Placenta Non Grata: A Rare Presentation of a Reemerging Disease

Maternal syphilis rates in the United States have risen dramatically, from 87.2 per 100,000 births in 2016 to 357.9 per 100,000 births in 2024, according to Centers for Disease Control and Prevention (CDC) reports. Congenital syphilis rates have also been on the upswing, increasing from 60.0 to 109.6 per 100,000 births between 2020 and 2024, with cases on the rise for the twelfth consecutive year. This trend poses a pressing public health concern. Diagnosing syphilis, particularly in pregnancy, can be challenging due to its variable and often nonspecific presentation. Delayed recognition and treatment, however, can result in severe maternal and fetal complications.

We report a 28-year-old patient in her third trimester of pregnancy who presented to a rural emergency department (ED) with abdominal cramping, malodorous vaginal discharge, fever, hypotension, and altered mental status concerning for sepsis secondary to intrauterine infection. Pertinent social history included homelessness, an absence of prenatal care, and substance use. Fetal distress ultimately necessitated emergent delivery, after which testing confirmed maternal syphilis infection and congenital syphilis in the neonate. Later histopathologic analysis of the placenta revealed spirochete invasion consistent with syphilitic chorioamnionitis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Histopathologic confirmation of syphilitic chorioamnionitis is seldom available to emergency clinicians in real time; however, this should not be taken as evidence of rarity. EDs are likely already encountering patients experiencing the downstream consequences of unrecognized syphilis infection. Because emergency physicians often represent the sole point of medical contact for pregnant patients without prenatal care-those most at risk-strong clinical suspicion is required to prompt appropriate testing and initiation of penicillin therapy. Notably, standard empiric antibiotic regimens for chorioamnionitis do not reliably treat syphilis. As incidence rates rise, failure to recognize and treat this infection in the ED may result in preventable adverse maternal and fetal outcomes. Further, incorporating syphilis screening into ED protocols is increasingly warranted, particularly in high-prevalence regions.