Case of the Week #586

Petra Turnova
Slovakia

Posting Dates: Jul 15, 2023 - Jul 30, 2023

27-year-old woman with poor social history was sent to our unit in the 34th week of pregnancy. The father of the fetus was unknown and the patient was unaware of her pregnancy for the first 16 weeks. Two days prior to our examination, the fetus was alive on an ultrasound scan. As we performed our ultrasound examination, the patient mentioned that she did not feel fetal movements for approximately 12 hours.

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Answer

We demonstrate a case of congenital syphilis resulting in fetal demise.

The patient was treated for syphilis during the 16th week of pregnancy. Despite treatment, severe fetal infection occurred resulting in fetal death.

Congenital syphilis is caused by an infection with spirochete Treponema pallidum which crosses the placenta during pregnancy. Maternal syphilis is associated with a 6% risk for preterm delivery, 21% risk for intrauterine death and a 9% risk of neonatal death. Although all pregnant women should be screened for syphilis at the first prenatal visit, the treatment can be delayed if the first prenatal visit occurs late in pregnancy as in our case.

Sonographic findings consistent with congenital infection include placentomegaly, hepatomegaly, ascites, polyhydramnios and non-immune hydrops. In our case, we identified a severely ill fetus with starry night appearance of the liver and hyperechogenic nodules. Starry night appearance of the liver refers to the sonographic finding of a hepatic parenchyma with bright echogenic dots and decreased echogenicity of liver parenchyma.

References:

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[2] Cooper JM, Sanchez PJ. Congenital syphilis. Sem Perinatology 2018;42:176-84.
[3] Gomez GB, Kamb ML, Newman LM, Mark J, Broutet N, Hawkes SJ. Untreated maternal syphilis and adverse outcomes of pregnancy: a systematic review and meta-analysis. Bulletin of the World Health Org 2013;91:217-26.
[4] Hollier LM, Harstad TW, Sanchez PJ, et al. Fetal syphilis: clinical and laboratory characteristics. Obstet Gynecol 2001;97:947-53.
[5] Matthias JM, Rahman MM, Newman DR, et al. Effectiveness of prenatal screening and treatment to prevent congenital syphilis, Louisiana and Florida, 2013-2014. Sex Transm Dis 2017;44:498-502.
[6] Sheffield JS, Sanchez PJ, Morris G, et al. Congenital syphilis after maternal treatment for syphilis during pregnancy. Am J Obstet Gynecol 2002;186:569-73.
[7] Society for Maternal-Fetal Medicine, Norton ME, Chauhan SP, Dashe JS. Clinical Guideline #7: Nonimmune hydrops fetalis. Am J Obstet Gynecol 2015;212:127-39.
[8] Warren HP, Cramer R, Kidd S, et al. State requirements for prenatal syphilis screening in the United States, 2016. Matern Child Health J 2018;22:1227-32.