Syphilis infection during pregnancy is a serious public health problem, and it is related to congenital syphilis. Congenital syphilis, in most cases, is associated with pregnant women who do not screen for syphilis, and/or who are not treated properly or who have not been treated. Thus, detection and management of syphilis in pregnancy is important¹1 Padovani C, Oliveira RR, Pelloso SM. Sífilis na gestação: associação das características maternas e perinatais em região do sul do Brasil. Rev Latino-Am Enfermagem. 2018;26:e3019..

In September 2017, the Department of Surveillance, Prevention and Control of STI, HIV/AIDS and Viral Hepatitis launched, through the Information Notice Nº 2-SEI/2017-. DIAHV/SVS/MS²2 Nota Informativa Nº 2 (MS/SEI). DIAHV/SVS/MS. Altera os Critérios de Definição de Caso para notificação de Sífilis Adquirida, Sífilis em Gestante e Sífilis Congênita. Disponível em: http://portalsinan.saude.gov.br/images/documentos/Agravos/Sifilis-Ges/Nota_Informativa_Sifilis.pdf
http://portalsinan.saude.gov.br/images/d... , new criteria for definition of congenital, acquired and pregnant syphilis, in line with the recommendations of the Pan American Health Organization (PAHO) and the World Health Organization (WHO).

To consider the occurrence of syphilis in pregnant women, the following situations were defined: women who were not treated and had a positive test result for at least one type of test, treponemic or not, positive during pregnancy, but also at the baby birth and puerperium; symptomatic women who had at least one test positive during the same period; and women who were treated, but presented both reagent tests, also in the same period. In case of congenital syphilis, different criteria are defined for newborns, younger than thirteen years and results of biopsies and necropsies. Among changes made in these criteria that were proposed by Information Notice Nº 2²2 Nota Informativa Nº 2 (MS/SEI). DIAHV/SVS/MS. Altera os Critérios de Definição de Caso para notificação de Sífilis Adquirida, Sífilis em Gestante e Sífilis Congênita. Disponível em: http://portalsinan.saude.gov.br/images/documentos/Agravos/Sifilis-Ges/Nota_Informativa_Sifilis.pdf
http://portalsinan.saude.gov.br/images/d... are: absence of consideration of the mother’s sexual partner’s treatment to define inadequate treatment, need to perform at least two dilutions for non-treponemal test and, finally, the possibility of obtaining nasal secretion material or skin lesion for laboratory evaluation²2 Nota Informativa Nº 2 (MS/SEI). DIAHV/SVS/MS. Altera os Critérios de Definição de Caso para notificação de Sífilis Adquirida, Sífilis em Gestante e Sífilis Congênita. Disponível em: http://portalsinan.saude.gov.br/images/documentos/Agravos/Sifilis-Ges/Nota_Informativa_Sifilis.pdf
http://portalsinan.saude.gov.br/images/d... .

For epidemiological analysis of congenital syphilis and in pregnant women in Brazil, a reference document is the Syphilis Epidemiological Bulletin (2017). According to this bulletin, the incidence rates of congenital syphilis and syphilis in pregnant women increased about three times between 2010 and 2016, and the increase from 2015 to 2016 was, respectively, 4.7% and 14.7%. Among the cases, approximately 51.6% of pregnant women with syphilis were in the 20-29 age group in 2005/2007, and in 2016, 53.6% of the women did not have completed high school. The disease is responsible for causing signs of bone, neurological and cardiovascular complications in mothers; and, in babies, is responsible for causing premature birth, pneumonia and malformation. Syphilis in pregnancy is growing in Brazil and needs to be precisely notified for the proper design of governmental actions. Considering that syphilis is a 100% preventable condition, with the appropriate measures to pregnant women³3 Secretaria de Vigilância em Saúde, Ministério da Saúde (MS). Boletim Epidemiológico - Sífilis. Brasília: Departamento de Vigilância, Prevenção e Controle das IST, do HIV/Aids e das Hepatites Virais - DIAVH/SVS/MS; 2017. Disponível em: http://portalarquivos.saude.gov.br/images/pdf/2017/novembro/13/BE-2017-038-Boletim-Sifilis-11-2017-publicacao-.pdf
http://portalarquivos.saude.gov.br/image... , the need to identify and notify the disease, as well as to have knowledge about the care of affected mothers and children, is clear.

