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Toxoplasmosis in pregnancy: analysis, risk consequences

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The author - Sozinova AV practicing obstetrician-gynecologist. Experience in the specialty s2001g.


toxoplasmosis It refers to TORCH-infections, joint one feature - the ability to transfer prenatal pathogen (vertical) by, ie, from mother to child. Disease-causing intracellular parasite belonging to the simplest, Toxoplasma.

Toxoplasmosis for many people in the worst case can only be a nuisance, but infection during pregnancy can lead to tragic consequences.

transmission path

Susceptibility to infection is very high, 20% of the population registered in Russia infected with these parasites. A particularly high proportion of infections in warm climates and among women (higher than that of men in the 2-3 times). Are 4 ways of transmission of Toxoplasma:

  • alimentary (poorly-done meat, eating raw meat, greens, vegetables and fruits from the ground);
  • contact (contact with the cat, especially with the homeless and "strangers" cats, cat care products: tray, bowl, toys, bedding, through the soil - dirty hands);
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  • transplacental - intrauterine infection in acute toxoplasmosis during pregnancy;
  • organ transplantation, blood transfusion.

During pregnancy infected with Toxoplasma 1% of women and 20% of infected pregnant happens transplacental transmission of the parasite to the fetus.

It was found that the transplacental transmission of Toxoplasma is possible only in case of infection after pregnancy. If it has repeated pregnancy, the vertical transmission of the pathogen does not occur.

  • In the case of infection more than 6 months before the present pregnancy, the fetus is not usually affected.
  • If Toxoplasma infection occurred less than six months before pregnancy, in most cases it is possible miscarriage.

The risk of fetal infection is directly proportional to gestational age (this is due to increased permeability of the placenta). But it should be noted that the chances of having a child with severe signs of congenital toxoplasmosis in the event of acute infection of women in late pregnancy are reduced.

Risk of Pregnancy

Possible infection of the fetus in pregnant women in the event of a primary Toxoplasma infection in the case of reactivation (ie infectious process was hidden, but during Pregnancy is activated, it is very rare and is less than 1%) of Toxoplasma during gestation in seropositive women (with immunoglobulin G).

The fruit is exposed to infection at any stage of pregnancy, but it is especially dangerous infection occurs in the first and second trimesters. If a woman is sick with toxoplasmosis during the third trimester, in most cases at the newborn marked asymptomatic disease with the development of clinical symptoms in a few months and years.

The severity of the fetus depends on the stage of pregnancy:

  • in 0-8 weeks, the risk of infection is 17%, and leads to severe malformations or fetal death (Anencephaly, stillbirth, spontaneous abortion, anophthalmia, hydrocephalus, enlarged liver and spleen and etc.);
  • 8-18 weeks in the risk of infection is 25% and leads to severe brain lesions (hydrocephalus, calcifications in the brain), liver, eye, and convulsions;
  • 18-24 weeks risk of contamination is 65% and leads to the dysfunction of internal organs: jaundice, anemia, hepatosplenomegaly, anemia;
  • at 24-40 weeks, the risk of fetal infection is 80%, and congenital toxoplasmosis occurs in 90% of asymptomatic infants with manifestation manifestation of a few years (deafness, mental retardation, chorioretinitis, epilepsy seizures).

Diagnostics

For laboratory diagnostics toksoplozmoza commonly used serological tests:

  • reaction of indirect immunofluorescence (or RNIF) and
  • linked immunosorbent assay (ELISA).

By means of serological methods the blood of pregnant determine the presence / absence of immunoglobulin M and G (antibodies to Toxoplasma IgM and IgG).

The diagnosis is confirmed by the growing and high titers of immunoglobulin in the dynamics (the study was repeated twice with an interval of 2-4 weeks). If there is an increase titers of 4 times or detect immunoglobulin M and G (IgM and IgG), then one speaks of a fresh infection.

IgM antibodies persist in the blood for up to 6 th month of infection, whereas IgG are formed with 6-8 weeks of infection and evidence of non-sterile immunity or chronic toxoplasmosis

To confirm the diagnosis requires a comparison of serological tests in the dynamics, that is, repeated blood tests of women within 2-4 weeks.

