Clinical and epidemiological features of congenital syphilis with antenatal fetal asphyxia

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Introduction

Syphilis is a classic sexually transmitted disease [1], characterized by a long-term undulating course with lesions of the skin, mucous membranes, internal organs, the musculoskeletal system and the fetus in the mother’s womb, having adverse consequences up to disability and lethal outcome [2]. Over the past 10 years, a steady decline in the incidence of syphilis has been observed.

In 2020, in the Russian Federation, it amounted to 10.4 per 100,000 population and was represented by early forms of syphilis – 5.3 per 100,000 population, late forms of syphilis – 3.0 per 100,000 population, other and unspecified forms of syphilis – 2.1 per 100,000 population [3]. There were 15 registered cases of congenital syphilis, of which 14 cases were early congenital and one was late congenital syphilis. Despite the low statistics, the problem of undetected syphilitic infection remains, which may have more serious and profound consequences [4; 5]. There are several ways of syphilis infection: sexual, through a direct contact from an infected person to a healthy one and/or through household items, blood transfusion, occupational and vertical – from a pregnant woman to the fetus with the development of congenital syphilis [6]. The highest probability of fetal infection is observed when a woman is infected during pregnancy or a year before its onset (Kossovich’s law). Fetal infection occurs at 16–20 weeks of pregnancy, mainly through the placenta, umbilical vein, and lymphatic clefts of the umbilical cord [7]. The placenta increases in size, with changes in its vessels and villi, leading to the development of microabscesses, peri- and endoarteritis, and perivascular infiltrates, which result in a fetal trophic disorder [8]. Congenital syphilis is accompanied by a pathology of the internal organs and musculoskeletal system of the fetus with the development of diffuse inflammatory processes, in severe cases leading to non-viability [9; 10]. The outcome of pregnancy depends on the degree of the syphilitic infection activity: miscarriage – approximately 65 %, stillbirth – on average 11 %, premature birth or delivery of a child with active manifestations of the disease and latent syphilis – on average 12 %, birth of healthy children – on average 12 % [2; 11].

Clinical Case

Patient M., aged 36, visited the antenatal clinic on November 27, 2023 about delayed menstruation since September 26, 2023. Obstetric-gynecological history: in 2006 the pregnancy ended in antenatal asphyxia of the fetus at 30 weeks; in 2011 – non-developing pregnancy at 7–8 weeks; in 2014, 2016 and 2017 – term delivery; in 2023 – the current pregnancy. Gynecological diseases and sexually transmitted infections: colpitis, trichomoniasis. Objectively: somatic status is unremarkable; pregnancy was diagnosed at 8–9 weeks. According to microscopy results of vaginal discharge trichomonads were found, molecular biological study to confirm the diagnosis was not performed.

Before visiting the obstetrician-gynecologist the patient independently took tests: complete blood count revealed the 1st degree anemia (hemoglobin 93 g/l), markers of viral hepatitis and HIV infection were negative, syphilis test was in process.

The diagnosis established: pregnancy 8–9 weeks, chronic iron-deficiency anemia of the 1st degree, cervicitis, trichomoniasis. Treatment for trichomoniasis, iron-deficiency anemia, consultations with a therapist, ophthalmologist, dentist were prescribed.

After visiting the obstetrician-gynecologist, the results of the enzyme immunoassay for syphilis were received: antibodies to Treponema pallidium were detected – IgG, M, titer 1:1280.

Pregnancy course: follow-up visit on December 20, 2023, diagnosis: 12–13 weeks of pregnancy, BOGH (burdened obstetric-gynecological history), chronic iron-deficiency anemia, trichomoniasis (treated). Early latent syphilis (?). Threatened by fetal growth restriction syndrome. A referral for a consultation with a dermatovenerologists was issued. An examination of husband for sexually transmitted infections (STIs) was recommended.

The next visit to the obstetrician-gynecologist was at 17–18 weeks of pregnancy. No dermatovenerological examination was performed. Trichomoniasis was detected again at 21–22 weeks of pregnancy. The doctor’s recommendations were not followed by the patient or her husband.