Important material that can help medical doctors and other health professionals is the “Pocket guide for management of syphilis in pregnant women and congenital syphilis”, published in 2016, by the Coordination of Disease Control of the State of São Paulo⁴4 Centro de Referência e Treinamento DST/AIDS-SP. Coordenadoria de Controle de Doença, Secretaria de Estado da Saúde de São Paulo. Guia de bolso para o manejo de sífilis em gestante e sífilis congênita. 2a Edição. São Paulo: Secretaria de Estado da Saúde; 2016. Disponível em: http://www.saude.campinas.sp.gov.br/doencas/sifilis/guiadebolsodasifilis_2edicao2016.pdf
http://www.saude.campinas.sp.gov.br/doen... . The content of the Guide addresses the issue in a complete and comprehensive manner, ranging from the definition disease cases to clinical and laboratory diagnosis, treatment, referral and epidemiological surveillance. Syphilis requires attention: clinical signs vary according to disease stages; the diagnosis does not include specific serological tests, which, in addition to varying degrees, react with different precision according to the stage of syphilis and, like any other disease, treatment varies according to variables such as: the patient having lost doses, being allergic to the medication or being infected by another disease - especially HIV. Therefore, syphilis requires a high technical, academic and scientific knowledge for its correct management, being only one of the diseases that health professionals need to be familiar, especially in their undergraduate and specialization courses, which brings value to the “Pocket guide” as a reference material.

As discussed, syphilis has several forms of diagnosis, drug dosage and manifestation, and each case has its specific management. The flowcharts and charts presented in the “Pocket guide” become valuable tools: syphilis evolution scheme, which shows the reactivity of serological tests and the chance of vertical transmission; clinical manifestations of the disease in phases, describing the type of lesion, location, among other aspects; flowcharts of attention to pregnant woman; flowchart of newborn care. By placing the information, usually technical and operational, in a graphical way, the text load of the book is relieved, and the reader’s understanding becomes easier, and even a better mental organization of the content takes place. These resources, however, could be used more frequently to replace certain texts, since it is a pocket guide, a name that suggests that each subject is written in a concise way. In the case of the topic that deals with the follow-up and control of the cure of newborns with congenital syphilis or exposed to maternal syphilis, for example, information is repeated in the diagram that follows the text, and this diagram presents the information more clearly, being sufficient in itself.

While some sections might have been more concise - another example being the explanatory note of inadequate treatment for maternal syphilis, repeated less than fifteen pages later - the topic of Laboratory Diagnostic Aspects (item 1.2.2) could have been deepened. Treponemal tests, that is, those that react according to specific antibodies to Treponema pallidum and non-treponemal tests, are presented with the latter being used for monitoring the treatment since the former can be reagents throughout life, even after infection has ceased. The way these non-treponemal tests work could have been explained, which would contribute to a better understanding of the difference between the two types of tests and also why the chances of false-positive in non-treponemal tests are only mentioned in the “Pocket guide”. In addition, it is indicated that the rapid test should be the first to be performed as a screening procedure, but, among the subsequent tests, that is, of confirmation or follow-up, it is only reported whether or not they are treponemic, without indicating whether FTA-Abs or ELISA should be used. Thus, despite the sensitivity and specificity of each test being shown in the table, it was not clear which test of each type is the most appropriate for recurrent use and what should be the criteria of choice in each situation, or whether they should be used in combination.

Despite the mentioned issues, the “Pocket guide for management of syphilis in pregnant women and congenital syphilis” is undoubtedly very well written and structured. In fact, guides, usually based on clinical guidelines, can improve the quality of clinical decisions, offering explicit recommendations to physicians who are not sure how to proceed, and thus help promote up-to-date practices and improve consistency of care⁵5 Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ 1999;318(7182):527-530.. Therein lies the greatest virtue of having available guides such as this one, which is also available in the internet.

Finally, the questions at the end of the two sessions deal with more complex cases that may raise questions for health professionals. The concern to put them in the “Pocket guide” shows the intention of the technical staff who wrote it to, in addition to make the reading more dynamic, elucidate any issues that might appear in the day to day of a reference center in infectology. Also, the “Pocket guide” is an initiative of the Health Secretariat of the State of São Paulo, which is in line with the Agenda of Strategic Actions for Syphilis Reduction in Brazil⁶6 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Departamento de Vigilância, Prevenção e Controle das Infecções Sexualmente Transmissíveis, do HIV/Aids e das Hepatites Virais. Agenda de Ações Estratégicas para Redução da Sífilis no Brasil. Brasília: Ministério da Saúde; 2017. Disponível em: http://www.aids.gov.br/pt-br/pub/2017/agenda-de-acoes-estrategicas-para-reducao-da-sifilis-no-brasil
http://www.aids.gov.br/pt-br/pub/2017/ag... , that replaced, in 2017, the Agenda of Strategic Actions for Congenital Syphilis Reduction in Brazil. Finally, the publication of a new edition is suggested, given the fact that some of its concepts have become out of date with the changes made by the Information Notice Nº. 2²2 Nota Informativa Nº 2 (MS/SEI). DIAHV/SVS/MS. Altera os Critérios de Definição de Caso para notificação de Sífilis Adquirida, Sífilis em Gestante e Sífilis Congênita. Disponível em: http://portalsinan.saude.gov.br/images/documentos/Agravos/Sifilis-Ges/Nota_Informativa_Sifilis.pdf
http://portalsinan.saude.gov.br/images/d... .

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