Antenatal Care (ANC)

(Prenatal Care)

Ahmed Abdella, MD, MSc. (PHDC)

Obstetrics & Gynecology, 2021
Outline
• Introduction
• ANC objectives & purpose
• ANC models
• ANC assessment and investigations
• Common conditions in ANC
• Minor illnesses/ disorders of pregnancy
Introduction
• Pregnancy is basically a physiologic process.

• About 75-85% of pregnancies culminate without major

complication.

• ANC refers to the health care provided to a pregnant woman

throughout pregnancy until labor.
• “…. the complex of interventions that a pregnant woman and
adolescent girl receives from skilled health care professionals in order
to ensure the best health conditions for both mother and baby during
pregnancy conditions for both mother and baby during pregnancy.”
FMOH; Obstetrics Management Protocol for Hospitals. MOH, Ethiopia, 2021
 Purpose of Antenatal Care
• ANC reduces maternal and perinatal morbidity and
mortality through*:
• Screening, diagnosis and management of the risk factors
and pregnancy-related complications.
• Identification of women and girls at increased risk of
developing complications.
• Provides an important opportunity to prevent and manage
concurrent diseases through integrated service delivery.
• Ensuring referral to an appropriate level of care
• As maternal mortalities & morbidities decrease, ANC
focuses on fetal/ neonatal mortality & morbidity
leading to widening dimensions of interventions
* FMOH, 2021
ANC program activities/
strategies
Components- basically ANC program intended to
• Health promotion and disease prevention;
• Screening, diagnosis and management or referral
for disease;
• Birth planning and complication readiness.
ANC specifics purposes:
1. Provide evidence based interventions and care
which can prevent and treat complications of
pregnancy (mother, fetus/NB)
• Screening for and diagnosis and management of pre-
existing maternal disorders (DM, CVD, infections etc.)
• Diagnosis and management of Obstetric and other
maternal complications during pregnancy including
minor disorders of pregnancy.
• Detection and management or preferable prevention
when feasible of fetal complications including structural
anomalies, infections and growth restriction.
 ANC purpose specifics (2):
2. Planning for labor and delivery, care of the newborn
and future reproductive performance.
• To encourage skilled attendance at delivery
• To discuss plans for emergency transport and funds in the case
of an emergency and to identify the nearest site of EOC
• (To provide a link between women and the health care
system)

3. To provide health education on key issues (promotive

& preventive)
Models of ANC

• Traditional method:
• > 12 ANC visits
• High/ low risk pregnancy
• WHO Focused ANC models:
• 4±1 ANC visits for all
• Special care for those with complications/ risks
• 2016 WHO ANC model (& adopted by FMOH-2021):
• ≥ 8 contacts
• Fetal/ NB wellbeing

WHO recommendations on ANC for a positive pregnancy experience. Geneva: WHO:

https://apps.who.int/iris/bitstream/handle/10665/250796/9789241549912eng.pdf;js
essionid=8087302032AD2F29EC612A7F08C7AA58?sequence=1
 ANC contact schedules
• Antenatal care model
with a minimum of eight
contacts are
recommended to reduce
perinatal mortality and
improve women’s
experience of care

Every 4 & then 2 weeks

Classify type of care

Previous FANC scheme

ANC assessment
• Pregnancy oriented history & physical examination
some of which vary with GA and coexisting
complication
• First 2 issues with first trimester contact
• “Is she pregnant?”
• Gestational age: the most important finding in pregnancy!!
• Either both or at least one of the two: US, LMP
• If no or unreliable US or LMP: FH ≤ 20 weeks (umbilicus)
• If none of the above is available: any other available estimator
such as urine pregnancy test, late US, quickening, FHB ..
• Further details of assessment …
 ANC assessment* (cont.)
• Current or previous obstetric • Psychological, substance
complications/ experience:
• Gravidity, parity, abortion, ectopic
use, violence …
• Multiple pregnancy • Personal and environmental:
• Rh-negative
• previous CS,
• Malaria
• SB, END, etc. • Hook worm
• APH, PPH … • Wanted/ preplanned
• Medical/ gynecologic/surgical illnesses: pregnancy
• Anemia • Partner/ family support,
* Details of the assessment are
• DM
• Hypertension
financial
dealt with in your history &
• Myoma • Educational
examination session.
status Handouts,
….age…
clinical protocol of the Department
• Infertility BMI…
and FMOH guideline also include a
• STI (HIV, syphilis, HB..), chapter in the subject
• TB
 Basic investigations (in
Ethiopia*)
• All women:
• Urine analysis: UTI, proteinuria (≤12; 26; 34 WKS)
• Urine mid-stream culture (≤12
• Syphilis (RPR or VDRL) (≤12
• HIV: Op-tout (≤12 & 28-36)
• HBsAg (≤12
• Blood-group (ABO and rhesus) (≤12
• Hemoglobin or hematocrit (≤12; 32,38 WKS)
• Blood glucose using 75 g (24-28 wks)
• Ultrasound (FMoH 2021: @ < 24 wks)
• Stool exam: In high risk communities or clinically suspected

