Although is an easily preventable disease, there are flaws in the primary care network because part of the infected pregnant women is not adequately treated. They are infected by their partners, maintaining the transmission chain and, consequently, the high rates of syphilis. The main obstacles are failures in counseling, difficulties in doing tests, treatment not performed at the diagnosis site and no follow-up.⁴

Gestational Syphilis (GS) has significant importance for public health due to its impact during pregnancy. It can affect the development of the fetus and the newborn, increasing susceptibility to abortion, premature birth, skeletal malformations, meningitis, and pneumonia.⁵ One of the preventive measures for the nurses is the Rapid Test for Syphilis in each gestational trimester. They enable them to take treatment measures for a long time, avoiding CS, and preventing Vertical-Transmission.

A study conducted in northeastern Brazil found that its primary health units had professionals trained to perform rapid tests and these tests were available. However, none of the units performed them during prenatal consultations. Those who performed the conventional test, Venereal Disease Research Laboratory (VDRL), reported delayed results. None of the primary health units investigated collected daily biological material, hindering the diagnosis. When they came to receive the results of the VDRL test, the guidance from counseling was restricted to informing them about the test results and the need to treat their sexual partners.⁴

In the prenatal period, the test to diagnose GS should be performed in the first trimester of pregnancy. The nurse must request the quantitative VDRL around 19 weeks of gestation.⁶ Despite the protocols of the Ministry of Health and the availability of diagnosis and treatment of syphilis in the health services responsible for prenatal care, the elimination of CS is still a challenge. Health professionals, managers and the general population need to improve the quality of prenatal care with inclusion and co-responsibility of sexual partners and the use of methods such as rapid diagnostic tests.⁷

In this context, the research question is: How do primary care nurses perform rapid syphilis tests on pregnant women? Thus, the objective was to know how primary care nurses perform rapid tests for syphilis in pregnant women.

Method

This is qualitative, exploratory, and descriptive research in which we observed the behavior of the professional nurse regarding the performance of rapid syphilis tests in gestational trimesters. It was carried out in ten Family Health Strategies (FHS) in a municipality in southern Brazil. The units were defined at random. The municipality has 18 FHS units and each unit has a nurse.

Ten nurses working in these units for at least one year doing prenatal care participated in the study. Those who agreed to participate in the study signed the Informed Consent Form.

Data were collected in September and October 2018 through semi-structured interviews. The participants were asked about how they follow the protocol of the Ministry of Health for conducting rapid tests for syphilis in pregnant women. The researchers invited them to participate in the study verbally and performed their work shift in a room to ensure privacy. They lasted about 40 minutes, being audio-recorded and transcribed. Then, the data were submitted to Content Analysis.⁸First, a floating reading was performed to structure the data, and afterward, the material and treatment were explored in which the authors studied and discussed the topic.

We respected the Resolutions 466/2012 and 510/2016 of the National Health Council. The Research Ethics Committee approved the project under opinion 2,799,661 (CAAE: 94794518.0.0000.5340). The approval date was August 3, 2018. The survey participants were identified by the letter “E” followed by the number of interviews.

Results

Ten nurses between 25 and 50 years old were interviewed. Five of them were single, four married and one was divorced. They worked in the FHS between one and 26 years. They performed prenatal care between 17 years (two), 14 years (two), nine years (one), five years (three), and one year (two). The data analysis generated the following categories: Protocol followed by the nurses of primary care in the performance of the rapid tests for syphilis in pregnant women and the Nurses' behaviors when facing the rapid test with a positive result for syphilis.

The protocol followed by primary care nurses when performing rapid tests for syphilis in pregnant women

The participants reported that they do the rapid tests for Syphilis in all gestational trimesters during prenatal care in all pregnant women and that it is mandatory and that they provide guidance about the test they are performing.

Yes. We performed the rapid syphilis test on pregnant women during prenatal care, in the three trimesters of pregnancy. (E2)

Yes, we do three rapid tests, in the first, second, and third trimester. We inform the pregnant woman of what she is doing. (E5)

Yes. I do the rapid test in the three trimesters, first, second, and third. (E9)

Yes. We perform it here in the first, second, and third trimester of routine. (E10)

In the municipality, pregnant women are first assisted at a referral unit and after the pregnancy diagnosis and the first rapid test, they are sent to their neighborhood units. This reference unit is support for guidance, clearing doubts, and monitoring the pregnant woman together with health professionals. They also are a gateway for pregnant women from other municipalities in the region.

