No. 285-Toxoplasmosis in Pregnancy: Prevention, Screening, and Treatment

Genetic Counseling of Fetal Microcephaly

Fetal microcephaly is a small head with various losses of cerebral cortical volume. The affected cases may suffer from a wide range in severity of impaired cerebral development from slight to severe mental retardation. It can be an isolated finding or with other anomalies depending on the heterogeneous causes including genetic mutations, chromosomal abnormalities, congenital infectious diseases, maternal alcohol consumption, and metabolic disorders during pregnancy. It is often a lifelong and incurable condition. Thus, early detection of fetal microcephaly and identification of the underlying causes are important for clinical staff to provide appropriate genetic counseling to the parents and accurate management.

Toxoplasma gondii Infection in Pregnancy - Recommendations of the Working Group on Obstetrics and Prenatal Medicine (AGG - Section on Maternal Disorders)

Aim The AGG (Working Group for Obstetrics and Prenatal Diagnostics, Section Maternal Diseases) has issued these recommendations to improve the detection and management of Toxoplasma gondii infection in pregnancy. Methods Members of the Task Force developed the recommendations and statements presented here using recently published literature. The recommendations were adopted after a consensus process by members of the working group. Recommendations This article focuses on the epidemiology and pathophysiology of Toxoplasma gondii infection in pregnancy and includes recommendations for maternal and fetal diagnosis, transmission prophylaxis, therapy, prevention, screening, and peripartum management.

Guideline No. 441: Antenatal Fetal Health Surveillance

OBJECTIVE

To summarize the current evidence and to make recommendations for antenatal fetal health surveillance (FHS) to detect perinatal risk factors and potential fetal decompensation in the antenatal period and to allow for timely intervention to prevent perinatal morbidity and/or mortality.

TARGET POPULATION

Pregnant individuals with or without maternal, fetal, or pregnancy-associated perinatal risk factors for antenatal fetal decompensation.

OPTIONS

To use basic and/or advanced antenatal testing modalities, based on risk factors for potential fetal decompensation.

OUTCOMES

Early identification of potential fetal decompensation allows for interventions that may support fetal adaptation to maintain well-being or expedite delivery.

BENEFITS, HARMS, AND COSTS

Antenatal FHS in pregnant individuals with identified perinatal risk factors may reduce the chance of adverse outcomes. Given the high false-positive rate, FHS may increase unnecessary interventions, which may result in harm, including parental anxiety, premature or operative birth, and increased use of health care resources. Optimization of surveillance protocols based on evidence-informed practice may improve perinatal outcomes and reduce harm.

EVIDENCE

Medline, PubMed, Embase, and the Cochrane Library were searched from inception to January 2022, using medical subject headings (MeSH) and key words related to pregnancy, fetal monitoring, fetal movement, stillbirth, pregnancy complications, and fetal sonography. This document represents an abstraction of the evidence rather than a methodological review.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

All health care team members who provide care for or education to obstetrical patients, including maternal fetal medicine specialists, obstetricians, family physicians, midwives, nurses, nurse practitioners, and radiologists.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Directive clinique no 441 : Surveillance prénatale du bien-être fœtal

OBJECTIF

Résumer les données probantes actuelles et formuler des recommandations pour la surveillance prénatale du bien-être fœtal afin de détecter les facteurs de risque périnatal et toute potentielle décompensation fœtale et de permettre une intervention rapide en prévention de la morbidité et la mortalité périnatales.

POPULATION CIBLE

Personnes enceintes avec ou sans facteurs maternels, fœtaux ou gravidiques associés à des risques périnataux et à la décompensation fœtale.

OPTIONS

Utiliser des examens prénataux par technologie de base et/ou avancée en fonction des facteurs de risque de décompensation fœtale. RéSULTATS: La reconnaissance précoce de toute décompensation fœtale potentielle permet d'intervenir de façon à favoriser l'adaptation fœtale pour maintenir le bien-être ou à accélérer l'accouchement. BéNéFICES, RISQUES ET COûTS: Chez les personnes enceintes ayant des facteurs de risque périnatal confirmés, la surveillance du bien-être fœtal contribue à réduire le risque d'issue défavorable. Compte tenu du taux élevé de faux positifs, la surveillance du bien-être fœtal peut augmenter le risque d'interventions inutiles, ce qui peut avoir des effets nuisibles, dont l'anxiété parentale, l'accouchement prématuré ou assisté et l'utilisation accrue des ressources de soins de santé. L'optimisation des protocoles de surveillance d'après des pratiques fondées sur des données probantes peut améliorer les issues périnatales et réduire les effets nuisibles. DONNéES PROBANTES: Des recherches ont été effectuées dans les bases de données Medline, PubMed, Embase et Cochrane Library, de leur création jusqu'à janvier 2022, à partir de termes MeSH et de mots clés liés à la grossesse, à la surveillance fœtale, aux mouvements fœtaux, à la mortinaissance, aux complications de grossesse et à l'échographie fœtale. Le présent document est un résumé des données probantes et non pas une revue méthodologique. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Tous les membres de l'équipe de soins qui prodiguent des soins ou donnent de l'information aux patientes en obstétrique, notamment les spécialistes en médecine fœto-maternelle, les obstétriciens, les médecins de famille, les sages-femmes, les infirmières, les infirmières praticiennes et les radiologistes. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Toxoplasmosis Screening during Pregnancy in a Romanian Infectious Diseases Tertiary Center: Results of a 15 Years Follow-Up Program