*Source: FMOH guidelines

Routine prenatal US
• WHO 2016: One US scan before 24 weeks to:
• estimate gestational age (GA),
• improve detection of fetal anomalies
• Most done @ 18-22 (other than nuchal translucency screening @
11-13+6)
• multiple pregnancies

• Practical Implication -
1. One US policy: Second trimester at 16 -18 (24) weeks
2. Two US policy: First US in first trimester, second in STM -
16-18 (24) weeks
IF Rhesus negative AND indirect coomb’s test is*:

• Negative - administer antenatal anti-D

immunoglobulin:
• at 28 weeks and
• Postpartum (as early as possible within 72 hours) after
checking blood group of newborn from cord blood
• Positive - monitoring for hydrops fetalis,
transfusion, delivery….
* FMOH 2021
• [DETAILS IN THE SPECIFIC LECTURE]
IF HBsAg is
• Positive, determine HBV DNA viral load:
• If load >200,000 IU/mL of blood - virus is active - give
tenofovir from 28 wks of gestation until delivery
• If laboratory test for HBV viral load is not available, determine
HBeAg: If HBeAg IS detectable, give tenofovir from 28 wks of
GA until delivery
• Linkage/ referral for medical evaluation is also important
for assessment of eligibility for lifelong treatment and
follow up
• * FMOH 2021
*FMOH
2021:
adopted
from
WHO
2020
Tetanus toxoid vaccination
• Prevent neonatal tetanus significantly (& also for
the mother)
• Two TT doses 1 month apart irrespective of GA –
protects for 1-3 years
• Third dose after 6 months - protects for 5 years
• Fourth and 5th dose one year apart (or subsequent
pregnancies): 5 doses protect throughout reproductive
age
Anemia: Definition
• A pregnant woman is considered to be anaemic if her Hb
concentration (at sea level):

• first and third trimester of gestation <11.0 g%

• second trimester of pregnancy <10.5g%

• usually decreases by approximately 0.5 g%due to maximized blood volume
increment

• Early postpartum anemia: Hb <10.0g/dl

• Late puerperium: 12 g%
WHO. 2012. Guideline: Daily iron and folic acid supplementation in pregnant women.
Anemia: Definition
• Anemia severity grading

• Mild > 90g/L: Don’t rely on conjunctiva paleness to diagnose

mild anemia – peripheral hyperemia of pregnancy!

• Moderate anemia: Hb 70–90 g/L

• Severe anemia Hb <70 g/L

• < 4g%: Anemic CHF!

• [DETAILS IN THE SPECIFIC LECTURE]

WHO. 2012. Guideline: Daily iron and folic acid supplementation in pregnant women.
Anemia: causes & diagnosis
• Anemia in pregnancy is commonly associated with
iron and folate deficiencies.
• Folate deficiency- neural tube defect too
• If anemic, besides detailed history & examination
on sign & symptoms of anemia, possible causes
etc., at least check for
• Blood smear OR RBC indices (hypochromic, microcytic)
• Stool exam if HW etc. suspected
• Therapeutic trial for 2-3 weeks with adequate treatment
Anemia: prevention

• Supplementation (prevention/ promotion)

