Screening for Syphilis in Pregnancy

Practice Advisory PA
April 2024

Reaffirmed October 2025

This Practice Advisory was developed by the American College of Obstetricians and Gynecologists. The American College of Nurse-Midwives, the Association of Women’s Health, Obstetric and Neonatal Nurses, the National Association of Nurse Practitioners in Women’s Health, and the Society for Maternal-Fetal Medicine endorse this document.

Updated ACOG Recommendation

The American College of Obstetricians and Gynecologists (ACOG) continues to endorse the Centers for Disease Control and Prevention (CDC) Sexually Transmitted Infection Treatment Guidelines, 2021 1 . However, in the context of the rapidly increasing rates of congenital syphilis, obstetrician–gynecologists and other obstetric care professionals should screen all pregnant individuals serologically for syphilis at the first prenatal care visit, followed by universal rescreening during the third trimester and at birth, rather than use a risk-based approach to testing.

Rationale

Congenital syphilis cases are increasing at an alarming rate across the United States. From 2012 to 2021, congenital syphilis cases increased by 755%2 . In the United States, in 2022 alone, there were 3,755 cases of congenital syphilis. According to the CDC, 88% of congenital syphilis cases in 2022 could have been prevented with timely screening and treatment2.

Notably, two in five infants with congenital syphilis were born to people who did not receive any prenatal care2. Therefore, it is important to make any health care encounter during pregnancy—including those in emergency departments, jails, syringe service programs, and maternal and child health programs—an opportunity to screen for syphilis2.

In addition, racial and ethnic inequities exist in congenital syphilis rates3 Table 1. It is important to acknowledge the harm and mistrust of the medical and public health establishment caused by the U.S. Public Health Service Untreated Syphilis Study at Tuskegee, which was conducted on a group of Black men—without collecting informed consent—and involved knowingly withholding syphilis treatment. It is necessary to approach our response to today’s congenital syphilis public health crisis with cultural awareness, humility, and sensitivity to build trust4.

Rates of Reported Congenital Syphilis Cases by Race/Hispanic Ethnicity of the Mother, United States, 2022

Data from Centers for Disease Control and Prevention. Sexually transmitted infections surveillance – Table 33, 2022. CDC; 2024. Accessed April 4, 2024. Available at https://www.cdc.gov/std/statistics/2022/tables/33.htm

Treatment of Syphilis in Pregnancy

Benzathine penicillin G is the only known effective treatment for syphilis in pregnancy and the prevention of congenital syphilis1. Timely initiation and completion of treatment are imperative and often complicated by stigma, multiple injections, treatment shortages, reporting and follow-up requirements, and mistrust of the medical system. In patients with a known severe allergy to penicillin, desensitization followed by penicillin treatment is recommended.

There is currently a shortage of benzathine penicillin G, sold as Bicillin L-A5. The U.S. Food and Drug Administration has exercised enforcement discretion for the temporary importation and use of Extencilline (benzathine benzylpenicillin injection, powder, for suspension) to mitigate the effects of the Bicillin L-A drug shortage. Extencilline is currently authorized and marketed in other countries. For more information on the use of Extencilline, read the Maternal Immunization Task Force Statement Obstetric Care Professionals Support the Availability and Use of Extencilline (Benzylpenicillin Benzathine) for the Treatment of Syphilis

When needed, local health departments, disease intervention specialists, and trusted community organizations can play an important role in helping people and their sex partners overcome barriers to accessing and completing treatment.

For additional information about syphilis in pregnancy and congenital syphilis, please see the following resources:

Please contact [email protected] with any questions.

References

Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep 2021;70(RR-4):1-187. doi: 10.15585/mmwr.rr7004a1
Article Locations:
Article Location Article Location
Centers for Disease Control and Prevention. Vital signs: syphilis in babies reflects health system failures. CDC; 2023. Available at: https://www.cdc.gov/vitalsigns/newborn-syphilis/index.html. Accessed April 12, 2024.
Article Locations:
Article Location Article Location Article Location Article Location
Centers for Disease Control and Prevention. Sexually transmitted infections surveillance, 2022. CDC; 2024. Available at: https://www.cdc.gov/std/statistics/2022/default.htm. Accessed April 12, 2024.
Article Locations:
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Importance of social determinants of health and cultural awareness in the delivery of reproductive health care. ACOG Committee Opinion No. 729. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131:e43-8. doi: 10.1097/AOG.0000000000002459.
Article Locations:
Article Location
Food and Drug Administration. Penicillin G benzathine injection. Current and resolved drug shortages and discontinuations reported to FDA. FDA; 2024. Available at: https://www.accessdata.fda.gov/scripts/drugshortages/dsp_ActiveIngredientDetails.cfm?AI=Penicillin%20G%20Benzathine%20Injection&st=c Accessed April 12, 2024.
Article Locations:
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The American College of Obstetricians and Gynecologists recognizes and supports the gender diversity of all patients who seek obstetric and gynecologic care. In original portions of this document, authors seek to use gender-inclusive language or gender-neutral language. When describing research findings, this document uses gender terminology reported by investigators. To review ACOG’s policy on inclusive language, see https://www.acog.org/clinical-information/policy-and-position-statements/statements-of-policy/2022/inclusive-language.

A Practice Advisory is a brief, focused statement issued to communicate a change in ACOG guidance or information on an emergent clinical issue (eg, clinical study, scientific report, draft regulation). A Practice Advisory constitutes ACOG clinical guidance and is issued only online for Fellows but may also be used by patients and the media. Practice Advisories are reviewed periodically for reaffirmation, revision, withdrawal or incorporation into other ACOG guidelines. This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publications may not reflect the most recent evidence. Any updates to this document can be found on www.acog.org/clinical.

While ACOG makes every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. ACOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither ACOG nor its officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

Publications of the American College of Obstetrician and Gynecologists are protected by copyright and all rights are reserved. The College’s publications may not be reproduced in any form or by any means without written permission from the copyright owner.

The American College of Obstetricians and Gynecologists (ACOG) is the nation’s leading group of physicians providing evidence-based obstetric and gynecologic care. As a private, voluntary, nonprofit membership organization of more than 60,000 members, ACOG strongly advocates for equitable, exceptional, and respectful care for all women and people in need of obstetric and gynecologic care; maintains the highest standards of clinical practice and continuing education of its members; promotes patient education; and increases awareness among its members and the public of the changing issues facing patients and their families and communities. www.acog.org

Topics

Infectious diseases Mass screening Pregnancy Pregnancy complications Syphilis Sexually transmitted diseases Sexually transmitted infections