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A systematic review (Swartzendruber et al 2015) reported substantial increases in antenatal syphilis testing following introduction of point-of-care syphilis testing in low and middle income countries. Adequate training for health care workers and supplies of commodities were cited as key implementation barriers. Women with infectious syphilis need to be informed of the infectious nature of the condition, even in the absence of visible lesions or symptoms, and to abstain from sexual activity for 5 days post-treatment or until symptoms have resolved, 5 days post treatment of their partners or until symptoms have completely resolved (whichever is longer). The risk of reinfection should be reinforced and the possible signs and symptoms of a new syphilis infection discussed. The importance of follow-up and repeat syphilis serology testing to monitor the response to treatment and detect reinfection should be emphasised and women assisted to access this 211 follow-up (eg through recall systems). The woman should be informed that she is likely to continue to have positive treponemal specific tests for life, even after successful treatment. Seek advice from an expert in sexual health or infectious diseases regarding the care of women who test positive and their partners. Ensure contact tracing (including offering testing and treatment to identified contacts) is carried out. Involve an expert in contact tracing if required or seek advice from a sexual health clinic or other relevant expert. Observational studies in settings of very high prevalence were consistent in finding treatment in the first trimester to be more effective than treatment in the third trimester (Hong et al 2017; Zhang et al 2016). Evidence-based recommendation 39 For women with newly confirmed infectious syphilis, recommend an intramuscular dose of 1. Due to the high risk of mother-to-child transmission during pregnancy, particular care is required to conduct follow-up serology to monitor the response to treatment. Local guidance about testing schedules and treatment should be sought in areas affected by an outbreak. Women should be reassessed at every antenatal visit for symptoms of syphilis, and/or change in risk factors, and additional testing outside of the routine screening intervals should be considered based on clinical indication.

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