• A healthy diet contains adequate energy, protein, vitamins
and minerals, obtained through the consumption of a
variety of foods, including green and orange vegetables,
meat, fish, beans, nuts, whole grains and fruits
• “Eat as much you get”
• “Coffee, tea: one hour before or after diet, don’t mix”
decrease use
• “Lemon, orange etc. with diet”
• Deworming
• Iron-folate supplementation
 Anemia: supplementation (prevention)
• Daily oral iron and folic acid through out pregnancy –
(or after FTMP) and during puerperium
• 30 mg to 60 mg of elemental iron and
• 400 μg (0.4 mg) folic acid
• Folic acid should be commenced as early as possible
(ideally before conception) to prevent neural tube
defects
• Intermittent oral iron and folic acid supplementation
with 120 mg of elemental iron and 2.8 mg of folic acid
once weekly is recommended if daily iron is not
acceptable due to side effects
Anemia: treatment
• If anemia diagnosed during pregnancy, her daily
elemental iron should be increased to 120 mg until
her Hb concentration rises to normal (Hb 11 g/dL or
higher). Thereafter, she can resume the standard
daily antenatal iron dose to prevent recurrence of
anemia
• The equivalent of 60 mg of elemental iron is
• 300 mg of ferrous sulfate hepahydrate, or
• 180 mg of ferrous fumarate or
• 500 mg of ferrous gluconate
Anti-helminitcs (deworming)

• Recommendation:
• Prevalence of hook worm and whip worm is >20% or
• Prevalence of anemia is a severe public health problem
(prevalence > 40%)

• Deworming dose:
• Albendazole 400mg stat or
• Mebendazole 500mg stat
• Both are started in the second or third trimester
Malaria prevention in endemic areas

• Intermittent preventive treatment with sulfadoxine-

pyrimethamine is recommended (Fansidar) for all
pregnant women.
• Started in the second trimester
• Given at least one month apart
• Objective is ensuring at least three doses are received
• Insecticide-treated nets ITNs)
Gestational diabetes mellitus
(Physiologic)
Symptoms during pregnancy
• Some women experience an increased sense of wellbeing during
pregnancy OTHERS may be marred by considerable discomfort and
distress caused by ‘minor’ symptoms of pregnancy.
• These symptoms may include
• nausea, vomiting,
• heartburn,
• Constipation
• faintness (syncope)
• low blood pressure when lying on one’s back (supine hypotension),
• varicose veins, haemorrhoids,
• Swelling (oedema)
• backache,
• cramps
• frequency of emptying the bladder.
Less common symptoms include
• inflammation of the gums
(gingivitis),
• craving for unusual foods
(pica)
• diarrhoea, flatulence
• rapid heart beats
(palpitations)
• nose bleeds (epistaxis)
• separation of the pubic bones
at the front of the pelvis
(symphyseal separation)
• urinary incontinence,
• Headache
• Insomnia
• Tiredness
• difficulty with breathing
(dyspnoea),
• skin and hair changes
• pain in the breasts (mastalgia)
• restless leg syndrome,
• heat intolerance
• hand discomfort.
Thank you
• The presentation is not ON everything about ANC
as ANC is a program that incorporates every thing
in obstetrics and program management, policies …
• But … more in other lectures & sessions …. PMTCT,
syphilis, medical illnesses …
• I have included additional slides on minor illnesses
for your reading mainly taken from WHO’s
recommendation

• Q&A?
Morning sickness
Nausea, emesis gravidarum

• Begins at weeks 5–6, do • Causes are unclear:

not last longer than 3–4 • High level of hCG in the
months, and are more first trimester
common in cases of • First trimester pregnancy
multifetal gestation and pro-inflammatory response
molar pregnancy • Distension of stomach
(Progesterone smooth
muscle effect
• Unwelcome and
unplanned pregnancy as
well as conflict in the
mother-daughter
relationship….
 Management
• Usually not necessary: counsel
about comfort measures
• Eat small, meals frequently
• Keep crackers at bedside and eat
before getting out of bed
• Eat fruit or drink fruit juice
before going to sleep
• Avoid oily spicy food
• Get out of bed slowly
• Symptoms should not extend
beyond first 3 months: if severe
and persistent, see your health
care provider HYPEREMESIS GRAVIDARUM DETALS IN OTHER SESSIONS
• Provide Vitamin B6, 50 mg
BID
• If symptoms are severe,
consider hospitalization
and IV fluids
• Medication may include:
• Promethazine (Phenergan)
• Diphenhydramine
(Benadril)
• Other antihistamines
• Birth defects not associated
with these drugs
Dyspepsia (heartburn)
• Common especially in the third trimester
• Exclude preeclampsia!
• Cause:
• Progesterone smooth muscle effect o gastro-esophageal sphincter
lowering of the resting tension with incomplete gastro-esophageal
closure
• Compression of the stomach by the third trimester pregnant uterus
• Lying supine
• Treatment:
• Avoidance of bending down and carrying heavy loads
• Distribution of food intake over a number of smaller meals
• Lying down, sleeping with elevated upper body (raising the head end of
the bed)
• If needed anti-acid treatment
Hemorrhoids
• Hypervolemia, vasodilation, obstructed venous
drainage, and pushing in the second stage of labor
and in puerperium can all lead to the development of
hemorrhoids
• Treatment:
• Local treatment with sitz baths, creams, suppositories
• Ensuring that bowel movements are soft
Varicosities
• Cause:
• hypervolemia and generalized vasodilation increase venous pressure in
the legs.
• Promoted by blood flow obstructions (large uterus, constrictive clothing,
working in a standing position)
• Treatment
• Medication is rarely successful
• Wear support hose (elevate legs before putting on hose for maximum
support) Elastic stockings (compression grade II) should be prescribed at
an early stage
• Daily elevation of the legs periodically
• Leg exercises and swimming
• Consult/ refer if severe and painful
• Vulvar varicose veins: Avoid veins in episiotomy
Constipation
• Common
• Cause:
• Progesterone (relaxation of smooth muscles)
• Treatment:
• Increase water intake (8 glasses)
• High-fiber diet:
• large amounts of fruit, vegetables, dairy products, whole wheat
bread, dried fruits, fruit juices, dried figs, or prunes which have
been soaked in water overnight
• Daily exercise
• Mild laxatives last resort if necessary
Vaginal discharge
• Differentiate from abnormal discharge due to:
• Infections: itching, irritation, unpleasant odor …
• Abortion, APH: Bloody discharge …
• PROM: gush of fluid …
• Etc.
• Management:
• Clean genitalia daily
• Wear cotton underwear
• Use light sanitary pads if discharge is heavy
• Avoid vaginal douching
Headache
• Exclude preeclampsia (danger sign)

• Treatment:
• Paracetamol 300 mg /3-4 hours
• For severe headache or migraine: codeine or other
related narcotic
 Muscle cramps
• Cause:
• Unknown
• mineral or pantothenic acid deficiency
• Treatment:
• During cramping, straighten leg slowly with heal pointing and
the toes towards or push the heel against the floor if standing..
• Exercise daily to enhance circulation
• Elevate leg periodically
• Eat calcium rich food (dairy and dark green leafy vegetables
• ± Calcium tablets daily(Ca++ carbonate or lactate)
Backache
• Management:
• Exclude UTI and labor
• Avoid excessive bending, lifting or walking without a rest
period
• Rock pelvic periodically during the day for relief
• Heat or ice to back for relief, whichever is more
comforting
• Wear supportive, low –heeled shoes
• If severe: wear a maternity girdle for additional support
Danger signs during pregnancy
Rights of the Pregnant Woman*
• Health care providers should be aware of the client’s
rights when offering antenatal care services. The
pregnant woman has the right to:
• Information about her health
• Discuss her concerns, thoughts, and worries
• Know in advance about any planned procedure to be
performed
• Privacy
• Confidentiality
• Express her views about the services she receives

*FMOH guideline
Nutritional advice
 Template for ANC case note
(Draft)
• History
• Client Name__________________________ Age ____
Card No.__________ Initial booking Date ________
• Gravidity _____Parity______­­Abortion
______LNMP____________ Due Date________
• Basic Investigation results
• BG&RH________ HGB/HCT _______HBsAg _______
VDRL____________
Template for ANC case note (Draft)

• Identified past & current obstetric problems

• Multiple pregnancy Yes □ No □: Rh iso immunization:
Yes □ No □:DM Yes □ No □: Hypertension: Yes □ No □:
Cardiac disease Yes□ No □: Anemia Yes□ No □ C/S
/Uterine Scar: Yes □ No □:
• Previous bad pregnancy outcome: Yes □ No □: Specify if
yes__________________________________________
____________________
• □ Other (Specify)
_____________________________________________
 Template for ANC case note (Draft)
                 
Date of visit                
Gestational age                

TT vaccine                
Iron & folic acid                

Calcium                
supplementation

Abnormal lab test                

Instituted                
treatment

Remark                
Sign                

Currently available is for FANC ..