Maternal infection with Toxoplasma gondii during pregnancy may have serious consequences for the fetus. In Romania, screening for toxoplasmosis is included in the first antenatal visit. A retrospective study was performed on all toxoplasmosis antenatal screening patients between May 2008 and February 2023. Twenty-seven thousand one hundred sixty-nine (27,169) pregnant women presented for prenatal screening once (22,858) or several times: during the same pregnancy (209) or during multiple pregnancies (4102). Thirty-one thousand six hundred fifty-eight (31,658) tests for IgM and IgG antibodies were performed. Nine thousand eighty-three (9083) tests (28.69%), corresponding to 7911 women (29.12%), were positive for IgG antibodies. The seroprevalence increased with patients' age, decreased in time intervals, and was more frequently associated with rural residence. At risk for acquiring the infection during the pregnancy were women with negative anti-Toxoplasma IgG antibodies (70.88%), but only 0.9% of them presented for rescreening during the same pregnancy. Acute Toxoplasma infection (ATI) was suspected in 44 patients (0.16%) due to IgG seroconversion and/or low or borderline IgG avidity. A questionnaire follow-up interview was performed, and no congenital toxoplasmosis was identified in children born from mothers with probable ATI. Our study demonstrates poor compliance with the screening program in the Romanian population.

Anti-Toxoplasma gondii Effects of Lipopeptide Derivatives of Lycosin-I

Toxoplasmosis, caused by Toxoplasma gondii (T. gondii), is a serious zoonotic parasitic disease. We previously found that Lycosin-I exhibited anti-T. gondii activity, but its serum stability was not good enough. In this study, we aimed to improve the stability and activity of Lycosin-I through fatty acid chain modification, so as to find a better anti-T. gondii drug candidate. The α/ε-amino residues of different lysine residues of Lycosin-I were covalently coupled with lauric acid to obtain eight lipopeptides, namely L-C12, L-C12-1, L-C12-2, L-C12-3, L-C12-4, L-C12-5, L-C12-6, and L-C12-7. Among these eight lipopeptides, L-C12 showed the best activity against T. gondii in vitro in a trypan blue assay. We then conjugated a shorter length fatty chain, aminocaproic acid, at the same modification site of L-C12, namely L-an. The anti-T. gondii effects of Lycosin-I, L-C12 and L-an were evaluated via an invasion assay, proliferation assay and plaque assay in vitro. A mouse model acutely infected with T. gondii tachyzoites was established to evaluate their efficacy in vivo. The serum stability of L-C12 and L-an was improved, and they showed comparable or even better activity than Lycosin-I did in inhibiting the invasion and proliferation of tachyzoites. L-an effectively prolonged the survival time of mice acutely infected with T. gondii. These results suggest that appropriate fatty acid chain modification can improve serum stability and enhance anti-T. gondii effect of Lycosin-I. The lipopeptide derivatives of Lycosin-I have potential as a novel anti-T. gondii drug candidate.

Maternal and congenital toxoplasmosis in Mayotte: Prevalence, incidence and management

BACKGROUND

Toxoplasmosis is an infection caused by an intracellular protozoan, Toxoplasma gondii. It is usually asymptomatic, but toxoplasmosis acquired during pregnancy can cause congenital toxoplasmosis, potentially resulting in fetal damage. Epidemiological information is lacking for toxoplasmosis in Mayotte (a French overseas territory). We evaluated (1) the prevalence of maternal toxoplasmosis, (2) the incidence of maternal and congenital toxoplasmosis, and (3) the management of congenital toxoplasmosis in Mayotte.

METHODOLOGY / PRINCIPAL FINDINGS

We collected all the available data for toxoplasmosis serological screening during pregnancy and maternal and congenital cases of toxoplasmosis obtained between January 2017 and August 2019 at the central public laboratory of Mayotte (Mamoudzou). Using toxoplasmosis serological data from samples collected from 16,952 pregnant women we estimated the prevalence of toxoplasmosis in Mayotte at 67.19%. Minimum maternal toxoplasmosis incidence was estimated at 0.29% (49/16,952, 95% CI (0.0022-0.0038)), based on confirmed cases of maternal primary infection only. The estimated incidence of congenital toxoplasmosis was 0.09% (16/16,952, 95% CI (0.0005-0.0015). Missing data made it difficult to evaluate management, but follow-up was better for mothers with confirmed primary infection and their infants.

CONCLUSIONS / SIGNIFICANCE

The seroprevalence of toxoplasmosis among pregnant women and the incidence of toxoplasmosis are higher in Mayotte than in mainland France. There is a need to improve the antenatal toxoplasmosis screening and prevention programme, providing better information to physicians and the population, to improve management and epidemiological monitoring.

