Congenital Syphilis Morbidity & Mortality Review
This toolkit is a prevention tool tailored for local STD programs. It includes case reviews, mother and infant timelines, healthcare facility details, and more to address congenital syphilis morbidity and mortality effectively.
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Presentation Transcript
1 THE CONGENITAL SYPHILIS MORBIDITY & MORTALITY REVIEW TOOLKIT A Prevention Tool for Local STD Programs This slide set should serve as a template; please tailor slides to meet local needs and the specifics of the case being examined.
2 CASE #1
3 Mother of Baby Characteristics Age; Race/Ethnicity HIV status Risk factors, e.g. drug use, correctional history, etc. Prenatal care? Number of sex partners reported in past 12 months Additional details about sex partners
4 Mother & Infant Timeline YEAR Date Healthcare Facility #1 Signs/symptoms Laboratory test results? Treatment? (## weeks GA) Date Report received at health dept
5 Healthcare Facility #1 Detail Date Mother chief complaint? Diagnosis? Laboratory test results? Treatment? Risk history? Other relevant information? Missed opportunity?
6 Mother & Infant Timeline YEAR (1) Date Healthcare Facility #1 Signs/symptoms Laboratory test results? Treatment? (## weeks GA) Date Healthcare Facility #2 Signs/symptoms Laboratory test results? Treatment? (## weeks GA) Date Report received at health dept
7 Healthcare Facility #2 Detail Date Mother chief complaint? Diagnosis? Laboratory test results? Treatment? Risk history? Other relevant information? Missed opportunity?
8 Mother & Infant Timeline YEAR (3) Date Healthcare Facility #1 Signs/symptoms Laboratory test results? Treatment? (## weeks GA) Date Healthcare Facility #3 Signs/symptoms Laboratory test results? Treatment? (## weeks GA) Date Healthcare Facility #2 Signs/symptoms Laboratory test results? Treatment? (## weeks GA) Date Report received at health dept
9 Healthcare Facility #3 Detail Date Mother chief complaint? Diagnosis? Laboratory test results? Treatment? Risk history? Other relevant information? Missed opportunity?
10 Mother & Infant Timeline YEAR (2) Date Healthcare Facility #1 Signs/symptoms Laboratory test results? Treatment? (## weeks GA) Date Healthcare Facility #3 Signs/symptoms Laboratory test results? Treatment? (## weeks GA) Date Infant Born Healthcare facility Signs/symptoms Laboratory test results? Treatment? (## weeks GA) Date Healthcare Facility #2 Signs/symptoms Laboratory test results? Treatment? (## weeks GA) Date Report received at health dept Date Interview conducted Date Case closed
11 Baby Characteristics Date of Birth (gestational age at birth) HIV Status Syphilis test(s): date, type and result Signs/symptoms Physical exam results, e.g. physical signs, low birth weight, etc. Long bone x-rays CSF cell & protein count Treatment: date and type CS case classification
12 Partner/Father of Baby Characteristics Age; Race/Ethnicity Stage of syphilis; signs/symptoms HIV status Syphilis test: date, type and result Treatment: date and type Risk factors, e.g. drug use, correctional facility, sex with other men, etc. Number of sex partners reported in past 12 months Additional details about sex partners
13 Case #1: Discussion What were potential missed opportunities to prevent this case? Disease Investigation Perspective Clinical Perspective Policy/Systems Level Perspective Surveillance/Informatics Perspective Other perspectives? What are potential intervention points to prevent a similar case from happening?
14 Framework to Consider Missed Opportunities Disease Investigation Perspective ___________________________________________________ Clinical Perspective ___________________________________________________ Policy/Systems Level Perspective ___________________________________________________ Surveillance/Informatics Perspective ___________________________________________________ Other perspectives? ___________________________________________________
15 CLOSING Identify & Delegate Follow-up: See accompanying document
16 SAMPLE CASE #1 Identifying names, dates, locations, and other characteristics have been changed in the following sample case.
