Washington, D.C. — May 2025 — The U.S. Preventive Services Task Force (USPSTF) has reaffirmed its recommendation for universal syphilis screening in pregnant women, emphasizing the critical need for early detection to prevent congenital infections. The update follows a thorough re-evaluation of current evidence and maintains the Task Force’s previous 2018 guidance.
In 2023, the United States reported 3,882 cases of congenital syphilis—the highest number in three decades. Public health experts estimate that 90% of these cases could have been prevented with timely maternal diagnosis and treatment.
Of the infants affected last year, 279 died either in utero, during delivery, or shortly thereafter. Congenital syphilis can lead to severe complications including premature birth, low birth weight, skeletal deformities, anemia, enlarged liver and spleen, as well as vision and hearing impairments and meningitis.
The highest incidence rates occurred among Native American and Alaska Native women, with 680 cases per 100,000 live births. Other affected groups included Native Hawaiian/Pacific Islander women (296), Black women (222), and Latina/Hispanic women (125). White women experienced 57.3 cases per 100,000 live births, while multiracial and Asian women recorded 82 and nine cases, respectively. Experts point to socioeconomic inequalities and cultural and demographic disparities as contributing factors.
The USPSTF reaffirmed its grade “A” recommendation—indicating high certainty of substantial benefit—for syphilis screening in pregnancy. The guidance advises all pregnant individuals to undergo syphilis testing early in pregnancy, regardless of their risk profile or previous screening history.
“Early treatment significantly reduces the risk of adverse outcomes,” the USPSTF noted, while acknowledging that even late intervention can prevent congenital transmission.
Screening for syphilis typically involves a two-step process. Initial tests may include non-treponemal methods such as the Venereal Disease Research Laboratory (VDRL) or Rapid Plasma Reagin (RPR) tests, which detect non-specific antibodies. Positive results are confirmed with treponemal tests, such as the Treponema pallidum particle agglutination assay (TP-PA), which identifies antibodies specific to the syphilis-causing bacterium.
Some protocols begin with automated treponemal tests—such as enzyme-linked or chemiluminescence immunoassays—followed by a second confirmatory treponemal test if initial results are inconsistent. Point-of-care tests for T. pallidum antibodies are available but remain insufficiently validated for widespread clinical use.
The Centers for Disease Control and Prevention (CDC) recommends penicillin G as the first-line treatment for syphilis during pregnancy. For the approximately 10% of patients with a reported penicillin allergy, desensitization followed by treatment is advised. If syphilis is diagnosed in the second half of pregnancy, fetal ultrasound is recommended to assess for complications.
While effective, treatment can result in adverse reactions. Penicillin-induced allergic responses occur in about 5% of patients. Additionally, around 2.5% may experience a Jarisch-Herxheimer reaction, which includes symptoms such as fever, rash, muscle aches, rapid heartbeat, and low blood pressure shortly after antibiotic administration. Among high-risk allergy patients, adverse event rates reach 27% after oral desensitization, compared to 2.5% with intravenous desensitization.
Despite early screening, about 5% of congenital syphilis cases are identified late in pregnancy. Among these, 41% occurred in Black women, 28% in Latina/Hispanic women, and 20% in White women.
Several professional organizations—including the CDC, the Women’s Preventive Services Initiative (WPSI), and the American Academy of Pediatrics (AAP)—recommend rescreening pregnant women considered high-risk. These include those residing in high-prevalence areas, individuals with HIV, those incarcerated, or women with multiple sexual partners. The American College of Obstetricians and Gynecologists (ACOG) goes further, advocating for rescreening of all pregnant women regardless of risk.
However, the USPSTF maintains that current evidence is insufficient to support universal rescreening. The Task Force calls for further research on its effectiveness and urges clinicians to consider local syphilis rates and state-level screening mandates when determining screening frequency.
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