[Preventive activities in women. PAPPS update 2022]

In the 2022 PAPPS update we present those specific preventive activities for women's health, except those related to cancer prevention (which are included in another document) and those aspects related to differential gender morbidity, a cross-cutting aspect for all working groups. Contraception is an essential preventive activity, considering basic the right to decide both the number of children and the time to have them. We must inform about the possible contraceptive methods, guaranteeing the monitoring of their safety, efficacy and effectiveness (tables are included on changing from one method to another to preserve contraceptive protection). We must inform about emergency contraception and propose it in the event of unprotected intercourse. All this will be done through opportunistic screening without requiring screening for thrombophilia or dyslipidemia, but for arterial hypertension. Pregnancy is an important life experience and the family doctor should not remain oblivious. We must be competent both in the preconception consultation (recommending the intake of folic acid, avoiding exposure to occupational and environmental risks, screening for certain pathologies and assessing the intake of drugs not indicated during pregnancy) and in the monitoring of pregnancy. Whether or not we monitor the pregnancy, we must not disregard its control, taking advantage of this period to promote healthy lifestyles and participating in the intercurrent processes that may occur. Menopause in general and osteoporosis in particular exemplify the strategy of medicalization of vital processes that has been followed from different instances and organizations. In our update we address the prevention and treatment of symptoms secondary to estrogen deprivation. We also propose the prevention of osteoporosis, including carrying out densitometry based on the risk of fracture in the next 10 years, and therefore densitometric screening is not recommended in women under 60 years of age. In risk assessment we recommend the use of the frax tool or better, the calibration of the risk of hip fracture with prevalence data from our setting. We linked the indication for treatment with the Z-Score (bone mineral density compared with women of the same age), as it is a condition associated with aging.

Assessment of the clinical benefits of prenatal screening for toxoplasmosis in southern Taiwan

OBJECTIVE

The present study aimed to investigate the seroprevalence and risk factors for toxoplasmosis among pregnant women in southern Taiwan and to determine the clinical benefits of screening for the same.

MATERIALS AND METHODS

The current study included 458 pregnant women who received prenatal care from the first trimester at the Kaohsiung and Chiayi Chang Gung Memorial Hospitals during the time period from 2014 to 2015. Serological tests performed to detect the presence of Toxoplasma IgG and IgM antibodies. Amniocentesis was scheduled and real-time polymerase chain reaction (PCR) was employed to detect Toxoplasma DNA. Moreover, the maternal characteristics and risk factors, perinatal outcomes related to the seropositivity for Toxoplasma infection were analyzed.

RESULTS

Among the pregnant patients included in the current study, 39/458 (8.5%) were IgG+ and 2/458 (0.6%) were IgM+. The present study analyzed the maternal characteristics and risk factors, perinatal outcome pertaining to the IgG seropositive group by means of the multiple logistic regression analysis revealed a female predominance (10.8%), compared to the males (6.4%), (adjusted OR = 0.48 (95%, 0.24-0.98), P = 0.043∗). The number cases with gestational age above 37 weeks at the time of delivery was significantly lower, compared to the cases below 37 weeks (adjusted OR = 0.32 (0.12-0.94), P = 0.038∗). Among one case with low avidity cannot exclude recent infection, the amniocentesis did not show any evidence of vertical transmission.

CONCLUSION

The scenario may not warrant general screening and the results will not influence the clinical decisions. Although the present study failed to identify the maternal risk factors related to Toxoplasma infection, the results imply that health education is essential, owing to the slightly higher rate of preterm delivery in the IgG seropositive group.

Quality of clinical practice guidelines for gestational and congenital toxoplasmosis: A systematic review of the literature

OBJECTIVE

To evaluate the methodological quality and transparency of the clinical practice guidelines (CPGs) for the prevention, diagnosis, and treatment of gestational and congenital toxoplasmosis (CT).

METHODS

Systematic review of the literature on gestational and CT CPGs conducted in the MEDLINE, Embase, TripDatabase, Biblioteca Virtual en Salud databases and extensive manual searches in 19 CPG repositories. The characteristics of each of the guidelines were extracted using My AGREE PLUS on-line. Three reviewers assessed overall quality using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool.

RESULTS

The combined systematic review found 8651 citations. Of them 46 full texts were reviewed, and eight documents were finally included: four toxoplasmosis CPGs, three prenatal care CPGs that included recommendations on toxoplasmosis, and one pregnancy infection guideline that also included recommendations on toxoplasmosis. The AGREE II domains found to have the highest scores were 'clarity of presentation' (85%; [37%-100%]), followed by 'scope and purpose' (73%; [33%-98%]), and 'editorial independence' (51%; [3%-94%]); the domains with the lowest scores were 'rigour of development' (36%; [11%-79%]), 'stakeholder involvement' (34%; [24%-85%]), and 'applicability' (17%; [6%-83%]). The Colombian and Spanish-Agencia de Evaluación de Tecnologías Sanitarias de Andalucía (AETSA) CPGs had the highest global AGREE II scores. Absolute interrater agreement was good to excellent.

CONCLUSION

Substantial quality variation was found among CPGs, which provided recommendations in accordance with the context of the disease in the corresponding country or region. Only two of the CPGs appraised obtained a good score and are classified as 'recommended'.