17 Mother of Baby Characteristics (1) 39 years old; Black/African-American RPR 1:64; stage late latent syphilis HIV negative (a/o 10/22/14) Limited prenatal care
18 Mother & Infant Timeline 2014-15 (1) 2/1/15 OBGYN #1 RPR 1:64; TPPA+ No treatment documented (27 weeks GA)
19 OBGYN #1 2/1/15 No medical records from visit uploaded to CalREDIE RPR noted as part of prenatal screening panel Lab results returned with RPR 1:64; TPPA+ No treatment documented
20 Mother & Infant Timeline 2014-15 (2) 2/1/15 OBGYN #1 RPR 1:64; TPPA+ No treatment documented (27 weeks GA) 3/2/15 OBGYN #2 RPR 1:32; TPPA+ No treatment documented (31 weeks GA) 2/6/15 Lab report received at health dept
21 OBGYN #2 3/2/15 No medical records from visit uploaded to CalREDIE RPR 1:32; TPPA+ No treatment documented
22 Mother & Infant Timeline 2014-15 (3) 2/1/15 OBGYN #1 RPR 1:64; TPPA+ No treatment documented (27 weeks GA) 3/14/15 Hospital #1 RPR 1:64 No treatment documented (33 weeks GA) 3/2/15 OBGYN #2 RPR 1:32; TPPA+ No treatment documented (31 weeks GA) 2/6/15 Report received at health dept
23 Hospital #1 3/14/15 Mother presents with pregnancy complication (unrelated to syphilis) RPR 1:64 No treatment documented
24 Mother & Infant Timeline 2014-15 (4) 3/17/15 Hospital #1 RPR 1:64 No treatment documented (33 weeks GA) 2/1/15 OBGYN #1 RPR 1:64; TPPA+ No treatment documented (27 weeks GA) 3/2/15 OBGYN #2 RPR 1:32; TPPA+ No treatment documented (31 weeks GA) 2/6/15 Report received at health dept 3/20/15 Hospital #2 Baby born Mom BIC x 1 Baby pen x 10d (34 weeks GA)
25 Hospital #2 3/20/15 Mother returned for further evaluation and admitted for c-section Mother received BIC x 1 on 3/20/15 Baby born on 3/20/15 (34 weeks gestation) Admitted to NICU for evaluation + Penicillin x 10d Prenatal care reported in medical record medical records from these visits not uploaded to CalREDIE: October 2014 (10 weeks GA)
26 Baby Characteristics (1) DOB: 3/20/15 (34 weeks gestation) 3/20/15 RPR 1:16 3/22/15 HIV negative No physical signs/symptoms upon exam No information in CalREDIE on if long bone x-rays or lumbar puncture were done Treatment penicillin x 10d Probable CS case
27 Mother & Infant Timeline 2014-15 (5) Prenatal care: Early October 2014 (10 weeks GA no documentation in CalREDIE 2/1/15 OBGYN #1 RPR 1:64; TPPA+ No treatment documented (27 weeks GA) 3/17/15 Hospital #1 RPR 1:64 No treatment documented (33 weeks GA) April 2015 Mom BIC x 3 3/21/15 CMR received at health dept 3/2/15 OBGYN #2 RPR 1:32; TPPA+ No treatment documented (31 weeks GA) 4/2/15 Interview conducted 2/6/15 Report received at health dept 3/20/15 Hospital #2 Baby born Mom BIC x 1 Baby pen x 10d (34 weeks GA) 6/1/15 Case closed 4/4/15 Missed appt with OBGYN for Tx
28 Mother s Interview No signs/symptoms described; no history of syphilis Risk factors: Methamphetamine use (oral, not IV; last used Nov 2014) Sex while intoxicated or high on drugs Patient described her OBGYN as not having medicine available DIS followed-up with OBGYN; health dept provided BIC to OBGYN DIS brought mother to treatment for BIC x 3 3 male partners reported in past 12 months 1 partner named Refused sex partner risk questions
29 Father of Baby Characteristics 35 years old Unable to locate patient named partner but did not provide any additional identifying information Unknown stage of syphilis; mother of baby reports no signs/symptoms observed Mother of baby stated that partner has already been tested and treated
30 Case #1: Discussion What were potential missed opportunities to prevent this case? Disease Investigation Perspective Clinical Perspective Policy/Systems Level Perspective Surveillance/Informatics Perspective Other perspectives? What are potential intervention points to prevent a similar case from happening?