 Case for discussion:

• Direct obstetric causes of maternal deaths in Ethiopia:

• Hemorrhage
• Preeclampsia
• Infection
• Obstructed labor
• Abortion
• Strategies required in Preventing MD are:
• Skilled birth attendant (SBA)
• Emergency obstetric care (EmOC)
• Family planning
Case for discussion (continuation):

• “…By implementing timely and appropriate evidence-based practices,

ANC can save lives…..”
A question to ponder with:

What is the role of ANC in

preventing maternal &
perinatal death? ****

Consider the role of ANC

in preeclampsia
• Treatment of maternal syphilis is critical to prevent
congenital infection: 70–100% of infants born to
untreated mothers will be infected vs 1–2% of
those born to women adequately treated in
pregnancy.
• Jarisch–Herxheimer in the latter half of pregnancy, can
lead to uterine contractions, preterm labor, and/or non-
reassuring fetal testing.
Syphilis
• Early syphilis (<1 year) includes
• Primary
• Secondary, and
• Early latent
• Latent syphilis refers to asymptomatic infection with positive
serology and no physical findings. It is divided into early (<1 year)
and late latent (>1 year).
• Tertiary syphilis occurs after early or latent syphilis, and typically
involves the central nervous system (CNS), the cardiovascular
system, or skin and subcutaneous tissues. It can arise as soon as 1
year after initial infection or up to 25–30 years later.

• [DETAILS IN THE SPECIFIC LECTURE]

Syphilis
• WHO syphilis screening guideline
• Screening all pregnant women for syphilis during the first
antenatal contact
• In settings with a high prevalence of syphilis (5% or greater),
on-site rapid syphilis test (RST) and, if positive, provision of a
first dose of treatment and a rapid plasma reagin (RPR) test,
and then, if the RPR test is positive, provision of treatment
according to duration of syphilis (Strategy C). The WHO STI
guideline suggests this sequence of tests and treatment
rather than a single on-site RST (Strategy A) or a single on-site
RPR test (Strategy B).
• treat early syphilis and chancroid:
• Give single dose benzathine benzylpenicillin 2.4MU IM or if
penicillin allergic and not pregnant/breastfeeding, doxycycline
100mg PO BID for 14 days and
• Give single dose azithromycin 1g PO or ciprofloxacin 500mg PO
BID for 3 days or erythromycin 500mg PO QID for 7 days. If
penicillin allergic and pregnant/breastfeeding, give ceftriaxone
1g IM daily for 8-10 days.
• If penicillin allergic, do baseline RPR. Advise patient to return
for repeat RPR in 6 and 12 months. If RPR positive after 12
months, refer.
Early syphilis (primary, secondary and early latent
syphilis of not more than two years’ duration)

