In our sixth episode, Larry Prescott and Amy Carter speak with Dr. Emily Adhikari, Medical Director of Perinatal Infectious Diseases at Parkland Hospital and Assistant Professor in the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology at the University of Texas Southwestern Medical Center in Dallas, Texas. They discuss the difference between standard prenatal care and Maternal-Fetal Medicine and the importance of attending specialist appointments. They also explain the possible effects of untreated syphilis during pregnancy and why treatment should not be delayed.

Weblinks:

https://www.dshs.state.tx.us/hivstd/reporting/#syphilis

https://www.dshs.state.tx.us/hivstd/info/cs/provider.shtm

https://www.parklandhealth.org/gynecology

https://www.dshs.state.tx.us/hivstd/

Welcome to Exploring an Epidemic: Congenital Syphilis in Texas. I'm your host, Larry Prescott. In this podcast series, we will explore what's happened with syphilis and congenital syphilis in Texas through interviews with national and local experts. Talk about babies diagnosed with congenital syphilis in Texas and discuss how we can address the rising rates of congenital syphilis in Texas. After all, this is a 100% preventable disease with tests and treatment at our disposal if we all do our part. Of course, I have with me again today, my wonderful and beautiful cohost, Ms. Amy Carter, who's our department of state health services, congenital specialist. Amy, why don't you tell everybody hello this morning and welcome them in.

Hey, how are you guys doing this morning? Larry, we've talked a little bit about what I do with this state, but we haven't really talked about what you do. So can you give everybody a little bit of a brief history of Larry Prescott as consultant extraordinaire with department of state health services?

Oh, well, I guess I can. I've been in the field for 27 years, started as a DIS of course, doing the regular DIS work and progressing my career from the DIS to a little bit maternal and pregnancy involvement, then got recruited back into SCD when CDC brought out the syphilis elimination initiative, spearheaded that. Helped along not only in Houston, but Dallas and San Antonio and all the other funded areas that was involved with syphilis elimination. Created a lot of different things to help get the syphilis race down in Houston and across the state of Texas. From that point I went on to be, what we called our Field Operations Manager, which oversees supervisors who oversees, of course the DIS workforce. Again, fixing problems and plugging holes. One of the nicknames they gave me at the city of Houston was [Swiss 00:01:52], and I knew what that meant, Swiss army knife. I guess that we utilized for a lot of different things, which is fun for me. Because the more I was involved, the more I got to know all about personnel.

Did a lot of training. I went on from field operations to doing some program manager at the city of Houston for maybe about eight months prior to my retirement over there. Then December, 2018, I don't want to say recruited, but between us I was recruited to do consulting work at the state health department, become a program consultant there, which is what I'm currently doing right now. I have several different programs that I manage, Austin, Copper, Galveston, what we call two regionals, 65 in the region 11 of Rio Grande valley. And of course, any other projects that they give me at the department of state health service, including podcasting. So that's a brief overview of where I am and how we got to this point, but I just appreciate all the knowledge that I've obtained and don't mind sharing it within and everyone.

Yeah, you've got a wealth of information that's for sure. So does our guest today, I'm really excited about this, our guest today. Because she actually helped me when I got started in congenital syphilis learning kind of the clinical side of things and is definitely a resource in the Dallas area. So Dr. Adhikari, do you want to go ahead and give us a little introduction of yourself?

I'm Emily Adhikari, I'm an assistant professor of obstetrics and gynecology and I'm a maternal fetal medicine specialist. And that means I do high risk pregnancy care at Parkland specifically, I work at UT Southwestern, and I've been there since probably 2018. I've grown into the role as medical director of perinatal infectious diseases. And so that means that I supervise and help train our providers to care for women that have syphilis in pregnancy.

