LESSON PLAN

ON
CONGENITAL
SYPHILIS
 LESSSON PLAN ON CONGENITAL SYPHILIS

Name of the subject : Child Health Nursing.

Group : IYear MS.c. (N) Students.

Language : English.

Method of teaching : Lecturer cum discussion

Hours prescribed : 1 hour

Topic : congenital syphilis

Av-aids : LCD.

Name of the teacher : Asso. Professor Renuga.V .MS.c [N]

 GENERAL OBJECTIVES:

At the end of the class the student will be able to gain knowledge on congenital syphilis and able to apply their knowledge in their clinical
practice.

SPECIFIC OBJECTIVES: The student will be able

 introduced the topic

 define congenital syphilis

 mention the causes of congenital syphilis

 describe pathophysiology of congenital syphilis

 list out the signs and symptoms of congenital syphilis

 mention the diagnostic evaluation congenital syphilis

 explain the therapeutic management of congenital syphilis

 describe the nursing management of congenital syphilis

 discuss the preventive management of congenital syphilis

 TEACHERS LEARNERS
TIME OBJECTIVES CONTENT ACTIVITY ACTIVITY AV AIDS EVALUATION
CONGENITAL SYPHILIS

INTRODUCTION

2 mts The students Most recognized syphilitic disease in children is congenital.

will be able to Medical professionals should assume that children with
introduced the acquired syphilis have been infected through sexual abuse, L L
unless another mechanism of transmission is identified. E I
topic
C S
Syphilis-especially in its later stages-can have numerous and T T
complex manifestations and may resemble a number of other U E
diseases. Indeed, William Osler called syphilis "the Great E N
Imitator." R I
N
3 mts The students DEFINITION: C G LCD define the
will be able to Congenital syphilis is a severe, disabling, and often life- U congenital
define the threatening infection seen in infants. A pregnant mother who M A syphilis?
has syphilis can spread the disease through the placenta to the N
congenital
unborn infant. D D
syphilis I
ETIOLOGY: S A
5mts The students C N
will be able to Syphilis is caused by Treponema pallidum, which belongs to U S mention the
mention the the Spirochaetaceae family. S W causes of
causes of S E congenital
Syphilis transmission usually occurs transplacentally or by I R
congenital syphilis?
sexual contact. O I
syphilis N N
Other modes of transmission include contact with G
contaminated blood or infected tissues.

Children experience 2 forms of syphilis: acquired syphilis,

which is almost exclusively transmitted by sexual contact, and
congenital syphilis, which results from transplacental
transmission of spirochetes.
TIME OBJECTIVS CONTENT TEACHERS LEARNERS AV AIDS EVALUATION
ACTIVITY ACTIVITY
Vertical transmission of early syphilis during pregnancy
results in a congenital infection in at least 50-80% of exposed
neonates.

Congenital syphilis is caused by the bacterium Treponema

pallidum, which is passed from mother to child during fetal L L
development or at birth. Nearly half of all children infected E I
with syphilis while they are in the womb die shortly before or C S
after birth. T T
U E LCD
10min The students PATHOPHYSIOLOGY: E N Describe patho
will be able to R I
physiology of
describe patho Secondary infection becomes latent within 1-2 months after N
onset. Relapses with secondary manifestations can be seen C G congenital
physiology of syphilis?
during the first year of latency, a period referred to as the early U
congenital M A
latent period. Early latent syphilis (ie, duration < 1 y) is when
syphilis the recurrent lesions of secondary syphilis are most likely to N
occur. No relapses occur after the first year; what follows is D D
late syphilis, which may be either asymptomatic (ie, late I
latent) or symptomatic (ie, tertiary). Late latent syphilis is S A
associated with resistance to both reinfection and relapse. C N
U S
Tertiary syphilis can manifest in various ways. Meningeal S W
syphilis rarely occurs and presents a few years after the S E
original infection. Late neurosyphilis may present as focal I R
ischemia of the CNS or stroke as a result of endarteritis of O I
small blood vessels of the brain. Meningovascular syphilis can N N
affect any part of the CNS. Actual destruction of the nerve G
cells in the cerebral cortex leads to a combination of
psychiatric manifestations and neurologic findings.