Most patients do it twice. In the second and third trimester. The gateway is the Reference Unit. She already comes to us, with the first test performed. (E1)

Yes, the tests are performed at the Reference Unit. They already do the rapid tests and are already sent to the unit in their neighborhood with the rapid tests done. (E6)

I take the test at the reception. They already arrive at the clinic with the test done. So, I do it at the first moment and every trimester. (E7)

Usually, she comes with the first rapid tests performed. If she is positive, she is already notified that she has to undergo treatment there at the referral center. (E8)

The main guidelines given by the nurses to the pregnant women were about the importance of performing the rapid syphilis test, the early start of treatment, and the damages caused to the fetus.

For the damage, it brings to the baby. Congenital malformations. The importance of treatment and the earlier the test is performed it will be possible to identify the diagnosis. (E3)

The importance of identifying contagion. Transmission to the fetus for the risk of miscarriage, malformations. (E10)

Nurses' behavior towards the rapid test with a positive result for syphilis

In the rapid positive syphilis test, the nurses reported making the case notification and immediately starting treatment. A quantitative VDRL is requested to confirm the diagnosis.

Our behavior following the protocol, we performed the test, giving a positive result, we have already notified and on the same day we have already carried out the treatment. (E1)

We immediately deal with it. Confirmation of the quantitative VDRL is not expected. It is treated with benzathine penicillin. We do three weeks of applications, then we request the VDRL. (E3)

Only one of the participants reported that after the rapid positive syphilis test, the treatment is not started immediately. He said that the pregnant woman should wait for the confirmatory result of the quantitative VDRL to start the treatment.

When the test is positive, I do not treat it, I wait to do the quantitative VDRL. When it is confirmed, I start weekly treatment with 2,400 benzetacil. (E9)

Two participants reported that syphilis in pregnant women is treated as tertiary, starting treatment with 2,400,000 IU of benzathine penicillin per week for three weeks, totaling 7,200,000 IU.

We treat it as tertiary. So, it's three weeks of treatment. At the moment I took the rapid test and it was positive, she will already make the first dose of the medication. (E2)

We treat it as tertiary syphilis in the case to settle. Three weeks on the run. Where the monthly control is done requesting the VDRL, for better monitoring. (E5)

They emphasized that it is common for partners to not adhere to the treatment together with the pregnant woman, hindering to re-infect it, and increasing the chances of vertical transmission.

There are cases in which the partner has refused to treat. We went after the pregnant woman and she ended up losing her fetus because she was re-contaminated. (E3)

Treating a partner is much more difficult. We have to go after him or the pregnant women say: I'm separated. I don't know who the father is. Treatment is quite complicated. (E5)

It happens a lot. They do all the treatment and the husband stays away and doesn't show up. (E8)

Discussion

The rapid tests for syphilis in pregnant women are performed in the three trimesters of pregnancy. A study showed that half of the cases of mothers with syphilis (48.4%) were monitored from the first trimester of pregnancy. However, most pregnant women had a late diagnosis.⁹ In Fortaleza, the diagnosis of syphilis occurred in 75.4% of cases during pregnancy, in which 86.1% were diagnosed between the second and third trimester.^10-11

Rapid tests are performed during the consultation by collecting a blood sample, making the diagnosis possible within 20 minutes. The introduction of rapid tests in prenatal care provides better coverage of screening for syphilis in pregnancy, allowing for immediate diagnosis and treatment in pregnant women.¹² However, the global elimination of CS will require improved access to screening and early treatment of syphilis, clinically monitoring all women and children diagnosed with syphilis, partner management and reducing the prevalence of syphilis in the general population through the expansion of rapid tests.¹³

