Congenital Syphilis

What is congenital syphilis?

Congenital syphilis occurs when a pregnant person has syphilis, and the infection passes to the baby either during pregnancy (by crossing the placenta) or at the time of delivery (through exposure to infected lesions). Syphilis is a sexually transmitted infection (STI) that you can cure with treatment (antibiotics). That’s true even if you’re pregnant — treatment during pregnancy can cure you and, in many cases, protect the fetus.

But if you’re pregnant, have syphilis and don’t receive treatment, the infection can cause serious harm to the fetus and/or issues after birth. Congenital syphilis can cause miscarriage, stillbirth or death of your baby soon after birth. If your baby survives, they may have a range of health issues.

If you’re pregnant and think there’s even a small chance you could have syphilis, ask a healthcare provider about syphilis testing. This allows you to know if you have syphilis. If you do, you can get treatment right away. Treatment early in pregnancy — ideally, during the first trimester — can often prevent congenital syphilis.

But it’s also important to talk to your sexual partner(s) about testing since it’s possible they’re infected and need treatment. Without treatment, they could reinfect you (and you’d need treatment all over again). The rates of both syphilis and congenital syphilis have been going up in the U.S. This means more people have syphilis and may not know it than in years past. Honest conversations with partners can help you stay healthy and have a healthy pregnancy.

Types of congenital syphilis

Healthcare providers classify congenital syphilis according to when signs and symptoms first appear:

• Early congenital syphilis: Signs and symptoms appear before a baby is 2 years old (usually within three months of birth).
• Late congenital syphilis: Signs and symptoms appear after age 2.

What are the signs and symptoms of congenital syphilis?

Signs and symptoms of early congenital syphilis (birth to age 2) include:

• Bone abnormalities, like osteochondritis.
• Enlarged liver.
• Enlarged spleen.
• Jaundice.
• Low red blood cell count (anemia) and low platelet count (thrombocytopenia).
• Soft, wart-like lesions called condyloma lata.
• Peeling skin on their hands or feet.
• Rash on their neck, arms and mouth area.
• Runny nose (syphilitic rhinitis, or “snuffles”). This is typically persistent and often starts within one week of birth. The drainage may look white and/or contain blood.

As many as 6 in 10 newborns with symptoms of congenital syphilis have neurosyphilis. This may involve one or more of the following:

• Disrupted blood flow to the brain (stroke).
• Eye abnormalities, like cataracts or chorioretinitis.
• Seizures.

Some babies have no signs or symptoms at birth but develop them days, weeks or even months later. Providers will still give these babies immediate treatment if testing shows a risk of infection.

Signs and symptoms of late congenital syphilis (over age 2) include:

• Abnormal bone growth.
• Eye abnormalities, like inflammation of the cornea.
• Hearing loss.
• Teeth that are notched or have gaps between them (Hutchinson’s teeth).

You may notice some of these signs and symptoms on your own. But most of them require a healthcare provider’s evaluation.

What causes congenital syphilis?

A syphilis infection in a pregnant person causes congenital syphilis. “Congenital” means present at birth. Babies are born with this infection. But in some cases, the infection is fatal to the fetus before a live birth can occur.

The specific type of bacteria that causes syphilis (Treponema pallidum) spreads to the fetus through the placenta. The bacteria go directly to the fetus’s bloodstream. From there, they can spread all through its body, causing inflammation in its bones and major organs. Some babies get congenital syphilis from contact with syphilis sores during delivery, but this is less common.

Not every baby born to a parent with syphilis will develop congenital syphilis. The risk varies according to when the infection began in the birthing parent. More recent infections (immediately before or during pregnancy) pose a greater risk than infections that began more than a year prior to pregnancy.

What are the risk factors for this condition?

One of the biggest risk factors for congenital syphilis is lack of prenatal care. This means you don’t see a healthcare provider at all while you’re pregnant, or you go much later than recommended. Without prenatal care, you may not know you have syphilis. If it’s not treated, the infection can lead to congenital syphilis and related complications (including pregnancy loss).

It’s important to start seeing a provider for prenatal appointments during your first trimester. These appointments allow your provider to catch any issues early — including any health conditions that could affect your pregnancy.

Other things that can raise a person’s risk of developing syphilis while pregnant (potentially leading to congenital syphilis) include:

• Having multiple sexual partners.
• Using nonprescribed drugs along with sexual activity.
• Having sex in exchange for money or services (transactional sex).

What are the complications of this condition?

Congenital syphilis may lead to pregnancy complications, including:

• Miscarriage.
• Preterm (premature) birth.
• Low birth weight.
• Stillbirth.
• Death of a baby soon after birth.

Without treatment, babies born with congenital syphilis can develop severe symptoms or die.

How is congenital syphilis diagnosed?