Because inflammatory changes do not occur in the fetus until

after the first trimester of pregnancy, organogenesis is
unaffected..
TIME OBJECTIVES CONTENT TEACHERS LEARNERS AV AIDS EVALUATION
ACTIVITY ACTIVITY
Nevertheless, all organ systems may be involved. With early-
onset disease, manifestations result from transplacental
spirochetemia and are analogous to the secondary stage of
acquired syphilis. Congenital syphilis does not have a primary
stage. Late-onset disease is seen in patients older than 2 years
and is not considered contagious.
L L
5 mts The students SYMPTOMS: E I
will be able to C S list out the signs
list out the Symptoms in newborns may include: T T LCD and symptoms
U E of congenital
signs and
 Failure to gain weight or failure to thrive E N
symptoms of syphilis?
 Fever R I
congenital  Irritability N
syphilis  No bridge to nose (saddle nose) C G
 Rash of the mouth, genitals, and anus U
 Rash -- starting as small blisters on the palms and soles, and
M A
later changing to copper-colored, flat or bumpy rash on the
face, palms, and soles
N
 Watery fluid released from the nose D D
I
Symptoms in older infants and young children may include: S A
C N
 Abnormal notched and peg-shaped teeth, called Hutchinson U S
teeth S W
 Bone pain S E
 Blindness I R
 Clouding of the cornea O I
 Decreased hearing or deafness N N
 Gray, mucus-like patches on the anus and outer vagina G
 Joint swelling
 Refusal to move a painful arm or leg
 Saber shins (bone problem of the lower leg)
 Scarring of the skin around the mouth, genitals, and anus
TIME OBJECTIVES CONTENT TEACHERS LEARNERS AV AIDS EVALUATION
ACTIVITY ACTIVITY
 Poorly developed maxillae.
 Enlarged liver.
 Enlarged spleen.
 Petechiae.
 Other skin rash.
 Sabre shins. L L
E I
 Anemia.
C S
 Lymph node enlargement.
T T
 Jaundice. U E
 Pseudoparalysis. E N
R I
5mts The students DIAGNOSIS: N
will be able to C G mention the
If the disorder is suspected at the time of birth, the placenta U LCD
mention the diagnostic
will be examined for signs of syphilis. A physical examination M A
diagnostic of the infant may show signs of liver and spleen swelling and evaluation
N
evaluation bone inflammation. congenital
D D
congenital I syphilis?
syphilis A routine blood test for syphilis is done during pregnancy. The S A
mother may receive the following blood tests: C N
U S
 Fluorescent treponemal antibody absorbed test (FTA- S W
ABS) S E
 Rapid plasma reagin (RPR) I R
 Venereal disease research laboratory test (VDRL) O I
N N
An infant or child may have the following tests: G
 Bone x-ray
 Dark-field examination to detect syphilis bacteria under
a microscope
 Eye examination
 Lumbar puncture
TIME OBJECTIVES CONTENT TEACHERS LEARNERS AV AIDS EVALUATION
ACTIVITY ACTIVITY
MANAGEMENT:

 Parenteral penicillin
The students explain the
8 mts Pregnant women:
will be able to L L therapeutic
explain the Pregnant women in the early stages of syphilis receive E I management of
therapeutic benzathine penicillin G (2.4 million units IM in a single dose). C S congenital
management of For later stages of syphilis or neurosyphilis, the appropriate T T syphilis?
congenital regimen for nonpregnant patients should be followed (see Late U E
syphilis or tertiary syphilis). Occasionally, a severe Jarisch-Herxheimer E N
reaction occurs after such therapy, leading to spontaneous R I
abortion. Patients allergic to penicillin may be desensitized and N
then treated with penicillin. After adequate treatment, RPR and C G
VDRL test results decrease 4-fold by 6 to 12 mo in most U
patients and revert to negative by 2 yr in nearly all patients. M A
Erythromycin therapy is inadequate for both the mother and N
fetus and is not recommended. Tetracycline is contraindicated D D LCD
. I
S A
Early congenital syphilis: C N
U S
In confirmed or highly probable cases, 2010 Centers for S W
Disease Control and Prevention (CDC) guidelines recommend S E
aqueous crystalline penicillin G 50,000 units/kg IV q 12 h for I R
the first 7 days of life and q 8 h thereafter for a total of 10 days O I
or procaine penicillin G 50,000 units/kg IM once/day for 10 N N
days. If ≥ 1 day of therapy is missed, the entire course must be G
repeated. This regimen is also recommended for infants with
possible syphilis if the mother fits any of the following criteria:

 Untreated
 Treatment status is unknown
 Treated ≤ 4 wk before delivery
TIME OBJECTIVES CONTENT TEACHERS LEARNERS AV AIDS EVALUATION
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 Inadequately treated (a nonpenicillin regimen)
 Maternal evidence of relapse or reinfection (≥ 4-fold
increase in maternal titer)

In infants with possible syphilis whose mothers were not

adequately treated but who are clinically well and have a
completely negative full evaluation, a single dose of L L
benzathine penicillin 50,000 units/kg IM is an alternative E I
treatment choice in selected circumstances, but only if follow- C S
up is assured. T T
U E
Infants with possible syphilis whose mothers were adequately E N
treated and who are clinically well can also be given a single R I
dose of benzathine penicillin 50,000 units/kg IM. N
Alternatively, if close follow-up is assured, some clinicians C G
defer penicillin and do nontreponemal serologic testing U LCD
monthly for 3 mo and then at 6 mo; antibiotics are given if M A
titers rise or are positive at 6 mo. N
D D
Older infants and children with newly diagnosed congenital I
syphilis: S A
C N
CSF should be examined before treatment starts. The CDC U S
recommends that any child with late congenital syphilis be S W
treated with aqueous crystalline penicillin G 50,000 units/kg S E
IV q 4 to 6 h for 10 days. A single dose of benzathine I R
penicillin G 50,000 units/kg IM may also be given at the O I
completion of the IV therapy. Alternatively, if a full evaluation N N
is completely negative and the child is asymptomatic, G
benzathine penicillin G 50,000 units/kg IM once/wk for 3
doses may be used. Many patients do not revert to
seronegativity but do have a 4-fold decrease in titer of reagin
(eg, VDRL) antibody. Patients should be reevaluated at regular
intervals to ensure the appropriate serologic response to
therapy has occurred and that there is no indication of relapse.
TIME OBJECTIVES CONTENT TEACHERS LEARNERS AV AIDS EVALUATION
ACTIVITY ACTIVITY
Interstitial keratitis is usually treated with corticosteroid and
atropine drops in consultation with an ophthalmologist.
Patients with sensorineural hearing loss may benefit from
penicillin plus a corticosteroid such as prednisone 0.5 mg/kg
po once/day for 1 wk, followed by 0.3 mg/kg once/day for 4
wk, after which the dose is gradually reduced over 2 to 3 mo.
(Corticosteroids have not been critically evaluated in these L L
conditions.) E I
C S
Special Considerations: T T
U E
Penicillin Allergy: E N
R I LCD
Infants and children who require treatment for congenital N
syphilis but who have a history of penicillin allergy or develop C G
an allergic reaction presumed secondary to penicillin should be U
desensitized and treated with penicillin (see Management of M A
Persons with a History of Penicillin Allergy). Skin testing N
remains unavailable for infants and children because the D D
procedure has not been standardized for this age group. Data I
are insufficient regarding the use of other antimicrobial agents S A
(e.g., ceftriaxone) for congenital syphilis in infants and C N
children. If a nonpenicillin G agent is used, close clinical, U S
serologic, and CSF follow-up is required in consultation with S W
an expert. S E
I R
Penicillin Shortage:
O I
N N
During periods when the availability of penicillin G is
G
compromised, management options are similar to options for
the neonate (see Evaluation and treatment of infants during the
first month of life).
TIME OBJECTIVES CONTENT TEACHERS LEARNERS AV AIDS EVALUATION
ACTIVITY ACTIVITY
1. For infants and children with clinical evidence of congenital
syphilis, procaine penicillin G (50,000 U/kg/dose IM up to the
adult dose of 2.4 million units a day in a single daily dose for
10 days) is recommended. A single dose of benzathine
penicillin G 50,000 units/kg IM up to the adult dose of 2.4
million units in a single dose can be considered after the 10-
day course of procaine penicillin. If procaine or benzathine L L
penicillin G is not available, ceftriaxone (in doses appropriate E I
for age and weight) can be considered with careful clinical and C S
serologic follow-up. Infants and children receiving ceftriaxone T T
should be managed in consultation with an expert, as evidence U E
is insufficient to support the use of ceftriaxone for the E N
treatment of congenital syphilis in infants or children. For R I
infants aged ≥30 days, use 75 mg/kg IV/IM of ceftriaxone a N
day in a single daily dose for 10–14 days (dose adjustment C G
might be necessary based on current weight). For children, the U
dose should be 100 mg/kg of ceftriaxone a day in a single daily M A LCD
dose. N
D D
2. For infants and children without any clinical evidence of I
infection (see Scenario 2 and Scenario 3), use S A
C N
a. procaine penicillin G, 50,000 U/kg/dose IM a day in a U S
single dose for 10 days S W
S E
or I R
O I
b. benzathine penicillin G, 50,000 U/kg IM as a single dose. N N
G
TIME OBJECTIVES CONTENT TEACHERS LEARNERS AV AIDS EVALUATION
ACTIVITY ACTIVITY
PREVENTION :