The implementation of the “Rede Cegonha” by the Ministry of Health brought changes in the assistance of pregnant women by health professionals offering rapid tests to screen for syphilis and HIV (Human Immunodeficiency Virus) in primary care units. The rapid syphilis test should be done at the first prenatal consultation, in the first trimester of pregnancy, at the beginning of the third trimester (28^th week) and at the time of delivery or abortion, regardless of previous examinations.¹¹ The role of nurses in direct contact with patients is highlighted for the performance of rapid tests, identification of signs and symptoms of the disease, monitoring and offering guidance to the family.¹⁴

Prenatal care is an important tool in the diagnosis, guidance, and monitoring of pregnant women in the detection of GS, aiming at their early prophylaxis, avoiding the infection of the newborn.¹⁵ In places with limited resources, screening pregnant women for syphilis using simple rapid treponemal diagnosis (RDTs) is a fundamental tool in the prevention of CS since they allow greater coverage of screening and administration on the same day of treatment.¹⁶

Early diagnosis of CS is a necessary prerequisite for proper treatment. If the diagnosis of syphilis is done in the first two trimesters of pregnancy, the risk of its adverse results can be significantly reduced.¹⁷ The continuous increase in the syphilis cases in the general population can be due to the increased testing coverage, reduced condom use, resistance of health professionals in the administration of Penicillin in Primary Care, a worldwide shortage of Penicillin, among others.¹⁸ As there are many obstacles to the development of an effective vaccine against T. pallidum, universal prenatal screening and the appropriate treatment for the mother and the NB is the most effective strategy for preventing the transmission of syphilis from mother to child.¹⁹

Professional qualification, awareness, and standardization of the behavior of health professionals are necessary. Providing support to health professionals in their clinical practices through a supervisory process can contribute to the adoption of the recommended guidelines and the promotion of health care.⁴ We think that the nurse who performs low-risk prenatal care in the primary health unit should seek to know about sexually transmitted infections, especially the problems for the fetus. The lack of understanding and conviction of the individual before the pregnant woman can make the prenatal consultation insecure.

There are situations in which syphilis can be asymptomatic making diagnosis difficult and favoring the proliferation of Treponema pallidum. When this happens, it delays the treatment and increases the chances of the bacteria crossing the placental barrier, affecting the fetus. Syphilis can cause harmful effects to the mother and fetus if not identified and treated early.¹⁴

A study to investigate the fragility of the treatment in the family health strategy also showed that when the rapid test had a positive result for syphilis, the nurses notified the case and immediately started the treatment.²⁰ Also, the non-adherence of the partner to the treatment along with the pregnant woman was highlighted, allowing her reinfection, and increasing the chances of vertical transmission of the disease.

The partner should agree to carry out the treatment of syphilis together with the pregnant woman as an effective way to fight the disease. Treatment during prenatal care can be ineffective in up to 14% of cases and there is still a likelihood of reinfection if the partner has not done the treatment correctly. The same should be treated even when they have negative VDRL, with a single dose of 2,400,000 IU benzathine penicillin intramuscularly. When the result is positive, the treatment is the same as for tertiary syphilis.²¹

Conclusion

This study aimed to know how primary care nurses follow the protocol for conducting rapid tests for syphilis in pregnant women. These tests are performed in the three trimesters of pregnancy and the nurses advise them that its performance helps in the diagnosis of the disease and its risks for the NB.

When having a positive result for syphilis, they notify the case and immediately start the treatment of the pregnant woman. The partner's non-adherence to treatment is common, enabling their reinfection, and increasing the chances of vertical transmission. The nurse's important role in carrying out prenatal care and performing the rapid test as early as possible is highlighted, informing the diagnosis and starting the treatment of the pregnant woman and her sexual partner immediately.

Thus, the nurses should be trained about the disease and the Ministry of Health Protocol to perform the Rapid Test for Syphilis. However, we concluded that there are flaws in the continuing education of these professionals, compromising the prevention of the disease, its diagnosis, and treatment as well as the monitoring of infected pregnant women, their partners, and newborns.

The care practice is important to train all primary care nurses to perform rapid tests to detect syphilis in pregnant women, minimizing its effects, and qualifying prenatal care. Due to the study was carried out in only one municipality, it shows some limitations. New research must be carried out, searching for strategies to reduce syphilis cases, especially among pregnant women and newborns.