Infectious Posterior Uveitis - Toxoplasmosis, Treponema, Tuberculosis (TTT)

Toxoplasma gondii, Treponema pallidum and Mycobacterium tuberculosis are the most important infectious causes of posterior uveitis. The epidemiology, clinical picture, diagnostic and treatment strategies of these diseases are presented.

Hygiene measures as primary prevention of toxoplasmosis during pregnancy: A systematic review

Background Hygiene measures are recommended to prevent toxoplasmosis during pregnancy, although screening for seroconversion in pregnant women currently are debated and practices vary among countries. Objectives The purpose of this systematic literature review was to assess the effectiveness of hygiene measures during pregnancy to prevent toxoplasmosis infection. Search Strategy We followed the standard MOOSE and PRISMA criteria when conducting this systematic review and reporting the results. Selection criteria A systematic literature search was conducted for studies focused on congenital toxoplasmosis prevention, toxoplasmosis prevention during pregnancy, toxoplasmosis prevention and hygiene measures, which were published between 1970 and August 2020, using the databases of PubMed, Scope Med, EMBASE, and the Cochrane library. Data collection and analysis Our literature search identified 3964 articles, 3757 were excluded after review of title or abstract and 67 studies were considered relevant to the subject. We reviewed risk factors for toxoplasmosis infection during pregnancy and for congenital toxoplasmosis, preventive measures for toxoplasmosis during pregnancy, including: dietary recommendations, pet care measures, environmental measures, knowledge of risk factors and ways to control toxoplasmosis infection, knowledge of risk factors for infection by health professionals, knowledge of primary prevention measures by pregnant women. Conclusion: Hygiene measures are effective and applicable primary prevention to reduce toxoplasmosis and avoid congenital toxoplasmosis and its consequences. Funding No.

Congenital Toxoplasmosis: The State of the Art

Infection with the protozoan parasite Toxoplasma gondii occurs worldwide and usually causes no symptoms. However, a primary infection of pregnant women, may infect the fetus by transplacental transmission. The risk of mother-to-child transmission depends on week of pregnancy at the time of maternal infection: it is low in the first trimester, may reach 90% in the last days of pregnancy. Inversely, however, fetal disease is more severe when infection occurs early in pregnancy than later. Systematic serologic testing in pregnant women who have no antibodies at the beginning of pregnancy, can accurately reveal active maternal infection. Therefore, the risk of fetal infection should be assessed and preventive treatment with spiramycin must be introduced as soon as possible to reduce the risk of mother-to-child transmission, and the severity of fetal infection. When maternal infection is confirmed, prenatal diagnosis with Polymerase Chain Reaction (PCR) on amniotic fluid is recommended. If fetal infection is certain, the maternal treatment is changed to a combination of pyrimethamine-sulfonamide and folinic acid. Congenitally infected newborns are usually asymptomatic at birth, but at risk for tardive sequelae, such as blindness. When congenital infection is evident, disease include retinochoroiditis, cerebral calcifications, hydrocephalus, neurocognitive impairment. The diagnosis of congenital infection must be confirmed at birth and management, specific therapy, and follow-up with multidisciplinary counseling, must be guaranteed.

Every Mother and Every Fetus Matters: A Positive Pregnant Test = Multiple Offerings of Reproductive Risk Screening for personal, family, and specific obstetrical-fetal conditions

Structured OBJECTIVE: The requirement and need for a focused 'pregnant person -centered' antenatal care process with time for informed consent and shared decision making are important for optimal antenatal care. This commentary focuses on the evidenced -based screening test options and timing as part of the overall 'pregnant person-centered' preconception and antenatal care journey.

METHODS

A structured quality improvement (QI) review (Squire 2.0) was undertaken to examine the appropriate reproductive screening process in the periods of preconception and during pregnancy.

RESULTS

First, evaluated the broader antenatal care structure which, second, enabled the directed reproductive risk screening processes to be offered within an informed consent process. Four international pre-conception and antenatal evidenced-based consensus would routinely offer specific gestational age reproductive risk screening elements: totaling 21 screening elements (preconception 3; 1st trimester 9; 2nd trimester 3; 3rd trimester 4; intrapartum 1; postpartum 1).

CONCLUSION

The best evidenced-based opportunity for comprehensive and collaborative antenatal care with appropriate screening elements requires: single national access healthcare system; expert evidenced-based guideline creation; collaborative maternity care providers based for risk assessment, triage, and management; pregnant person (women) centered care model of maternity care; clearly identified evidenced-based gestational age directed screening elements; international pre-conception and antenatal guideline consensus.

Toxoplasmosis: Current and Emerging Parasite Druggable Targets

Toxoplasmosis is a prevalent disease affecting a wide range of hosts including approximately one-third of the human population. It is caused by the sporozoan parasite Toxoplasma gondii (T. gondii), which instigates a range of symptoms, manifesting as acute and chronic forms and varying from ocular to deleterious congenital or neuro-toxoplasmosis. Toxoplasmosis may cause serious health problems in fetuses, newborns, and immunocompromised patients. Recently, associations between toxoplasmosis and various neuropathies and different types of cancer were documented. In the veterinary sector, toxoplasmosis results in recurring abortions, leading to significant economic losses. Treatment of toxoplasmosis remains intricate and encompasses general antiparasitic and antibacterial drugs. The efficacy of these drugs is hindered by intolerance, side effects, and emergence of parasite resistance. Furthermore, all currently used drugs in the clinic target acute toxoplasmosis, with no or little effect on the chronic form. In this review, we will provide a comprehensive overview on the currently used and emergent drugs and their respective parasitic targets to combat toxoplasmosis. We will also abridge the repurposing of certain drugs, their targets, and highlight future druggable targets to enhance the therapeutic efficacy against toxoplasmosis, hence lessening its burden and potentially alleviating the complications of its associated diseases.