At 24–25 weeks of pregnancy complaints of productive cough and rhinitis appeared. For the first time the patient consulted a therapist: a mild acute respiratory infection was diagnosed. The patient and her husband initiated treatment for trichomoniasis with metronidazole. The next visit was on March 29,2024, at 26–27 weeks of pregnancy: trichomoniasis was sanitized.No dermatovenerological consultation was obtained throughout the entire pregnancy.

Routine ultrasound performed on April 12, 2024 revealed antenatal fetal asphyxia at 27 weeks, the fetus corresponding to 23,4 weeks of gestation, fetal growth restriction syndrome of the 1st-2nd degree. The patient was referred to a tertiary care hospital. During the hospitalization, an enzyme immunoassay for syphilis was repeated, revealing anti-treponema pallidium IgG, titer 1:1280.

A pathological anatomical autopsy of the fetus was carried out. The primary diagnosis of antenatal asphyxia of the fetus, amniotic fluid aspiration, skin maceration, postmortem changes of internal organs, postmortem hydrops of body cavities was made. Background diagnosis was: fetopathy, prematurity, extremely low birth weight (750 g) and small size of the fetus for the gestational age (28-29 weeks), intrauterine pneumonia.

Pathological examination data of the placenta: the placenta corresponds to a premature pregnancy, pronounced dystrophic compensatory changes; multiple false and true infarctions; chronic decompensated placental insufficiency, focal parietal chorioamnionitis; hypoplasia of Wharton’s jelly in the fetal part of the umbilical cord, postmortem changes.

Results and Discussion

A rare, illustrative case of antenatal fetal asphyxia due to the lack of necessary treatment and diagnostic measures is presented. The patient’s medical history reveals that the first two pregnancies had unfavorable outcomes: intrauterine fetal death at 30 weeks and missed miscarriage at 7–8 weeks, with the causes of these pregnancy outcomes remaining undetermined. During the current pregnancy, despite the detection of antibodies to the causative agent of syphilis and an extremely high antibody titer (1:1280), a consultation with dermatovenerologist, standard laboratory methods of study (microreaction for syphilis in combination with two of the four types of specific tests: RPHA, ELISA, IFR, ITR) and treatment of syphilitic infection were not carried out. If the appropriate measures had been taken, when the woman was registered, congenital syphilis could have been prevented. If they had been implemented in the future, it would have been possible to cure congenital syphilis successfully and give birth to a healthy, live infant. The underestimation of the situation’s severity led to the progression of syphilitic infection, causing antenatal fetal asphyxia.

Conclusions

1. Preconception care should be provided to every woman, taking into account her obstetric-gynecological history and somatic status.
2. If extragenital pathology is detected during pregnancy, comprehensive management and collaboration between the obstetrician-gynecologist and a specialist in the relevant comorbidity are essential.
3. It is necessary to carry out timely and effective treatment of the identified changes.

Each pregnancy should be conscious, planned and desired.

About the authors

M. Yu. Kobernik

Ye.A. Vagner Perm State Medical University

Author for correspondence.
Email: margo110875@yandex.ru
ORCID iD: 0000-0002-3549-0076

PhD (Medicine), Associate Professor of the Department of Dermatovenerology

Russian Federation, Perm

G K. Sadykova

Ye.A. Vagner Perm State Medical University

Email: margo110875@yandex.ru
ORCID iD: 0000-0003-1868-8336

Associate Professor of the Department of Obstetrics and Gynecology № 1

Russian Federation, Perm

A. P. Kolenchenko

Ye.A. Vagner Perm State Medical University

Email: margo110875@yandex.ru

5^th-year Student of the Medical Faculty

Russian Federation, Perm

Yu. S. Naumova

Ye.A. Vagner Perm State Medical University

Email: margo110875@yandex.ru

5^th-year Student of the Medical Faculty

Russian Federation, Perm

References

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