Pregnant women should be routinely tested for syphilis and

retested if they acquire other sexually transmitted diseases
during pregnancy. In 99% of cases, adequate treatment during
pregnancy cures both mother and fetus. However, in some
cases, treatment late in pregnancy eliminates the infection but L L
not some signs of syphilis that appear at birth. E I
C S
When congenital syphilis is diagnosed, other family members T T
should be examined for physical and serologic evidence of U E
infection. Retreatment of the mother in subsequent pregnancies E N
is necessary only if serologic titers suggest relapse or R I
reinfection. Women who remain seropositive after adequate N
treatment may have been reinfected and should be reevaluated. C G
A mother without lesions who is seronegative but who has had U
venereal exposure to a person known to have syphilis should M A LCD
be treated, because there is a 25 to 50% chance that she N
acquired syphilis. D D
I
NURSING CARE: S A
C N
The students Two other aspects of surveillance for congenital syphilis U S describe the
10mts will be able to warrant emphasis. First, a sensitive system is needed by which S W nursing
state and local sexually transmitted diseases (STD) control S E management of
describe the
programs are made aware of reactive STS. The programs I R
nursing congenital
should evaluate and follow individual reactive serologic test O I
management of N N syphilis?
reports and should monitor the reporting patterns of
congenital laboratories and diagnosticians. Furthermore, a quality G
syphilis assurance system is needed to confirm that all medical
laboratories performing tests for STD are complying with
official reporting regulations. Compliance should be checked
by letter, telephone, or personal visit at least every 6 months.
TIME OBJECTIVES CONTENT TEACHERS LEARNERS AV AIDS EVALUATION
ACTIVITY ACTIVITY
Second, state health departments should maintain a central
registry of patients who receive treatment for syphilis. Each
patient's record should include specific information about the
stage of disease, the type(s) and amount(s) of medication
administered, the types and results of laboratory tests, and, if
the patient is pregnant, the trimester during which she is L L
treated. This information is essential for the proper medical E I
management of pregnant women, their fetuses, and their C S
infants. Strict confidentiality and data security procedures must T T
be established, periodically reviewed, and independently tested U E
to ensure that registry information is neither misused nor E N
unintentionally revealed to unauthorized persons. R I
N
3. Control : C G
U
The control of early infectious syphilis is essential for the control of M A
congenital syphilis. When the prevalence of infectious syphilis N
substantially increases among reproductive-age women, cases of D D
congenital syphilis very likely will follow. Increased prevalence has I
been observed in several areas of the United States in recent years. S A
To prevent future cases of congenital syphilis, STD control
C N
programs need to place more emphasis on early syphilis control,
especially in areas with a high incidence. U S
S W
TD Program Priorities: S E
I R
Although no published studies have evaluated the benefit-to- O I
cost ratio in controlling early syphilis by using the traditional N N
method (see section 3.1) versus less laborious and time- G
consuming methods, the former has been a mainstay of most
STD control programs in the United States for many years.
The traditional syphilis-intervention process requires time,
commitment, and human resources, and -- like other public
health strategies
TIME OBJECTIVES CONTENT TEACHERS LEARNERS AV AIDS EVALUATION
ACTIVITY ACTIVITY
t should be periodically assessed by state and local STD programs
for its benefits and costs. In an era of increasing demands for public
health resources, the relative effectiveness of the traditional process
should be compared with that of less vigorous methods in areas of
both high and low syphilis incidence.