Promising Drug Targets and Compounds with Anti-Toxoplasma gondii Activity

Toxoplasmosis is a parasitic disease caused by the globally distributed protozoan parasite Toxoplasma gondii, which infects around one-third of the world population. This disease may result in serious complications for fetuses, newborns, and immunocompromised individuals. Current treatment options are old, limited, and possess toxic side effects. Long treatment durations are required since the current therapeutic system lacks efficiency against T. gondii tissue cysts, promoting the establishment of latent infection. This review highlights the most promising drug targets involved in anti-T. gondii drug discovery, including the mitochondrial electron transport chain, microneme secretion pathway, type II fatty acid synthesis, DNA synthesis and replication and, DNA expression as well as others. A description of some of the most promising compounds demonstrating antiparasitic activity, developed over the last decade through drug discovery and drug repurposing, is provided as a means of giving new perspectives for future research in this field.

National perinatal survey demonstrates a decreasing seroprevalence of Toxoplasma gondii infection among pregnant women in France, 1995 to 2016: impact for screening policy

Background

Toxoplasmosis during pregnancy can result in congenital anomalies or fetal death. Universal antenatal screening is recommended in France, a strategy in place since the 1970s.

Aim

We determined the seroprevalence of toxoplasmosis among pregnant women participating in the 2016 national perinatal survey (ENP), compared results with previous ENPs, and investigated factors associated with Toxoplasma gondii infection.

Methods

Using the 2016 ENP data, which contain sociodemographic and clinical information from all women giving birth during a one week period, we calculated adjusted prevalence ratios (aPR) by sociodemographic factors. Using available data from prior ENPs (1995, 2003 and 2010), we calculated age-standardised seroprevalences and aPRs for French women.

Results

In 2016, seroprevalence was 31.3% overall. Among French women, associations with increasing age (aPR: 1.54; 95% CI: 1.39–1.70), residence in Paris (aPR: 1.19; 95% CI: 1.08–1.31) or south-western regions (aPR: 1.19; 95% CI: 1.08–1.31), and higher professional status (aPR: 1.12; 95%CI 1.04–1.21) were observed. An association with increasing age was also evident among women from North Africa and sub-Saharan Africa. Age-standardised seroprevalence decreased from 55.0% in 1995 to 33.7% in 2016. Among French women, significant associations with age, Paris and south-west regions persisted across all ENPs.

Conclusion

Higher prevalences in older women may reflect a higher past risk of exposure while persistent geographical differences may reflect dietary or environmental differences. Toxoplasma seroprevalence among pregnant women continues to fall and will impact screening effectiveness. This warrants a comprehensive review to determine the appropriate future of prevention in France.

Reporting of financial conflicts of interest by Canadian clinical practice guideline producers: a descriptive study

BACKGROUND

The producers of clinical practice guidelines (CPGs) may not disclose industry funding in their CPGs. We reviewed Canadian national CPGs to examine the existence and disclosure of industry-related organizational funding in the CPGs, financial conflicts of interest of committee members and organizational procedures for managing financial conflicts of interest.

METHODS

For this descriptive study, we searched the asset map of the Strategy for Patient-Oriented Research Evidence Alliance and the CPG Infobase for CPGs published between Jan. 1, 2016, and Nov. 30, 2018. Eligible guidelines had to have a national focus and either a first-line drug recommendation or a screening recommendation leading to drug treatment. One investigator reviewed all CPG titles to exclude those that were clearly ineligible. Two reviewers independently reviewed all remaining guidelines and extracted data. We analyzed the data descriptively.

RESULTS

We included 21 CPGs: 3 from government-sponsored organizations, 9 from disease or condition interest groups and 9 from medical professional societies. None of the 3 government-sponsored organizations reported industry funding, and none of their committee members disclosed financial conflicts of interest. Among the 18 disease or condition interest groups and medical professional societies, 14 (93%) of the 15 that disclosed funding sources on websites (3 did not disclose) reported organizational funding from industry, but none disclosed this information in the CPGs; 12 (86%) of the 14 with conflict-of-interest disclosure statements in the CPG (4 did not include disclosures) had at least 1 committee member with a financial conflict (mean proportion of committee members with a conflict 56%); and for all 8 CPGs with identifiable chairs or cochairs (chairs or cochairs not reported for 10) at least 1 of these people had a financial conflict of interest. None of the guidelines described a plan to manage organizational financial conflicts of interest.

INTERPRETATION

Canadian CPGs are vulnerable to industry influence through funding of producers of guidelines and through the financial conflicts of interest of committee members. The CPG producers that receive industry funding should disclose organizational financial conflicts in the CPGs, should engage independent oversight committees and should restrict voting on recommendations to guideline panelists who have no financial conflicts.