31 Missed Opportunities For Prevention Disease Investigation Perspective Timeliness of health department follow-up Unable to locate father of baby Clinical Perspective Patient not treated after first positive RPR Report of prenatal care visits and unknown follow-up regarding positive RPR, if any Patient reports OBGYN didn t have medicine Discussion: Provider barriers to treatment Policy/Systems Level Perspective Surveillance/Informatics Perspective Other perspectives?
32 SAMPLE CASE #2 Identifying names, dates, locations, and other characteristics have been changed in the following sample case.
33 Mother of Baby characteristics (2) 29 years old; Hispanic/Latina HIV negative Methamphetamine use Limited prenatal care Reports 1 sex partner in past 12 months Partner likely having sex with other partners Partner lives in Central Valley Declined to name partner; she notified him of syphilis
34 Mom & Baby Timeline 2015-16 (1) 12/31/15 Hospital #1 Perineal/perianal lesions RPR 1:64, FTA-ABS+ No treatment (22 weeks GA)
35 Hospital #1 12/31/15 Patient presents to ED c/o perineal & perianal lesions; MD notes raised white lesions that might be HPV genital warts Fetal movement noted Diagnosis: perineal and perianal lesions (possible HPV) onset 4 days prior missed syphilis diagnosis No prenatal care before this visit RPR 1:64, FTA-ABS+ Patient was discharged before her test results came back No treatment given at this time
36 Mom & Baby Timeline 2015-16 (2) 12/31/15 Hospital #2 Perineal/perianal lesions RPR 1:64, FTA-ABS+ No treatment (22 weeks GA) 2/1/16 OBGYN Office Condylomas present RPR 1:64, TPPA+ No syphilis treatment (27 weeks GA) 1/6/16 CMR faxed to health dept. (23 weeks GA)
37 OBGYN Office 2/1/16 First prenatal/OBGYN visit Condylomas present missed syphilis diagnosis No mention of treatment for syphilis RPR 1:64, TPPA+ Positive titers for syphilis on prenatal labs however patient never returned to clinic for treatment 3 no shows after this visit
38 Mom & Baby Timeline 2015-16 (3) 3/8/16 Hospital #2 Stillbirth Condylomas still present RPR 1:64, TPPA+ Treatment: BIC x1 (32 weeks GA) 12/31/15 Hospital #1 Perineal/perianal lesions RPR 1:64, FTA-ABS+ No treatment (22 weeks GA) 2/1/16 OBGYN Office Condylomas present RPR 1:32, TPPA+ No treatment (27 weeks GA) 2/14/16 No show @ OBGYN Office (28 weeks GA) 1/6/16 CMR faxed to health dept. (23 weeks GA) 2/21/16 No show @ OBGYN Office (30 weeks GA)
39 Hospital #2 3/1/16 Presents to triage c/o decreased fetal movement for 3 days & contractions No fetal tones; still condylomas on vulva & perineum patient reports for past month Patient admitted for induced labor; fetal demise; stillbirth delivered Clinician observed lesions in her perineum consistent with condyloma lata secondary syphilis diagnosis RPR 1:64, Trep+ Patient treated BIC x1
40 Mom & Baby Timeline 2015-16 (4) 3/8/16 Hospital #2 Stillbirth Condylomas still present RPR 1:64, TPPA+ Treatment: BIC x1 (32 weeks GA) 12/31/15 Hospital #1 Perineal/perianal lesions RPR 1:64, FTA-ABS+ No treatment (22 weeks GA) 2/1/16 OBGYN Office Condylomas present RPR 1:32, TPPA+ No syphilis treatment (27 weeks GA) 3/24/16 Interview conducted 2/14/16 No show @ OBGYN Office (28 weeks GA) 1/6/16 CMR faxed to health dept. (23 weeks GA) 2/21//16 No show @ OBGYN Office (30 weeks GA) 4/15/16 Closed
41 Case #2: Discussion What were potential missed opportunities to prevent this case? Disease Investigation Perspective Clinical Perspective Policy/Systems Level Perspective Surveillance/Informatics Perspective Other perspectives? What are potential intervention points to prevent a similar case from happening?
42 Missed Opportunities for Prevention (2) Disease Investigation Perspective Investigation not initiated for nearly 3 months Clinical Perspective Patient s lesions not recognized to be syphilis Policy/Systems Level Perspective Positive RPR at Hospital #2 was not available to OBGYN Surveillance/Informatics Perspective Other perspectives?