Providers diagnose this condition by:

• Testing a pregnant person for syphilis. Blood tests can show if you have a syphilis infection. The results help providers determine the fetus’s risk for developing congenital syphilis.
• Fetal ultrasound. Providers can sometimes notice features of congenital syphilis (like an enlarged liver or fluid buildup) on an ultrasound. But congenital syphilis doesn’t always show up on ultrasounds. Some babies are born with the condition despite normal ultrasound findings.
• Physical exam and testing of the newborn. Providers carefully examine newborns who may have congenital syphilis to look for signs of the condition. They may run one or more tests, including blood tests, lumbar puncture and imaging tests. For example, X-rays can reveal bone abnormalities typical of babies with congenital syphilis.

Some babies may seem fine at birth but go on to develop congenital syphilis signs and symptoms later. This is known as late congenital syphilis. In children age 2 or older, providers do a thorough physical exam to look for congenital syphilis signs.

What is the treatment for congenital syphilis?

Healthcare providers use penicillin to treat congenital syphilis. They use one or both of the following methods:

• Treating you while you’re still pregnant. This involves giving you one or more injections (shots) of penicillin.
• Treating your baby after birth. This involves giving them penicillin through a vein (intravenously) or through injections.

The exact approach to treatment depends on:

• When providers diagnose syphilis in you.
• If (and when) treatment begins during pregnancy.
• Your baby’s risk for having syphilis at birth.
• Your baby’s signs and symptoms after birth.

Ideally, treatment begins during pregnancy and at least 30 days before delivery. This will cure your infection and may cure the fetal infection. Some babies are still born with congenital syphilis even if their parent received early enough treatment.

Providers will determine your baby’s risk for having syphilis at birth and plan treatment accordingly. Their risk depends on many things, including whether you received treatment and certain blood test results.

If you had syphilis and received adequate syphilis treatment before becoming pregnant, it’s unlikely that your baby will develop syphilis. And in most cases, your baby won’t require treatment.

If you have syphilis while pregnant, your healthcare providers will carefully evaluate your baby’s risk. Your providers will review your treatment history and determine your baby’s risk for congenital syphilis. Babies at a higher risk need to stay in the hospital for treatment with penicillin.

When you’re treated early in pregnancy, your baby may not need to stay in the hospital for treatment. They may be discharged with close follow-up, often after receiving a single injection of penicillin.

Your baby’s care team will tell you exactly what you can expect for treatment. 

Can congenital syphilis be prevented?

Yes. You can prevent (or greatly lower) your baby’s risk of congenital syphilis by:

• Practicing safer sex before and during pregnancy. Safer sex involves using protection (like condoms and dental dams) every time you have sex. It also involves asking your sexual partner(s) to get tested for STIs and be honest with you about the results. Keep in mind that condoms and other barrier methods can’t completely prevent STIs, but they can lower your risk. To prevent getting syphilis or another STI during pregnancy, you may choose to abstain from sexual activity until after your baby is born.
• Getting tested for syphilis during pregnancy. Most U.S. states require testing at your first prenatal visit, and some require it during the third trimester and/or at delivery, too. Your provider may recommend repeat testing if you have an increased risk for syphilis.
• Getting treatment for syphilis. If you test positive for syphilis before or during pregnancy, treatment can cure the infection and lower the risk of passing syphilis to your baby. The sooner you start treatment, the better. Treatment that begins within 30 days of delivery may not be as effective at protecting your baby. This is why testing during pregnancy is so important.

If you’re concerned about your risk of developing syphilis or any other STIs, talk to a healthcare provider. They can talk to you about testing and help you understand which STIs might affect pregnancy or your baby.

It might feel uncomfortable to talk about sex or STIs with a provider. But keep in mind it’s their job to help you and do everything possible to support your health. Find a provider who makes you feel comfortable, safe and respected.

What can I expect if my child has congenital syphilis?

It depends on how this condition affected fetal development and/or your baby’s health after birth. Antibiotics can cure the syphilis infection, but they can’t undo any damage that occurred before treatment. This means some babies may have lasting effects from the infection (like changes to their vision or hearing).

Your baby’s care team will explain what you can expect and how to support your child’s needs.

Can babies survive congenital syphilis?

Yes. Their odds of survival depend on many things, including when treatment begins. But, in some cases, congenital syphilis is fatal. Any pregnant person who has a fetal death after 20 weeks’ gestation should be tested for syphilis.

When should I seek medical care?

Contact a healthcare provider if you’re pregnant and believe you may have syphilis. It’s crucial to get tested right away so you can start treatment if you test positive. If you don’t have a usual primary care provider, there may be a community health center or organization in your area that can help.

If your child is diagnosed with congenital syphilis, they’ll need follow-ups after treatment has ended. These are crucial to make sure the infection is truly gone and check your child’s development. Make sure to take your child to all these appointments and follow their care team’s instructions.

A note from Cleveland Clinic

Maybe you’re pregnant and just learned you have syphilis. You might wonder, what now? Or maybe you’ve already given birth and providers are treating your baby for congenital syphilis. You might feel helpless or overwhelmed. This isn’t what you wanted or expected, yet here you are.

No matter where you’re at, know help is available. Talk to your care team about how you’re feeling, and they’ll connect you with support and resources. You don’t have to get through this alone.