Seroprevalence of Toxoplasma gondii infections in Syrian pregnant refugee women in Turkey

OBJECTIVE

Congenital infections in refugee women have been very rarely studied. The purpose of this study is to investigate the Toxoplasma gondii (T. gondii) seroprevalence in Syrian pregnant refugee women living in Turkey and to discuss the differences with Turkish pregnant women.

STUDY DESIGN

This is a retrospective cohort study including 752 pregnant refugee women and is based on the nine-year data of a reference public hospital in Ankara.

RESULTS

In the study group, T. gondii immunoglobulin G (IgG) and immunoglobulin M (IgM) seropositivity rates were 47 % and 0.4 %, respectively. Compared with a recent study conducted in the same center on Turkish native pregnant women, there was a significant difference in IgG seropositivity and no significant difference in IgM seropositivity.

CONCLUSION

Due to the seroprevalence difference between the indigenous and refugee groups, the Syrian refugee women has to be specifically considered in the prevention of congenital toxoplasmosis infections in Turkey.

[Preventive activities in women's care]

A review is presented of the scientific evidence on preventive activities in women's care in relation to pregnancy follow-up, preventive activities in the planning and follow-up of contraceptive methods, preventive activities in menopause, and the prevention of osteoporotic fractures.

Asymmetric eye size in an infant

Toxoplasmosis is an uncommon congenital infection in Canada, but one with potentially severe clinical manifestations, including fetal death. Neurologic and ocular manifestations are frequent in untreated disease; however, small eye size (microphthalmia) is a rare finding. This finding may be a marker of severe ocular disease. As universal screening does not occur in Canada, clinicians' early recognition is imperative, particularly given the lack of risk factors in many patients and the benefit that treatment may have even in initially asymptomatic disease. Here, we report a case of congenital toxoplasmosis and review the diagnostics and treatment of the infection.

Fifteen-minute consultation: Management of the infant born to a mother with toxoplasmosis in pregnancy

Congenital toxoplasmosis occurs following transplacental transfer of Toxoplasma gondii Irrespective of symptom status at birth, infants with congenital infection may develop serious long-term sequelae, including learning disability, seizures, hydrocephalus, motor and hearing deficits, chorioretinitis and retinal scarring with impaired vision. Timely diagnosis facilitates early initiation of therapy, aimed at prevention or amelioration of adverse clinical consequences. Diagnosis can be difficult, however, since acutely infected mothers are often asymptomatic and laboratory testing can be complex. Moreover, any decision to start treatment in the newborn must include careful consideration of the benefits and risks. This paper outlines a structured approach for managing an infant born to a woman with possible or confirmed T. gondii infection during pregnancy, including key aspects of the antenatal history, interpretation and timing of investigations, treatment and appropriate follow-up. Our recommendations are based on current evidence in the literature, consensus from two UK paediatric infectious disease centres and the UK specialist Toxoplasma Reference Unit.

Acute Perinatal Infection and the Evidenced-Based Risk of Intrauterine Diagnostic Testing: A Structured Review

BACKGROUND

The prevalence of perinatal infection from maternal exposure is increasing. The prevalence of acute maternal infections identifies cytomegalovirus, parvovirus B19, toxoplasmosis, and varicella as the most common organisms and in the order of frequency. Maternal informed consent and understanding is required before intrauterine testing for fetal infectious and possible genetic risk assessment.

METHODS

This structured review of the reproductive published literature focuses on the risks of amniocentesis and cordocentesis diagnostic procedure-related fetal loss rates and fetal vertical transmission (VT) rates from published infected pregnant cohorts.

RESULTS

The total postprocedure fetal loss rate for diagnostic amniocentesis procedures, in limited infectious cohorts, is 1.5% and does not appear to be increased compared to "noninfected" amniocentesis cohorts using an estimated background spontaneous fetal loss rate (no procedure) of 0.65%. The "pooled" unintended fetal loss rate is from small infected population cohorts, but can be used for counseling purposes. Postcordocentesis fetal loss risk, in an infected cohort, is not possible to estimate due to limited data. The "biological spontaneous fetal loss rate" risk with a perinatal infection (positive or negative fetal anomalies) and no diagnostic procedure before 20 weeks of gestation is reviewed. The risk of VT in acute infection cohorts as a result of the intra-amniotic diagnostic procedure is not found to be increased.

CONCLUSION

The unintended "fetal loss" rate after amniocentesis for perinatal infected cohorts is similar to that of noninfected cohorts, but the estimate is based on limited infected cohorts. There was no procedure-based risk of fetal VT in the infected cohorts, but identification of postprocedure maternal bleeding into the amniotic cavity increases the potential risk. Maternal knowledge translation and an informed consent process with risk-benefit maternal/fetal risk counseling are required prior to any diagnostic amniocentesis procedure.