Other Considerations:
L L
The interrelationship of syphilis and human immunodeficiency E I
virus (HIV) infection should be explored in areas with a high C S
incidence of syphilis. HIV infection may influence the T T
manifestation of syphilis or its response to therapy. The role, if U E
any, of the genital ulcers of syphilis in increasing the risk of E N
HIV transmission also needs study in U.S. population groups. R I
State and local STD programs need to coordinate control N
resources for both syphilis and HIV, offer STS to all women C G
requesting HIV tests, and perform periodic syphilis tests on all U
persons known to be HIV-antibody positive. M A LCD
N
Prenatal Care : D D
I
Comprehensive prenatal care started early in pregnancy is S A
essential in preventing congenital syphilis. Unfortunately, C N
many obstacles make it difficult for women, particularly some U S
poor and some minority women, to obtain needed care. These S W
obstacles include financial barriers, the limited availability of S E
health care providers who are willing to serve these I R
populations, provider difficulty in communicating with O I
patients who are poor or from different ethnic backgrounds, N N
organizational arrangements that minimize accessibility and G
acceptability of treatment, poor coordination of services, and
patients' inadequate understanding of the need for care.
TIME OBJECTIVES CONTENT TEACHERS LEARNERS AV AIDS EVALUATION
ACTIVITY ACTIVITY
4.2 Drug Addiction Programs:

All women of childbearing age who come to clinics for drug

addiction should also be asked the date of their last menstrual
period, and the same procedures should be followed as those
described for STD clinics, including on-site pregnancy testing.
If the test is positive, an on-site RPR should be performed and L L
referral made for prenatal care. Patients should also be E I
informed about the availability of family planning services and C S
potential fetal damage caused by STD, cigarette smoking, T T
alcohol, and drugs. U E
E N
Prenatal Care Sites : R I
N
Women must often wait several weeks for their first prenatal C G
appointment because of overcrowded schedules and delays in U LCD
determining Medicaid eligibility. Since a delay may reduce the M A
likelihood of successful treatment if syphilis is identified, N
efforts should be made to test women early in pregnancy, D D
possibly during a visit for laboratory tests. If syphilis is I
diagnosed, treatment and counseling should be started before S A
the regularly scheduled prenatal care visit. C N
U S
Prenatal Care Sites: S W
S E
Women must often wait several weeks for their first prenatal I R
appointment because of overcrowded schedules and delays in O I
determining Medicaid eligibility. Since a delay may reduce the N N
likelihood of successful treatment if syphilis is identified, G
efforts should be made to test women early in pregnancy,
possibly during a visit for laboratory tests. If syphilis is
diagnosed, treatment and counseling should be started before
the regularly scheduled prenatal care visit.
TIME OBJECTIVES CONTENT TEACHERS LEARNERS AV AIDS EVALUATION
ACTIVITY ACTIVITY
Neonatal Follow-up:

