Godfrey JA Walker

Congenital syphilis is an increasing problem in many developing countries and in the transitional economies of Eastern Europe and the former Soviet Union. In several countries this increase has been aggravated by HIV/AIDS. While the effectiveness of penicillin in the treatment of syphilis in pregnant women and the prevention of congenital syphilis was established shortly after the introduction of penicillin in the 1940s, there is uncertainty about the optimal treatment regimens. To identify the most effective antibiotic treatment regimen (in terms of dose, length of course and mode of administration) of syphilis with and without concomitant infection with HIV for pregnant women infected with syphilis. MEDLINE 1966 to March 2000; EMBASE 1974 to March 2000, the Cochrane Controlled Trials Register (last searched March 2001), the Cochrane Pregnancy and Childbirth group trials register (last searched March 2001) and the references of traditional reviews were searched. Experts in specialist units were contacted. It was planned that any trial in which an attempt is made to allocate treatment for syphilis during pregnancy by a random or quasi-random method would be included in this review. Information was extracted using a data extraction sheet and this included entry criteria, the source of controls, and whether the authors stratified by the stage of pregnancy when the diagnosis of syphilis was made. Twenty six studies met the criteria for detailed scrutiny. However, none of these met the pre-determined criteria for comparative groups and none included comparisons between randomly allocated groups of pregnant women. While there is no doubt that penicillin is effective in the treatment of syphilis in pregnancy and the prevention of congenital syphilis, uncertainty remains about what are the optimal treatment regimens. Further studies are needed to evaluate treatment failure cases with currently recommended regimens and this should include an assessment of the role of HIV infection in cases of prenatal syphilis treatment failure. The effectiveness of various antibiotic regimens for the treatment of primary and secondary syphilis in pregnant women need to be assessed using randomised controlled trials which compare them with existing recommendations.