Toxoplasmosis screening during pregnancy in France: Opinion of an expert panel for the CNGOF

Prenatal screening to prevent congenital toxoplasmosis as performed in France for several decades has been questioned in view of the decreasing incidence of this infection and the cost of testing. The French College of Obstetrics and Gynecology mandated a multidisciplinary panel of experts to perform a reassessment of the screening program in accordance with international good practice. In France, about 70% of pregnant women are not immune to T. gondii, and 0.2-0.25% become infected during pregnancy. The risk of maternal-fetal transmission of infection is on average 25-29% and depends greatly on the gestational age at seroconversion. In case of fetal transmission, the outcome is livebirth in 95% of cases, with latent congenital toxoplasmosis in 90% of cases and symptomatic forms in 10% of cases, of which 1/3 are severe and 2/3 moderate. Biological techniques have satisfactory performance regarding serologies for the diagnosis of maternal infections and PCR on amniotic fluid for the prenatal diagnosis of congenital toxoplasmosis. Primary prevention of toxoplasmosis is based on hygiene measures that are relatively simple, but poorly implemented. In case of maternal seroconversion, there is a strong case for prenatal prophylactic treatment as soon as possible (ideally within 3 weeks of seroconversion), spiramycin before 14 weeks of gestation (WG), and with a tendency to superiority of the pyrimethamine/sulfadiazine association over spiramycin beyond 14 W G, in order to reduce the risk of symptomatic congenital toxoplasmosis. In case of congenital toxoplasmosis, prompt initiation of treatment reduces the occurrence of cerebral signs and symptoms, as well as retinal lesions. Several medico-economic evaluations of the French toxoplasmosis screening program have been conducted including an individual cost-effectiveness approach with decision analysis which concluded on the profitability of prenatal screening as carried out in France (monthly surveillance of seronegative women, prenatal treatment in case of seroconversion, termination of pregnancy in severe forms). Though most international societies do not recommend systematic screening for mainly financial reasons, if congenital toxoplasmosis appears benign in France today, it is probably thanks to screening and the possibility of early treatment of fetuses and/or newborns. Thus, the panel recommends continuing for now the program in France for prevention of congenital toxoplasmosis.

Disease of the Year 2019: Ocular Toxoplasmosis in HIV-infected Patients

Ocular toxoplasmosis (OT) may be an initial manifestation of acquired immunodeficiency syndrome (AIDS) in human immunodeficiency virus (HIV)-infected patients. OT has different clinical manifestations and can mimic other intraocular infections. Clinical findings may show single or multifocal retinochoroidal lesions or panuveitis. Atypical presentations are associated with extensive uni- or bilateral areas of retinal necrosis. OT lesions not associated with preexisting retinochoroidal scars are usually due to acquired rather than congenital infection. When CD4+ T cell counts are <100 c/uL, vitritis is frequently mild. Isolated anterior uveitis has been reported in single cases. Positive immunoglobulin M (IgM) antibodies are rare but their presence can support the diagnosis. As atypical presentations of OT are common, anterior chamber puncture for multiplex polymerase chain reaction amplification of infectious DNA should be considered, as early diagnosis and treatment can prevent massive tissue destruction and preserve vision. This review provides an overview of OT in HIV-infected patients.

Unpasteurised milk consumption as a potential risk factor for toxoplasmosis in females with recurrent pregnancy loss

In women with a bad obstetric history, certain infections are associated with recurrent foetal loss. One of the common infectious agents is a protozoan parasite, Toxoplasma gondii. The aim of this study was to assess unpasteurised milk consumption as a potential risk factor for toxoplasmosis in females with recurrent pregnancy loss from the province of Khyber Pakhtunkhwa, Pakistan. In this study, we recruited a total of 360 females, comprising a study group of 180 females with previous history of recurrent pregnancy loss and a control group of 180 females with no such history. Blood serum from the participants was analysed for Toxoplasma gondii IgM antibodies by enzyme linked immunosorbent assay. Among the study group, 23 (12.8%) females were serologically positive for IgM antibodies against Toxoplasma gondii, whilst 157 (87.2%) were IgM negative. In the control group, only two (4.8%) females were IgM positive, whilst 178 (95.2%) were IgM negative. Bad pregnancy outcome in the study group and control group was observed to be significantly different (p < .0001). In both of these groups, unpasteurised milk consumption was found as a major risk factor for Toxoplasma gondii infection. A routine serological investigation should be carried out in pregnant women to rule out toxoplasmosis and reduce the risk of recurrent pregnancy loss as well as congenital toxoplasmosis in newborns.Impact statementWhat is already known on this subject? Seropositivity for Toxoplasma gondii antibodies ranges from 7% to 51% in different regions of the world. The prevalence rate varies because of differences in climate, culture, food habits, behaviour, personal hygiene and cooking habits of different societies and ethnic groups. Various risk factors have been identified that contribute to a high prevalence rate of the disease, including consumption of raw or poorly cooked meat, physical contact with cats or cat litter, consumption of unwashed raw vegetables and fruits, drinking of contaminated water and milk. We presumed that consuming unpasteurised milk could be a potential risk factor for developing toxoplasmosis in pregnant women.What the results of this study add? This study demonstrates high seroprevalence of Toxoplasma gondii antibodies in females of child bearing age that have consumed unpasteurised milk and is a potential risk factor for developing toxoplasmosis.What the implications are of these findings for clinical practice and/or further research? Our findings suggest that primary preventive measures (personal hygiene, frequent hand washing and consuming pasteurised milk) should be taken by health surveillance authorities to focus on families, especially pregnant women, to educate them about personal hygiene, contact with cattle or using their milk and milk products. The latter is especially important to aware them about the hazards of consuming unpasteurised and contaminated milk.