References

1. Garbin AJÍ, Martins RJ, Belila NM, Exaltação SM, Garbin CAS. Reemerging diseases in Brazil: sociodemographic and epidemiological characteristics of syphilis and its under-reporting. Rev Soc Bras Med Trop. 2019;52:e20180226:1-4. doi: 10.1590/0037-8682-0226-2018

2. Cunha ARC, Merchan-Hamann E. Sífilis em parturientes no Brasil: prevalência e fatores associados, 2010 a 2011. Rev Panam Salud Publica [Internet]. 2015 [acesso em 2018 set 20];38(6):479-86. Disponível em: https://www.scielosp.org/article/rpsp/2015.v38n6/479-486/pt/

3. Domingues RMM, Leal MC. Incidência de sífilis congênita e fatores associados à transmissão vertical da sífilis: dados do estudo nascer no Brasil. Cad Saúde Pública. 2016;32(6):1-12. doi: 10.1590/0102-311X00082415

4. Rocha AFB, Araújo MAL, Miranda AE, Leon RGP, Silva Junior GB, Vasconcelos LDPG. Management of sexual partners of pregnant women with syphilis in northeastern Brazil - a qualitative study. BMC Health Serv Res. 2019;19(1):65. doi: 10.1186/s12913-019-3910-y

5. Souza JM, Giuffrida R, Ramos APM, Morceli G, Coelho CH, Rodrigues MVP. Mother-to-child transmission and gestational syphilis: spatial-temporal epidemiology and demographics in a Brazilian region. PLoS Negl Trop Dis. 2019;13(2):e0007122. doi:10.1371/journal.pntd.0007122

6. Stafford IA, Berra A, Minard CG, Fontenot V, Kopkin RH, Rodrigue E, et al. Challenges in the contemporary management of syphilis among pregnant women in New Orleans, LA. Infect Dis Obstet Gynecol. 2019;Vol 2019:2613962. doi: 10.1155/2019/2613962

7. Silva Neto SE, Silva SSBE, Sartori AMC. Syphilis in pregnancy, congenital syphilis, and factors associated with mother-to-child transmission in Itapeva, São Paulo, 2010 to 2014. Rev Soc Bras Med Trop. 2018;51(6):819-26. doi: 10.1590/0037-8682-0377-2017

8. Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2009.

9. Lafetá KRG, Martelli Júnior H, Silveira MF, Paranaíba LMR. Sífilis materna e congênita, subnotificação e difícil controle. Rev Bras Epidemiol. 2016;19(1):63-74. doi: 10.1590/1980-5497201600010006

10. Cardoso ARP, Araújo MAL, Cavalcante MS, Frota MA, Melo SP. Análise dos casos de sífilis gestacional e congênita nos anos de 2008 a 2010 em Fortaleza, Ceará, Brasil. Ciênc Saúde Colet. 2018;23(2):563-74. doi: 10.1590/1413-81232018232.01772016

11. Machado I, Silva VAN, Pereira RMS, Guidoreni CG, Gomes MP. Diagnóstico e tratamento de sífilis durante a gestação: desafio para as enfermeiras? Saúde Pesqui [Internet]. 2018;11(2):249-55. Doi: 10.17765/2176-9206.2018v11n2p249-255

12. Araújo EC, Monte PCB, Haber ANCA. Avaliação do pré-natal quanto à detecção de sífilis e HIV em gestantes atendidas em uma área rural do estado do Pará, Brasil. Rev Pan Amaz Saúde [Internet]. 2018; 09(1):33-9. doi: 10.5123/s2176-62232018000100005

13. Korenromp EL, Rowley J, Alonso M, Mello MB, Wijesooriya NS, Mahiané SG, et al. Global burden of maternal and congenital syphilis and associated adverse birth outcomes-estimates for 2016 and progress since 2012. PLoS One. 2019;14(2):e0211720. doi: 10.1371/journal.pone.0211720

