Background Adult and congenital syphilis rates are rising in the United States. The aim of this pre- and post-implementation study was to determine whether implementation of an opt-out laboratory-based and rapid syphilis point-of-care testing program in the emergency department (ED) improves the detection and treatment of syphilis during pregnancy in a high-prevalence region. Methods This pre- and post-implementation study was conducted at the University of Texas Health Science Center, Houston, TX. During the pre-implementation phase (November 1, 2023–February 29, 2024), pregnant patients presenting to the ED underwent laboratory-based syphilis testing using the reverse algorithm only when clinically indicated. In the post-implementation phase (March 1, 2024–June 25, 2024), pregnant patients without prenatal care or with no documented syphilis result underwent opt-out syphilis testing using the Syphilis Health Check point-of-care test and the laboratory-based reverse syphilis testing algorithm. Patients with positive syphilis test results were treated by providers. All results were confirmed with the laboratory-based test, and patient follow-up was scheduled. Results During the pre-implementation period, 302 pregnant patients presented to the ED, and only 6 (2%) underwent syphilis laboratory-based testing, none of which yielded positive results. In the post-implementation period, 322 pregnant patients presented to the ED and 202 (62.7%) were approached. Of these, 114 (56.4%) were tested using either the Syphilis Health Check or laboratory-based reverse algorithm (P < 0.001). Four patients tested positive for syphilis, indicating a prevalence of 3.5%. Conclusions An opt-out and rapid syphilis testing program for pregnant individuals visiting the ED increased syphilis screening from 2% to 56.4%, and detected syphilis that might have otherwise been missed.