Congenital Toxoplasmosis Presenting as Eosinophilic Encephalomyelitis With Spinal Cord Hemorrhage

A 4-week-old male neonate with a history of intermittent hypothermia in the newborn nursery presented with an acute onset of bilateral lower extremity paralysis and areflexia. Extensive workup demonstrated eosinophilic encephalomyelitis and multifocal hemorrhages of the brain and spinal cord. Funduscopic examination revealed bilateral chorioretinitis with macular scarring. The laboratory values were notable for peripheral eosinophilia and cerebrospinal fluid eosinophilic pleocytosis (28 white blood cells/µL, 28% eosinophils), markedly elevated protein (1214 mg/dL), and hypoglycorrhachia (20 mg/dL). Toxoplasma gondii immunoglobulin M (IgM) test result was positive. Reference testing obtained at the Palo Alto Medical Foundation Toxoplasma Serology Laboratory confirmed the diagnosis of congenital toxoplasmosis in the infant with a positive immunoglobulin G (IgG) dye test result, immunoglobulin A enzyme-linked immunosorbent assay, and IgM immunosorbent agglutination assay. The diagnosis of an infection acquired during gestation in the mother was established by a positive maternal IgG dye test result, IgM enzyme-linked immunosorbent assay, immunoglobulin A, immunoglobulin E, and low IgG avidity. At 6-month follow-up, the infant had marginal improvement in his retinal lesions and residual paraplegia with hyperreflexia and clonus of the lower extremities. A repeat MRI demonstrated interval development of encephalomalacia with suspected cortical laminar necrosis and spinal cord atrophy in the areas of previous hemorrhage. Clinicians should be aware of this severe spectrum of congenital toxoplasmosis disease and should remain vigilant for subtler signs that may prompt earlier testing, diagnosis, and treatment.

Neurologic infections during pregnancy

Neurologic infections during pregnancy represent a significant cause of maternal and fetal morbidity and mortality. Immunologic alterations during pregnancy increase the susceptibility of the premature brain to damage. This chapter summarizes the epidemiology, pathophysiology, and clinical manifestations in the pregnant woman and the infant, and the diagnosis, treatment, and prevention of the major viral, parasitic, and bacterial infections known to affect pregnancy. These organisms include herpes virus, parvovirus, cytomegalovirus, varicella, rubella, Zika virus, toxoplasmosis, malaria, group B streptococcus, listeriosis, syphilis, and tuberculosis. There is an emphasis on the important differences in diagnosis, treatment, and fetal outcome between trimesters. An additional overview is provided on the spectrum of neurologic sequelae of an affected infant, which ranges from developmental delay to hydrocephalus and seizures.

Key Infections in the Placenta

Congenital infections are an important cause of morbidity and mortality worldwide, especially in low-income settings. This review discusses the main pathways of infections and associated adverse maternal and fetal outcomes, considering the TORCH pathogens, including Zika virus; the acronym stands for Toxoplasma gondii infection, other (Listeria monocytogenes, Treponema pallidum, and parvovirus B19, among others, including Zika virus), rubella virus, cytomegalovirus, and herpes simplex viruses type 1 and type 2.

Acetonic Fraction of Bidens pilosa Enriched for Maturase K Is Able to Control Cerebral Parasite Burden in Mice Experimentally Infected With Toxoplasma gondii

Toxoplasma gondii infection can cause abortions or congenital infection for a vast number of domestic animals and humans, leading to economic loss in veterinary sciences, as well as severe consequences for immunocompromised patients. Bidens pilosa Linné has been used in ethnopharmacology for treatment of diseases, as malaria, diabetes and hepatitis, in addition to its use as antioxidant, antiallergic, anti-inflammatory, and antiviral. The components of this plant have never been studied before for treatment of toxoplasmosis, and the conventional drugs currently used to treat this disease have high degree of toxicity. Thus, the aim of this study was to evaluate the effect of B. pilosa against T. gondii, by analyzing a total extract of this plant in parallel with a fraction obtained by precipitation in acetone. Also, it was assessed if the acetonic fraction could present lectinic activity, followed by its identification by mass spectrometry. It was observed with the experimental models designed that both total extract and acetonic fraction of B. pilosa were able to control T. gondii infection by in vitro and in vivo experiments, in addition to their low toxicity to host cells. Both total extract and acetonic fraction of this plant display capacity to impair replication of T. gondii tachyzoites. Interesting, the B. pilosa acetonic fraction treatment for 10 days after infection decreases significantly the number of T. gondii brain cyst in comparison with controls. The protein isolated from B. pilosa acetonic fraction was characterized as a novel lectin identified as maturase K. Taken together, these findings open new perspectives to treat patients infected by T. gondii. Future studies will be necessary to investigate the precise mechanism underlying the control of T. gondii infection to impair the replication of this parasite in the host cells after treatment with B. pilosa maturase K.