• benzathine penicillin G 2.4 million units once intramuscularly over procaine

penicillin 1.2 million units intramuscularly once daily for 10 days.
• When benzathine or procaine penicillin cannot be used (e.g. due to penicillin
allergy where penicillin desensitization is not possible) or are not available
(e.g. due to stock-outs), the WHO STI guideline suggests using, with caution,
erythromycin 500 mg orally four times daily for 14 days or ceftriaxone 1 g
intramuscularly once daily for 10–14 days or azithromycin 2 g once orally.
• Remarks: Although erythromycin and azithromycin treat the pregnant
women, they do not cross the placental barrier completely and as a result
the fetus is not treated. It is therefore necessary to treat the newborn infant
soon after delivery (see recommendations 9 and 10 for congenital syphilis).
Ceftriaxone is an expensive option and is injectable. Doxycycline should not
be used in pregnant women. Because syphilis during pregnancy can lead to
severe adverse complications to the fetus or newborn, stock-outs of
benzathine penicillin for use in antenatal care should be avoided.
Late syphilis (infection of more than two years’
duration without evidence of treponemal
infection)
• In pregnant women with late syphilis or unknown stage of syphilis, the
WHO STI guideline suggests benzathine penicillin G 2.4 million units
intramuscularly once weekly for three consecutive weeks over procaine
penicillin 1.2 million units intramuscularly once a day for 20 days When
benzathine or procaine penicillin cannot be used (e.g. due to penicillin
allergy where penicillin desensitization is not possible) or are not available
(e.g. due to stock-outs), the WHO STI guideline suggests using, with
caution, erythromycin 500 mg orally four times daily for 30 days. Remarks:
Although erythromycin treats the pregnant women, it does not cross the
placental barrier completely and as a result the fetus is not treated. It is
therefore necessary to treat the newborn infant soon after delivery (see
recommendations and 10 for congenital syphilis). Doxycycline should not
be used in pregnant women. Because syphilis during pregnancy can lead
to severe adverse complications to the fetus or newborn, stock-outs of
benzathine penicillin for use in antenatal care should be avoided.
• Syphilis diagnosis is based on the patient’s history,
physical examination, laboratory testing and
sometimes radiology. The available laboratory tests
for diagnosis of syphilis include direct detection
methods (i.e. darkfield microscopy, direct
fluorescent antibody test and nucleic acid
amplification test), serology (treponemal and non-
treponemal tests), and examination of
cerebrospinal fluids (6).
• DIRECT DETECTION METHODS
• Direct detection methods require exudates from
lesions of primary, secondary or early congenital
syphilis, and need careful collection of samples.
RAPID DIAGNOSTIC TESTS
• In the past decade, a number of point-of-care rapid
diagnostic tests (RDTs) for treponemal antibodies in
syphilis infection have been developed. RDTs provide
treponemal antibody results in 10–15 minutes and
can be performed in any setting since they do not
require refrigerated storage or laboratory equipment.
• The sensitivity of the RDTs ranges from 85% to 98%
and the specificity from 93% to 98%, compared to
the TPHA or TPPA as reference standards. In general,
RDTs with higher sensitivities tend to have lower
specificities and vice versa.
• Most of the initial range of RDTs use T. pallidum
antigens to detect treponema-specific antibodies.
Many of the tests use immunochromatographic
strips, which work by having a test strip
impregnated with treponemal antigens that react
with antibodies to syphilis in whole blood or serum.
The tests work on the same principle as the specific
treponemal tests described above, thus a positive
result does not distinguish between active and
previously treated infections
• More recently, tests that can detect antibodies
against cardiolipin-like materials have been
developed that work on the same principle as other
non-treponemal tests. They are available in
combination with the treponemal RDTs, providing
both a screening (RPR/VDRL equivalent) and
confirmatory (TPHA/TPPA equivalent) component.
However, these dual RDTs have not yet been
sufficiently evaluated or field-tested to be
recommended.
• SYPHILIS SEROLOGY
• There are two types of serological tests for syphilis:
• non-treponemal and treponemal. A presumptive
diagnosis of syphilis requires a positive result from at
least one of these types of tests. A confirmed diagnosis
requires positive results from both types of serologic
tests. Serum is the specimen of choice for serological
testing, although plasma can be used in some non-
treponemal serological tests. Cerebrospinal fluid is
used to diagnose congenital and tertiary syphilis and
when neurological symptoms are present.
• The most widely available non-treponemal tests are the microscopic
Venereal Diseases Research Laboratory (VDRL) and the macroscopic rapid
plasma reagin (RPR) tests. These tests detect anti-lipid immunoglobin M or G
(IgM or IgG) antibodies. Since these antibodies can also be produced in other
diseases, non-treponemal tests are not highly specific for syphilis and can
give false-positive results in conditions such as acute febrile viral infections
and some chronic autoimmune diseases. Most false-positive results have low
titres of less then 1 : 4. Non-treponemal tests may be negative for up to four
weeks after the lesion of primary syphilis first appears and can be negative in
late latent syphilis; additionally in primary and secondary syphilis, these tests
may be false negative due to a prozone reaction (i.e. interference by high
concentrations of antibodies in a specimen, which can be uncovered with
dilution and retesting). In primary syphilis, repeated testing at two and four
weeks may be required to exclude syphilis when suspect lesions are present.
A negative non-treponemal test at three months after onset of the primary
chancre virtually excludes the diagnosis of syphilis.
• Non-treponemal tests may be qualitative or quantitative.
Quantitative non-treponemal test titres can be used to monitor
response to treatment. Titres are expected to decrease following
effective treatment and increase in untreated active infection. A
four-fold change or higher in titre, equivalent to a change of at
least two dilutions (e.g. from 1 : 16 to 1 : 4 for effective positive
response to treatment, or from 1 : 8 to 1 : 32 for continued active
infection) is considered a significant difference between two
sequential tests using the same method (e.g. VDRL or RPR) and
preferably by the same laboratory. Titres that differ by only one
dilution (e.g. 1 : 8 versus 1 : 4 or 1 : 2 versus 1 : 1) are not
considered significant and may only represent differences in
laboratory interpretation).
WHO syphilis treatment guideline

• Pregnant women with early syphilis, single

benzathine penicillin G 2.4 million units once
intramuscularly (over procaine enicillin 1.2 million
units intramuscularly once daily for 10 days. )
• In late syphilis (more than two years’ duration) or
unknown stage of syphilis, benzathine penicillin G
2.4 million units intramuscularly once weekly for
three consecutive weeks