Wonderful. We're so glad to have you on board today and look forward to having a very challenging and interesting podcast as we continue to explore what's happening with syphilis and congenital syphilis throughout the state of Texas. Of course we do interviews with national as well as local individuals because we as a healthcare community, know if we all do our part, that this is 100% preventable because of the treatments and diagnosis that we have at our disposal. And Dr. Adhikari, I would like to open up our podcast, since you mentioned that you, I guess more or less a specialist in the maternal fetal medicine area, I would like to know what is, if there is in the difference between maternal fetal medicine and just general OB-GYN.

Great question. So from my role as a specialist, I get patients who are referred for care for complicated medical conditions or infections such as syphilis, but most generalists, OB-GYNs will do the initial prenatal care for patients. And so for pregnant patients to enter prenatal care for an initial pregnancy visit, for example, they should get their basic labs, their first prenatal labs done with the general OB-GYN, and their first prenatal exam done with the general OB-GYN.

And then for patients who have a diagnosis of syphilis, those patients sometimes depending on where they are receiving care may be treated at the general OB-GYNs. In our healthcare system, patients who are diagnosed with syphilis in pregnancy are referred into my clinic, [inaudible 00:05:17] clinic for pregnant women at Parkland, where we see and treat those patients.

So as a provider, can you describe for us if you can, a provider's clinical approach to maternal syphilis?

Yeah. So it's sometimes intimidating to think about how to approach syphilis because syphilis is a challenging infection to diagnose sometimes, and it's confusing sometimes to diagnose and interpret the tests that we use, but you can break it down into the clinical staging part of things. And that's the basics that a provider or clinician should really know. We ask patients about any STD history when they come to prenatal care. That should be one of the initial questions that we ask. "Have ever had an sexually transmitted infection such as..." And we ask about all of them. And then we do an exam and we do some labs. And that's our initial approach, oftentimes because syphilis is a masquerading infection. It often is asymptomatic. A patient doesn't know that she has syphilis until the doctor comes to her and says, "Hey, look, we've got some abnormal lab tests to talk about." That's the first job of the general OB-GYN. Is to talk about what those labs mean and talk a patient through an initial diagnosis of syphilis. And, what do we do about it?

Have you noticed in your clinical approach, if there's any difference from, say a local clinic that approaches a patient with this versus maybe a large hospital like Parkland, is there different approaches clinically?

What I've noticed is that sometimes community physicians sometimes don't know what their resources are. And so sometimes it can be a challenge for a community physician who has this sudden unexpected diagnosis to talk about. They may be able to talk about syphilis as a sexually transmitted infection, but then they don't know what to do about it. And in pregnancy it's a little intimidating. And so I think that's one of the keys, is that know who you can refer to and what to tell a patient about the next steps.

Yeah, that's definitely those next step conversations are really important. I know when I was interviewing clients when I was in Dallas, before we'd get them over to you guys over at Parkland, or if we got somebody from a local clinic, you get this pregnant person who's freaked out to be quite honest, because there are some big consequences, potential still births, potential miscarriages with pregnancy with syphilis. And so having that conversation with them to calm them down, let them know that this is treatable, there's some stuff that we can do. You might need an ultrasound, which she looks first different things. So with that, Dr. Adhikari, can we talk a little bit about what those, we refer to them as level two ultrasounds or the various targeted ultrasounds that you might get during your pregnancy if you're diagnosed with syphilis?

Yeah. So when we talk about next steps after a diagnosis is made, we really need to review the history and physical, do that first step again, and make sure that we're asking some fairly pointed questions about any new sexual partners and any clinical symptoms. So those can mean ulcers that can suggest primary chancre, rashes, fever, febrile illness type of thing. But then, do an exam, including a pelvic exam. Because we really want to do the steps to look for any signs in the pelvis of primary or secondary syphilis, because those are the most infectious. So it's important for a patient to know, but it's also important because it gives us a sense of how recent it was and how risky this is for the pregnancy.

And then in a pregnancy that has a new syphilis diagnosis where the pregnancy is far enough along, that usually after 20 weeks, sometime around viability, a level two ultrasound is a specific type of ultrasound that looks for signs of congenital infection. And that's not to diagnose congenital infection because we just assume all babies have an infection in order to make sure that we treat it adequately, but signs on an ultrasound mean the baby is severely affected.

