant death (defined as a death occurring between ages 29 and 365 days) to allow for the differentiation between neonates and infants.
Group 1 included studies calculating the frequency of an adverse pregnancy outcome involving women whose reproductive history was recorded before the existence of penicillin treatment.
All articles presented the findings of observational studies that included a a€?controla€? arm assessing adverse pregnancy outcomes among women without syphilis. The absolute differences were 21% for fetal loss or stillbirth, 9% for neonatal death and 6% for prematurity or low birth weight. This suggests that a considerable mortality burden is currently overlooked because of short follow-up periods in most cohort studies. Nevertheless, one strength of this review is that each study included a comparison group to assess adverse pregnancy outcomes among mothers without syphilis. There were also unacceptable heterogeneity in estimates across studies, variations in diagnostic tests across settings and periods, and a lack of control for potential confounders. First, women with stillbirths and fetal losses who did not seek care would not have enrolled in a study. Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.d. Previous estimates of adverse pregnancy outcomes in women with syphilis have been based on point estimates from single studies. Group 2 comprised studies in which the frequency of an adverse pregnancy outcome was calculated for women attending an ANC clinic that offered no treatment or testing for syphilis. Signs and symptoms of syphilis were found in 15% of the infants born to untreated women with syphilis.


This gave us the opportunity to estimate the excess adverse outcomes in the presence of maternal syphilis and give a broad idea of the risk of some of the adverse pregnancy outcomes in women with untreated syphilis. To improve the quality of these estimates in the context of WHOa€™s global initiative for the elimination of congenital syphilis,9,10 we performed a systematic review and meta-analysis of reported estimates of adverse pregnancy outcomes among women with untreated syphilis and women without syphilis. We focused on fetal, neonatal and infant outcomes because maternal outcomes of syphilis would not be expected for several years after disease onset and were unlikely to have been reported in the same studies. Group 3 comprised studies that examined the frequency of an adverse pregnancy outcome involving women attending an ANC clinic in which recruitment in the study was done at the time of delivery (and syphilis treatment was only available at that time).
The frequency of any adverse pregnancy outcomes was 52% higher among women with syphilis than among women without syphilis.
Similar estimates have also been reported for specific pregnancy outcomes in women with syphilis.
Reporting bias is possible because infants born to mothers known to have syphilis are more likely than infants born to mothers not known to have syphilis to be diagnosed with congenital syphilis. We canvassed experts in the field to identify additional studies, particularly older studies that may have been published before the availability of online databases.
We included studies of at least 30 patients that described the sampling strategy used to recruit patients from the community, hospitals or ANC clinics. Group 2 studies included only asymptomatic women and therefore may have underestimated adverse pregnancy outcomes in women with untreated primary or secondary syphilis, both of which make transmission to offspring more likely and are associated with a fatality rate of nearly 100% (as noted among seven cases included in the Wammock cohort). We excluded studies describing partially treated populations, unless adverse pregnancy outcomes were reported specifically among women who lacked syphilis testing or treatment (i.e.
Primary and secondary syphilis during pregnancy are not estimated to be common, so this potential bias is unlikely to change the magnitude of the findings. Another limitation associated with group 2 is that, although each study followed infants for at least a short period, the length of follow-up varied. Third, women in group 3 who partially or fully completed a regimen of syphilis treatment during pregnancy might not have had this information reflected on their maternity card. We considered a broad range of study designs, including clinical trials, observational studies, programme reviews and case series.
No antenatal syphilis testing programme existed at that time and seroreactivity was identified later on the basis of analysis of stored blood samples.
Therefore, the burden of congenital syphilis might have been underestimated because congenital syphilis may have been missed in some infants. This would have resulted in the misclassification of some women with syphilis as untreated. The lack of a search for grey literature sources could have introduced a reporting bias, but because of the nature of the research assessed we expect this to be minimal. Finally, because group 3 studies did not follow up study subjects after delivery, neonatal deaths, infant deaths and clinical manifestations that occurred after this period would have been missed.



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