Repeat third trimester syphilis screening may not be cost effective

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1. Overall incidence of syphilis and seroconversion were low and have decreased since 1993. 

2. The cost of VDRL screening in this high-risk population was much greater than the cost of empiric syphilis treatment of neonates. 

Evidence Rating Level: 2 (Good)           

Study Rundown: This study found that in a high-risk, urban population delivering at a tertiary care center, the incidences of syphilis and seroconversion during pregnancy were low. As such, the cost of third trimester VDRL screening greatly exceeded the cost of uniform newborn screening with treatment of all newborn for syphilis. There is little existing data on incident syphilis and seroconversion in pregnancy but existing studies suggests that syphilis incidence is too low for uniform maternal third trimester screening to be cost-effective. The major findings of this work support the limited benefit of third trimester syphilis screening, even in a high-risk population.

Evaluating the cost-benefit of repeat third-trimester syphilis testing in a high-risk urban population maximizes syphilis incidence and allows for results which may be generalized to lower-risk populations. Comprehensive data on maternal and fetal outcomes and costs allow for a more complete analysis of cost-benefit. Limitations include retrospective design and inclusion of only live births at >20 weeks gestational age introduces opportunity for selection bias whereby losses <20 weeks, including those due to intrauterine infections like syphilis, were excluded. Future studies might employ a prospective design and compare pregnancy, maternal and fetal outcomes to determine the broader impact of this different screening regimen.

Click to read the study in AJOG

Relevant Reading: Missed opportunities for preventing congenital syphilis infection in New York City

In-Depth [retrospective cohort study]: This study evaluated the temporal incidence of syphilis and seroconversion detected among 58,569 deliveries between 1993 and 2009. Screenings were performed at the first prenatal visit, in the third trimester and/or peripartum. Incident cases of syphilis, seroconversion (diagnosis following negative testing earlier in pregnancy) and cost of third trimester syphilis testing and of empiric neonatal treatment were assessed.

Overall, 113 incident cases of syphilis were diagnosed in pregnancy (192.9/100,000); 77.8% of cases were detected at the first prenatal visit and >30 days before delivery, allowing time for treatment prior to delivery. Of the 17 cases of seroconversion diagnosed, 10 were not detected until time of delivery. All neonates born to mothers with syphilis were asymptomatic, treated and were not observed to experience sequelae. The cost of repeat third trimester VDRL screen for all women in this study was $1,991,346, while the cost of treatment of a neonate for syphilis was $11,079.

By Denise Pong, MPH and Leah Hawkins, MD, MPH

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