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Screening for Syphilis Infection in Pregnant Women: A Reaffirmation Evidence Update for the U.S. Preventive Services Task Force [Internet].


Lin JS, Eder M, Bean S.


Rockville (MD): Agency for Healthcare Research and Quality (US); 2018 Sep. Report No.: 18-05238-EF-1.
U.S. Preventive Services Task Force Evidence Syntheses, formerly Systematic Evidence Reviews.



To systematically update the evidence for three questions to support updating the 2009 USPSTF A recommendation for screening for syphilis in pregnancy: KQ1) effectiveness of screening to reduce the incidence of congenital syphilis or other adverse pregnancy outcomes of syphilis, KQ2) harms of screening in pregnancy, and KQ3) harms of penicillin in pregnancy.


We conducted a literature search of MEDLINE, PubMed Publisher-Supplied Records, and the Cochrane Central Register of Controlled Trials (CENTRAL) from January 1, 2008 to June 2, 2017.


We screened 453 abstracts and 34 full-text articles against a priori inclusion criteria. We included studies conducted in countries categorized as “high” or “very high” on the Human Development Index.


Two investigators independently critically appraised each article that met inclusion criteria using design-specific criteria. We abstracted and narratively synthesized data from included studies.


We included one study for KQ1, six studies for KQ2, and no studies for KQ3. For KQ1, we included one study reporting longer-term follow-up from a previously included study. This observational study evaluated the implementation of syphilis screening in pregnancy in over 2 million women in China. From 2002 to 2012, screening for syphilis in all pregnant women increased from 89.8 percent to 97.2 percent, and the incidence of congenital syphilis decreased from 109.3 to 9.4 cases per 100,000 live births. For KQ2, we included five studies evaluating the false positives of treponemal tests (i.e., CIA, EIA, and TPPA) and one study evaluating the false negatives of nontreponemal tests (i.e., RPR). These studies found that false positives with EIA or CIA were common (46.5 to 88.2 percent), therefore warranting reflexive testing for all CIA or EIA test positives. One study demonstrated that 2.9 percent of discordant samples (RPR negative/TPPA positive) had a false-negative RPR test due to the prozone phenomenon.


Our review was designed to identify evidence that could result in a change in the 2009 USPSTF recommendation and therefore our review does not address the effectiveness of screening or early prenatal care in low- or middle-income countries, the comparative screening accuracy of traditional versus reverse sequence algorithm testing, or the efficacy of penicillin G or alternative antibiotic treatments for the treatment of syphilis.


Screening for syphilis in pregnancy is standard of care in the United States. Our brief evidence update found evidence that is consistent with the understanding that screening for syphilis in pregnancy reduces congenital syphilis and supports the need for reflexive testing to investigate discordant EIA/CIA positive/RPR negative testing in reverse sequence screening algorithms.

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