In accordance with the guidelines of the American Academy

of Pediatrics, follow-up for all infants should be incorporated
into routine newborn care at 1, 2, 4, 6, and 12 months.
Serologic tests should be performed until they become
nonreactive. Patients with persistent, stable, low titers should L L
be considered candidates for retreatment. Treated infants E I
should be similarly followed, with a CSF examination at 6- C S
month intervals until the examination becomes nonreactive. A T T
reactive CSF VDRL at 6 months is an indication for U E
retreatment. E N
R I
5 min The students PREVENTION OF CONGENITAL SYPHILIS: N
will be able to C G discuss the
discuss the 1. Ensure that official public health statutes and/or U preventive
regulations mandate STS on all pregnant women at the M A LCD management of
preventive
time of the initial prenatal visit and early in the third N
management of congenital
trimester. D D
congenital I syphilis?
2. Monitor public and private laboratories regularly to
syphilis ensure the prompt and thorough reporting of reactive S A
STS. C N
3. Assess the pregnancy status of women with diagnosed U S
syphilis and of women who are the sex partners of men S W
with diagnosed syphilis. S E
4. Ask early infectious syphilis patients or their I R
unexamined sex partners who reside in neighborhoods O I
with a high incidence of syphilis to identify women in N N
the area who may be pregnant. Refer all identified G
women for serologic testing and prenatal care.
5. Inform every woman of reproductive age who is seen
in an STD clinic (for any reason) about the need for
prenatal care and STS in future pregnancies.
 TEACHERS LEARNERS
TIME OBJECTIVES CONTENT ACTIVITY ACTIVITY AV AIDS EVALUATION
6. Encourage prenatal screening for syphilis wherever
pregnant women are seen for health care, including
women, infants, and children (WIC) programs,
methadone maintenance clinics, detention facilities,
and prenatal care facilities; whenever possible, review
existing clinic protocols and suggest specific
amendments to the clinic medical director.
7. Conduct selective serologic screening of women of L L
childbearing age in groups with an increased risk of E I
infection, e.g., women residing in neighborhoods that C S
have a particularly high incidence of syphilis. T T
8. Deliver educational messages to the medical U E
community about laboratory tests, diagnostic criteria, E N
treatment, and follow-up of patients who are at risk of R I
infection and who may be pregnant. N LCD
9. Develop and disseminate public service educational C G
messages to women who share demographic U
characteristics with the women most often diagnosed M A
with early syphilis. In many areas of the United States, N
these women are young, single, members of a minority D D
group, and residents of a central city neighborhood. I
Brief, well-targeted radio announcements in the S A
language and vernacular of the audience may be C N
particularly effective. U S
S W
S E
I R
O I
N N
G
 TEACHERS LEARNERS
TIME OBJECTIVES CONTENT ACTIVITY ACTIVITY AV AIDS EVALUATION

CONCLUSION:

2mts Congenital syphilis represents a significant financial and

emotional burden in developing countries. Even one case of
congenital syphilis is a sentinel public health event, since
timely diagnosis and treatment of syphilis infected pregnant
woman should prevent transmission almost entirely. L L
E I
POST EVALUVATION C S
5mts T T
 Define congenital syphilis. U E
E N
 What are the causes of congenital syphilis?
R I
 Mention signs and symptoms of congenital syphilis. N LCD
C G
U
M A
N
D D
I
S A
C N
U S
S W
S E
I R
O I
N N
G
Bibliography:
o Centers for Disease Control and Prevention. Sexually Transmitted Diseases Guidelines 2002. MMWR-Morb-Mortal-Wkly-Rep 2002; 2002(51
(RR-6)).
o Congress Alukura and Nganampa Health Council Inc. Minymaku Kutju Tjukurpa Women's Business Manual. 3rd ed. Alice Springs: Congress
Alukura and Nganampa Health Council Inc; 1999.
o National Centre in HIV Epidemiology and Clinical Research. HIV/AIDS, viral hepatitis and sexually transmitted infections in Australia Annual
Surveillance Report 2004. 2004.
o Sydney, NSW; Canberra, ACT, National Centre in HIV Epidemiology and Clinical Research, Australian Institute of Health and Welfare.
o World Health Organisation. Guidelines for the management of sexually transmitted infections 2003.

o http://www.who.int/reproductivehealth/publications/rhr_01_10_mngt_stis/guidelines_mngt_stis.pdf.