Do you have any stories you can share with us about your experiences with patients and clients who've gone through or come to you and maybe... Just something you can share with us?

Yeah. There's always cases that we remember vividly just because of how traumatic they could be. Those are some of the cases that I'll never forget and why I stayed passionate about this. I've had a patient who came late enough in her pregnancy, so into the second trimester of pregnancy when she established prenatal care. And so by the time she got those labs drawn and the diagnosis made, and her initial ultrasound which was a detailed ultrasound because we had the diagnosis at that point, she was already into the second middle of her pregnancy and the baby was severely affected.

And so there were really severe signs of congenital infection on the ultrasound. And that included a very large liver that we saw on the baby. There was a fluid, like retained fluid and swelling in different parts of the baby that essentially it's almost as if the baby goes into heart failure, and we'd call that high drops. And that is really a life threatening condition. That's the worst case scenario, especially when we know that this happens in the second trimester in some cases when we're diagnosing syphilis.

And if that happens, it's hard to fix that. And so this patient came in so late that we could not save this baby. The baby ended up passing away, even though we did make the diagnosis, but it was just too late by the time she came into prenatal care. And so I'll never forget that case.

Yes. In our line of work, we all have some stories that we take home with us because it's just a part of what we do, but I commend you because as public health individuals, without that compassion and that passion for what we do, things like this could easily turn us off from educating or doing whatever we can not to find ourselves in this particular situation once again. From your maternal fetal medicine position, are there any barriers, and if there's barriers, does it seem like it's systemic anywhere or just, is it complications to try to overcome those barriers if any?

I think some of the things we struggle with are getting the message out about early prenatal care, because what's so important about syphilis prevention and treatment is, when I don't see a woman outside because I'm a specialist that do maternal-fetal medicine, so I don't typically follow a woman through her entire life. I take care of a woman when she has a complication in her pregnancy. And so by the time she comes to me, she's already pregnant and she already has syphilis. So the key thing that I struggle with is sending that message to providers and to patients that early care is so critical. Because the earlier we diagnose and treat syphilis and pregnancy, the easier we can get rid of it. The baby will suffer less if a mom comes into prenatal care in that first trimester of pregnancy.

Yeah. I think that's one of the things that we see a lot from the public health side too, is that getting people into prenatal care sooner. I know I did a lot of interviews with you guys when I was in Dallas, because one of the things that they do that's unique is they actually have a DIS that goes to Dr. Adhikari's clinic, and will talk to newly diagnosed moms or pregnant people who are there to get them that importance of why they're being talked to, what's going on, getting their partners treated, but also just maintaining that, going to their appointments, especially if they need to have the series of three Bicillin injections. Because you get your provider telling you've got to do this and you get somebody from the health department coming in and reiterating that. These are important appointments for you.

So even if you've got a lot going on, make sure you're keeping those appointments. One time we interviewed somebody and we were able to go, because of that relationship between the health department and the hospital, we were able to go back and look at what the client had said to the disease intervention specialist and compare it with what was said to the provider and find some extra information. Because DIS interview differently than doctors do. We ask different questions, we ask them in a different way, but it still helps with that continuum of care and getting everybody on the same page and treated, because we also stage differently than maybe the clinicians do. We might have a little more information that we can share both ways because I think that's one thing that they've done a great job with that, is creating that bond and creating that pathway for sharing information.

I know we had a couple of confirmed cases in Dallas of congenital syphilis, which is rare. It's becoming more prevalent as providers do some of those additional testing because it's got to be on the infant for it to be a confirmed case. For public health follow up, we call them confirmed, we call them probable. So we have to have some additional testing. And I think one of the first cases actually, Dr. Adhikari helped recognize, I remember working on that one with her. But with that, what can a client expect when they come in to see you? When they get referred from their OB-GYN and they're not sure why it's so important to follow up or they're having some difficulties, why is it so important for them to make sure they maintain those appointments with you?

