Status of Prenatal Assistance services for Syphilis Infected Pregnant Women on Region of Baixada Santista, Sp, Brazil

In Brazil, the vertical transmission of syphilis remains a great public health problem. Over the last years, it has increasingly become a reemerging disease, with rates of congenital syphilis of about 3 for every 12 thousand children born alive [1-3], varying in different regions of the country [510]. According to data from the Ministry of Health, in 2016, 87,593 cases of acquired syphilis were recorded in Brazil, 37,436 cases of syphilis in pregnant women, and 20,474 cases of congenital syphilis, and among these, 185 deaths. The larger number of cases was reported in the southeastern region (53.5% of acquired syphilis, 46.9% of syphilis in pregnant women, and 41.5% of congenital syphilis). In Brazil, the prevalence of syphilis in pregnant women is four times higher than in cases of positive acquired immunodefi ciency virus (HIV) from the same group4. The general region of Santos comprises 9 cities and around 1.8 million inhabitants. The objectives of the study were to research the methodology used in prenatal care for pregnant women with syphilis between 2014 and 2016 in that region.


Introduction
In Brazil, the vertical transmission of syphilis remains a great public health problem. Over the last years, it has increasingly become a reemerging disease, with rates of congenital syphilis of about 3 for every 12 thousand children born alive [1][2][3], varying in different regions of the country [5][6][7][8][9][10]. According to data from the Ministry of Health, in 2016, 87,593 cases of acquired syphilis were recorded in Brazil, 37,436 cases of syphilis in pregnant women, and 20,474 cases of congenital syphilis, and among these, 185 deaths. The larger number of cases was reported in the southeastern region (53.5% of acquired syphilis, 46.9% of syphilis in pregnant women, and 41.5% of congenital syphilis). In Brazil, the prevalence of syphilis in pregnant women is four times higher than in cases of positive acquired immunodefi ciency virus (HIV) from the same group 4 . The general region of Santos comprises 9 cities and around 1.8 million inhabitants.

Results
Most pregnant women in this study (63.5 %) were between 18 and 30 years old, and 14.7 % were teenagers less than 18 years old. In six medical records there was no age stated. The coinfection with HIV were found in 7.4% of the cases studied, and 4.32% were coinfected with hepatitis B. Some of the pregnant women were diagnosed with hepatitis C (0.61%) and tuberculosis (2.46%).
As to the pregnancy trimester, more than half (69.7%) of the cases were diagnosed with syphilis during the fi rst trimester, 19.3% in the second, and 8.6% in the last trimester.
In 4 of the medical records there was no information about it.
The medication used for syphilis acquired during pregnancy was, predominantly, benzathine penicillin.
Of the pregnant women studied, 59.25% went to a few appointments for prenatal care, whereas 29.62% participated in all prenatal care established appointments. Only 11.13% of the seropositive pregnant women followed through with the VDRL assistance in all months of pregnancy. The study showed that 54 out of 162 (36.41%) of the partners received no syphilis treatment, against 59/162 (33.13%) who were treated; there is no information as to the remaining 49 pregnant women.
Additionally, in non-monogamous situations there was no record of treatment of more than one sexual partner.
Five death reports were found in the 162 medical records, 1 mother and 4 newborns. There was no cause of death reported on the medical records.
Among the laboratory tests collected, VDRL was the most frequently requested, corresponding to 96.91%. The treponemic test was applied in 64.19% of the cases. To reduce risk, the pregnant women with VDRL titles 1:2 and 1:4 received treatment on the assumption that they had not been treated before.
Late in 2016, the quick test was introduced, albeit without causing any impact on sampling.
There are no reports in the medical records of after birth treatments or the outcomes. The full data of the 162 researched records are detailed on table 1 (demographic characteristics of the sampling) and on table 2 (prenatal care data). The absence of basic data or ineligible handwriting from the assistant doctors was marked as "Not applicable."

Discussion
In the study, it was possible to verify the defi ciencies in  · The absence of basic data or ineligible handwriting from the assistant doctors was marked as "Not applicable." · Total value and its percentage for each variables it was impaired because the handwriting in the medical records was not clear enough to read or missing information. In each item is referenced in the right column. with syphilis is worrisome because the presence of syphilis facilitates the transmissibility of HIV to the fetus [14,15].
An improvement in the control of the prenatal care would be the Family Health professionals coordinating medical staff who provide prenatal care.
The absence of a program focused specifi cally on the man, like the important Women's Health, program is remarkable as well. Prenatal care training programs have proved effective [16], but not very proactive in many regions of Brazil.
Informatization of medical records will certainly bring welfare improvement and epidemiological effi cacy.
"To be born without syphilis is a universal right".

Conclusions
Prenatal care in pregnant women with syphilis in the studied area showed numerous fl aws in relation to the guidelines of the  Not applicable" indicates lack of information on medical records or because the handwriting was illegible. Total value and its percentage for each variables it was impaired because the handwriting in themedical records was not clear enough to read or missing information. In each item is referenced in the right column.