14. Ministério da Saúde (BR), Secretaria de Vigilância em Saúde, Departamento de DST, Aids e Hepatites Virais. Protocolo clínico e diretrizes terapêuticas para atenção integral às pessoas com infecções sexualmente transmissíveis [Internet]. Brasília (DF): Ministério da Saúde; 2015 [acesso em 2018 ago 15]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/protocolo_clinico_diretrizes_terapeutica_atencao_integral_pessoas_infeccoes_sexualmente_transmissiveis.pdf

15. Rodrigues VLR, Oliveira FM, Afonso TM. Sífilis congênita na perspectiva de um desafio para a saúde pública. Congresso Internacional de Enfermagem - CIE ; 2017 maio 09-12; Aracaju, SE. Anais. (Congresso Int Enferm [Internet]. 2017 [acesso em 2018 jun 23];1(1):1-4. Disponível em https://eventos.set.edu.br/index.php/cie/article/view/5958).

16. Langendorf C, Lastrucci C, Sanou-Bicaba I, Blackburn K, Marie-Hortense K, Crucitti T. Dual screen and confirm rapid test does not reduce overtreatment of syphilis in pregnant women living in a non-venereal treponematoses endemic region: a field evaluation among antenatal care attendees in Burkina Faso. Sex Transm Infect. 2018;95(6):402-4. doi: 10.1136/sextrans-2018-053722

17. Braccio S, Sharland M, Ladhani S. Prevention and treatment of mother-to-child transmission of syphilis. Curr Opin Infect Dis. 2016 Jun;29(3):268-74. doi: 10.1097/QCO.0000000000000270

18. Ministério da Saúde (BR). Boletim epidemiológico - sífilis [Internet]. Brasília (DF): Ministério da Saúde; 2017 [acesso em 2018 set 22]. Disponível em: http://www.aids.gov.br/pt-br/pub/2017/boletim-epidemiologico-de-sifilis-2017

19. Zhang X, Yu Y, Yang H, Xu H, Vermund SH, Liu K. Surveillance of maternal syphilis in China: pregnancy outcomes and determinants of congenital syphilis. Med Sci Monit. 2018 Oct 29;24:7727-35. doi: 10.12659/MSM.910216

20. Silva AS, Magalhães Sobrinho DDT, Nascimento MRL, Rodrigues TL, Vasconcelos LMO. Sífilis em gestantes: investigação da fragilidade do tratamento na estratégia saúde da família. X Mostra Científica da Farmácia. 2016; Quixadá, CE. Anais. (Mostra Cient Farm [Internet]. 2016 [acesso em 2018 ago 15];3(1). Disponível em: http://publicacoesacademicas.unicatolicaquixada.edu.br/index.php/mostracientificafarmacia/article/view/1270).

21. Ministério da Saúde (BR). Protocolo clínico e diretrizes terapêuticas para prevenção da transmissão vertical de HIV, sífilis e hepatites virais [Internet]. 2017 [acesso em 2018 set 15]. Disponível em: http://www.aids.gov.br/pt-br/pub/2015/protocolo-clinico-e-diretrizes-terapeuticas-para-prevencao-da-transmissao-vertical-de-hiv

Chief Scientific Editor: Cristiane Cardoso de Paula

Scientific Editor: Tania Solange Bosi de Souza Magnago

Corresponding author

Bruna Britto Pereira

E-mail: brunabritto94@hotmail.com

Endereço: Alameda das Corticeiras 165, Bairro Mato Grande. Canoas, Rio Grande do Sul.

CEP: 92320177

Author´s contributions

1 – Bruna Britto Pereira

Conception or design of the study/research, analysis, and/or interpretation of data, final review with critical and intellectual participation in the paper.

2 – Cristiano Pinto dos Santos

Conception or design of the study/research; analysis, and/or interpretation of data, final review with critical and intellectual participation in the paper.

3 – Giovana Calcagno Gomes

Conception or design of the study/research, analysis, and/or interpretation of the data, final review with critical and intellectual participation in the paper.

How to cite this article

Pereira BB; Santos CP, Gomes GC. Rapid syphilis tests on pregnant women by primary care nurses. Rev. Enferm. UFSM. 2020 [Access on: Month Day Year]; vol.10 e82: 1-13 DOI: https://doi.org/10.5902/2179769240034