Yeah. Our first visit with a patient who's referred for syphilis is pretty comprehensive. And so in addition to that full, again, redo of our history to get the really good deep dive into a sexual history for a patient and a comprehensive physical exam. We do a lot of counseling about what is syphilis and what does it mean to have syphilis in pregnancy specifically. We do a lot more to counseling about what we're going to look for on an ultrasound, if a patient needs to have that detailed ultrasound, and then what happens after that ultrasound is done. And in addition, as you mentioned, we have a DIS who comes to our clinic and we make the patient aware that our DIS is there to provide partner services and to really help make sure that this doesn't happen again. It's to establish that good relationship, but also make sure that partner treatment is emphasized because this will just happen all over again if you do not get partners treated.

And so it is a long visit, but the patients understand at the end of it, why it's so important. And so we do that part of the counseling, we get the ultrasound and then based on the ultrasound and how far along the patient is, we then decide, okay, is it safe to treat the patient and then let her go home? Or is it important to treat the patient while we're actually monitor her and the baby for a period of time. Because of the risk of having a reaction called [inaudible 00:15:59] reaction, which is a systemic type inflammatory response. So that first Bicillin injection in pregnancy, that can actually manifest as fetal distress sometimes because the fetus is also experiencing that inflammatory response, it can provoke preterm labor, all that stuff. So those are the kind of things that we have to think about and talk a woman through knowing that treatment's important, it's necessary, but here are the things that we need to think about.

That is amazing because this is why I love doing these podcasts and having experts talk about different things because in training my DIS and telling them about these reactions that patients may have to the penicillin, the anaphylaxis and their harsh [inaudible 00:16:44], I never thought in my head about this also affecting a fetus. I still love learning and hearing new things, so I'm so happy to be a part of this podcast today. And what would be take home messages you would give me as a new or even an old provider.

Oh, goodness. So many things, but-

Go right ahead. I'll write them down.

There's a few things.

I'll start writing them down.

Yeah. I think we appreciate this, but I would try to impress upon new trainees, especially because I work with a lot of trainees. The fact that syphilis is not just any old STD, any old infection, it is a challenge, it's mysterious, and it can surprise you. But the key thing is that the earlier we diagnose it and the earlier we treat it in pregnancy, that could be life saving for a baby, in particular. It takes a long time for syphilis to kill an adult, but it will kill a baby. And that's why it's so important to diagnose and to treat thoroughly in pregnancy. And then the other thing I would impress upon a trainee is that you need to know your clinical staging. You need to know how to recognize the physical signs of syphilis, because it can be anything. And pregnant women come to their visits and they complain of little things, but you need to have a heightened sense of awareness because syphilis can be anything.

Any rash can be syphilis. You need to check a syphilis test if you see rashes or spots or bumps or things like that, you need to know that it... you should be suspicious for it and then know what tests to send. And then the last thing I would say is, my experience in some cases has been that, for pregnant patients that have syphilis and need to be treated, who report a penicillin allergy, that's an urgent situation. That's not a, "Oh, we should probably get some allergy testing so we can eventually treat syphilis." That's not a, wait a week or two to see how it goes. You have to deal with that that same day. You don't wait on that penicillin allergy thing because that may be a life or death situation for the fetus.

I think one of the things that you guys do really well, that I got a lot of phone calls from new doctors while I was in Dallas and knowing where your local health authority is and who that is, also something super important for new and old providers, because you could have a client who comes in and says, "Oh yeah, I had syphilis two years ago, I got all my shots." But when you call your local health authority, they can say, "Oh yeah, they got two shots, but they didn't finish their course." Or, "They only got one. But because we couldn't confirm a negative, she didn't have signs or symptoms, she didn't have any partners, we recommend that she gets a re-treatment to stop that spread to make sure that all the spirochetes are dead and they don't transmit from mom to baby. Even if her RPR is non-reactive. If her treponemal tests are positive, still make that phone call.

