Toxoplasmosis, rubella, cytomegalovirus and herpes simplex
viruses are collective called as TORCH group of infections.
These are important infections that should be ruled out in
pregnancy because they can cause congenital malformations.
Toxoplasmosis
Causative organism:
Toxoplasma gondii
Transmission :
-Through encysted organisms by eating infected raw or
uncooked beef or pork.
-Through contact with oocytes in infected cat feces.
-The fetus can get infected by transplacental route.
Usually fetus will
be protected by maternal immunity. So if the women get infection during the pregnancy the fetus can get
affected.
Incidence:
Incidence of new infection in pregnancy is 0.5 to 8.1/1000.
Symptoms of maternal infection:
-Usually the infection will remain sunclinical.
-Some women may present with features like:
Fatigue
Muscle pains
Fever
Chills
Maculopapular rash
Lymphadenopathy etc.
-Infection can result in abortion or live baby with evidence
of disease.
Effect on the fetus:
-The possibility and severity of the congenital infection
depends on the gestational age when the fetus acquired it.
-With progression of pregnancy the risk of fetal infection
increases but severity decreases.
-Generally less than 25% of congenital toxoplasmosis
infected newborns will have clinical illness at birth. But later most of the
children can show some sequelae of infection. So follow-up is needed.
-Clinically affected infants at birth can present with:
Evidence of
generalized disease
Low birth weight
Hepatosplenomegaly
Icterus
Anemia
-Some infants can have neurological sequelae also, like:
Convulsions
Intracranial
calcifications
Mental retardation
Hydrocephaly or
microcephaly.
-All most all infected infants develop chorioretenitis.
Treatment:
-Routine screening is not recommended in general.
But in women with HIV infection screening should be done.
-In women with active toxoplasmosis (IgM positive)
antimicrobial treatment should be given.
Spiramycin, a macrolide antibiotic is usually used. Which
reduces the incidence of fetal infection but it may not modify its severity.
Pyrimethamine plus sulfadiazine can also be used when the
fetus is infected.
The usual followed protocol is:
If the pregnant suspected or confirmed of toxoplasmosis
during gestation:
-In less than 18 weeks – spiramycin therapy and fetal
ultrasound are adviced.
Amniotic fluid PCR
should be done after 18 weeks.
If PCR and ultrasound show negative results the spiramycin
therapy(1 g, thrice a day ttill deleivery) can be continued.
Or if PCR and/or ultrasound show positive result combination
therapy with pyrimethamin is preferred.
-In more than 18 weeks gestation: combination therapy with
pyrimethamin is preferred.
Ultrasound and
amniotic fluid PCR should be done.
Pyrimethamin combination therapy is:
Pyrimethamin - 50mg, twice a day for two days. Followed by
50mg, once a day till delivery.
Sulfadiazine- 75mg/kg body weight, twice a day for 2 days.
Followed by 50mg/kg body weight, twice a day till delivery.
Folinic acid- 10 to 20mg/day.
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