  • If a pregnant IgG and IgM were not found - this means that it has not been infected with Toxoplasma in general, therefore, there remains the risk of infection during pregnancy,
  • Upon detection of IgG <40 U / ml - Toxoplasma carriage, there is no risk of fetal infection.
  • In the case of detecting IgG> 200 U / ml, but no IgM as no increase in antibody titer in the dynamics - situation indicates chronic acquired toxoplasmosis. In both cases pregnancy is still present, the specific anti-parasitic treatments are not carried out.
  • If the detected antibodies of class G and M and their observed increase over time, the question of further prolongation of pregnancy.

The need for prenatal diagnosis (cordocentesis - a study of umbilical cord blood, amniocentesis - amniocentesis) for further inspection pregnant:

  • acute toxoplasmosis in women's plus fetal ultrasound data, confirming his defeat (absolute indication);
  • Acute toxoplasmosis women plus "normal" fetal ultrasound parameters (relative indication).

In case of fetal infection and ultrasonic signs of fetal damage pregnancy must be interrupted. If the ultrasound signs of damage to the fetus are detected, designated as antenatal and postnatal (after birth) care.

Treatment

Treatment of toxoplasmosis in pregnant carries obstetrician together with infectious disease.

Etirtropnaya therapy (aimed at Toxoplasma expulsion from the body), is conducted at revealing acute, subacute and innapparantnogo (offline clinic, laboratory-confirmed at toxoplasmosis) toxoplasmosis.

Chronic toxoplasmosis is treated under strict clinical indications, either before or after pregnancy. If a woman has no complaints or clinical indications (in the case of myocardial toxoplasmosis before pregnancy), they do not need therapy and regarded as healthy. Therapy is not until 12-16 weeks of gestation.

Causative treatment comprises administering antiprotozoal (antiparasitic) preparations of pyrimethamine (fansidor and Rovamycinum). The structure includes fansidora sulfadoxine and pyrimethamine. Treatment is carried out in 2-3 cycles (1 tablet 3 times a day a total of 8 tablets per cycle), the interval between cycles of 30 days. For the entire period of pregnancy is assigned to folic acid intake (due to bone marrow suppression). In the case of untreated group means pyrimethamine reception Rovamycinum shown, which includes spiramycin.

treatment cycle lasts 7 days reception Rovamycinum 1 tablet three times a day, then week break, only 2 cycles.

Depending on the gestational age it is advisable to spend at least 2 full (2-3 cycles) causal treatment courses with spaces between them in 1-1.5 months.

Antiprotozoal therapy is performed under the control of the KLA and weekly OAM.

pregnant treatment reduces the risk of damage to the fetus by 50-60%.

The consequences of toxoplasmosis during pregnancy

The most serious consequences arise when the likelihood of transplacental transmission is very low and the severity due to the lack of immunity in the embryo. In this case, either spontaneously aborted pregnancy or the baby is born with coarse organic pathology. It is possible in 15% of cases of infection in the first trimester of pregnancy.

In the second trimester risk of fetal infection is 20%, it carries acute congenital toxoplasmosis prenatally diagnosed at birth and latent chronic or symptomatic toxoplasmosis.

In chronic latent toxoplasmosis signs of intrauterine infection are detected or a few months after birth (the initial phenomenon chorioretinitis) or in adolescence. During the first 15 years of life latent toxoplasmosis transformed in the manifest (clinically expressed) form of 60%. It manifested as seizures, deafness, chorioretinitis, mental retardation.

If the infection of women happened in the last weeks of pregnancy (32-40), in 65% of cases of possible birth of a child with symptoms of acute congenital toxoplasmosis (fever, intoxication, profuse rash, hepatosplenomegaly, jaundice, pneumonia, myocarditis, gastrointestinal disorders, hemorrhagic syndrome).


Some studies in pregnancy

  • Smears during pregnancy.
  • Tests during pregnancy by trimester.
  • Ultrasound during pregnancy.
  • Urinalysis in pregnancy.
  • Coagulation.
  • Installing pessary.
  • Glucose tolerance test.
  • Homocysteine ​​in pregnancy.
  • Amniocentesis.
  • Anesthesia during childbirth.
  • Fetal CTG (cardiotocography)
  • Cordocentesis.
  • Epidural anesthesia during childbirth.
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