Yep. Trust, but verify. This is one of those situations where you trust, but you also verify. Having the relationship with your health department, knowing that even if the patient tells you she was treated, we should verify whether she was treated in the state or at another state, that's all possible. And it's possible through the health department, we need their help for that. That's really important.

And they will help you out. Even if it, like you said, if it's out of state, they can help get those records from out of state and get what she was staged as and what the treatments were. From most states, it might take a little bit, but they can definitely get it.

And the other thing I was going to say is most OB-GYN, this is what we learn in our training. But I guess some may forget that penicillin is the only thing we can use in pregnancy. It is penicillin is the only treatment that is effective to treat congenital syphilis, to actually rid the fetus of spirochetes. There are no other proven and approved treatments, but that's different for nonpregnant patients. So we have to keep that in mind. It's not an option to just use something else, we have to use penicillin.

It's great. I'm glad to hear that, I guess we have multiple people involved in this care and that there's some collaboration going on between all these providers. And what I really like is that everybody is stressing the urgency of getting this particular infection treated because that's the whole dynamic of what we do. Get people in. Yeah. I'm glad to hear you train your people about symptoms. I remember speaking with a lady, she had secondary, what we call palmer-plantar rash on the hands and feet. And she told me, "Well, I recently changed detergents, so I thought that was the reason I got this things in my hands and my feet. And I had to politically say, "No baby, I'm sorry. That's not what happened." [crosstalk 00:21:25]. That is not how you got those spots on your hands and feet. So let me explain it to you.

Well, and we've had it go the opposite way too. I had gotten a lab report and it was marked primary syphilis, and when we called back and said, "Hey, what were the signs and symptoms?" They were like, "Oh no, it's just the first time she's had syphilis." And it's like, "Nope, there's got to be a sore for it to be primary syphilis." And going through that with the provider as well. So yeah, your client's going to be like, "Oh, I changed my detergent, that's why I got this rash." Oh no, that generalized body rash might be syphilis.

Exactly. Yeah. That's what we train our trainees to emphasize, is that primary syphilis is not a new lab test, it is a clinical diagnosis, primary and secondary clinical diagnosis and you have to do an exam to make the diagnosis. And so the first lab test, it tells you there are syphilis there but it doesn't tell you what stage. So that clinical staging exam is then very important. Primary and secondary are much more infectious. And they also have higher risks associated with preterm birth, still birth, neonatal infections, those sorts of things. So it's important to make the diagnosis. And the treatment is very different in primary and secondary and early stage syphilis, you can get one and sometimes two penicillin injections, depending on where you're practicing. Some experts recommend two of the weekly bicillin injection. But for any latent syphilis, you get three weekly doses and there's no negotiating that one. You absolutely have to complete that regiment in pregnancy.

Yeah. I've transported clients that were pregnant because she's like, "I don't have a car." I'm like, "Okay, well I got a car, what time can I pick you up? Your appointments at eight?" "Okay, I'll be at your house at 7:30 and I'll drive you in and then I'll bring you back and then we'll do it again next week. And we'll do it the next week."

Okay. I'll call you next time I have a patient who needs a ride.

No, you'll call Dallas because I'm in Austin now remember.

Oh, yeah. My loss.

But they'll have someone in Dallas to do that because that's what we as DIS and public health follow up team people do, we do whatever it takes to collaborate with providers and anybody else to take care of the patient because we are their advocates. We are advocates for the patients and their health as well as the communities health as well.

Yeah. I have a great respect for that. I've learned so much about the level of dedication of our DIS in Dallas is really astounding and inspiring.

I'll pass that along. We'd like to thank you for joining us again today in our podcast about maternal fetal medicine and how it relates to general OB-GYN in congenital syphilis in the state of Texas. I want to thank my co-host Amy Carter for being here with us once again, and we want to thank our guest for joining us today. And we hope that everything that's said in this podcast can give you some great information and provide some insight on congenital syphilis in Texas. I'm your host Larry Prescott, we look forward to talking with you again later on. This podcast was developed by the Texas Department of State Health Services in collaboration with the Denver Prevention Training Center.