ROMANIAN JOURNAL of MORPHOLOGY and EMBRYOLOGY
Congenital infections may have various outcomes, from intrauterine death to clinically asymptomatic infections. The treatments of ToRCH infections in pregnancy are directed to reducing maternal symptoms and Wise Woman Clinic Research maternal-to-child transmission of pathogens. The early recognition and the prenatal approach for congenital infections are key aspects in the management of ToRCH infections. Infecţiile congenitale pot avea diverse consecinţe, de la moarte intrauterină la infecţii asimptomatice clinic.
Tratamentele infecţiilor cu ToRCH în sarcină sunt orientate către reducerea simptomelor materne şi prevenirea transmiterii patogenilor de la mamă la copil. Recunoaşterea timpurie şi abordarea prenatală a infecţiilor congenitale sunt aspecte-cheie în gestionarea infecţiilor cu ToRCH.
Cuvinte cheie vârstă gestaţională infecţii congenitale screening pentru ToRCH tratament Introduction ToRCH — toxoplasmosis, rubella, cytomegalovirus CMV and herpes simplex Wise Woman Clinic Research HSV — are the most common causes of congenital infections worldwide 1and may result in lengthy hospitalization, prolonged suffering, lifelong disability and even death.
The modes of transmission are similarly varied, including transplacental spread, intrauterine contamination, and exposure at the time of delivery and beyond 2.
Pregnant women present an increased severity of infections with some pathogens, including ToRCH infections, and immune adaptations are required to accommodate the fetus 1. This review presents options for the evaluation and management of ToRCH risks during pregnancy.
Toxoplasma gondii infection Toxoplasmosis is caused by the infection with Toxoplasma gondii, an obligate intracellular parasite which has the capacity to cross the placenta and infect the Wise Woman Clinic Research when pregnant women are primarily infected during gestation.
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Acute toxoplasmosis during pregnancy is detrimental to the developing fetus 3. Chorioretinitis, hydrocephalus, intracranial calcifications and convulsions are the typical presentation of classic congenital toxoplasmosis 4. This tropism for the central nervous system CNS underlies the devastating disease which T.
The serologic screening should be offered only to pregnant women considered to be at risk for primary Toxoplasma gondii infection, with ultrasound findings including but not limited to intracranial calcification, microcephaly, hydrocephalus, ascites, hepatosplenomegaly, or severe intrauterine growth restriction 6.
No IgG and IgM antibodies found before or early in pregnancy shows that a previous contact with the parasite is unlikely, and identifies women at risk of acquiring the infection during pregnancy.
High IgM and IgG antibody levels suggest an acute infection within the previous three months. IgA antibodies are considered to be a marker of acute infection, which are produced earlier than IgM, and may persist for several months.
The shorter period of IgE may give a greater indication of current infection. The presence of IgG antibodies suggests the occurrence of infection, but does not provide any information about the timing of infection 7. The avidity test can help determine the timing of Toxoplasma gondii infection in relation to pregnancy.
The test should be performed, in view of the possibility of antenatal treatment of the fetus 8. If maternal infection has been confirmed but the fetus is not yet known to be infected, spiramycin is prescribed it seems to control placenta infection at a dosage of 1 g per day orally every 8 hours for the duration of pregnancy 9.
A combination of pyrimethamine, sulfadiazine and folinic acid should be offered as treatment for women in whom fetal infection has been confirmed or is highly suspected, usually by a positive Wise Woman Clinic Research fluid polymerase chain reaction 6. Pyrimethamine: 50 mg on the first day, 25 mg on the following days, orally as a single dose potential teratogenic effect. Sulfadiazine-pyrimethamine combination with folinic acid alternates with spiramycin in three or four weekly cycles until delivery is given.
Weekly blood counts are needed to monitor hematopoiesis 8, Early in pregnancy transmission rates from mother to fetus tend to be low, while fetal disease severity is highest. In contrast, maternal infection in the third trimester often results in asymptomatic newborns 8,9. The prevalence of toxoplasmosis is decreasing markedly in Europe, weakening the effect of preventive measures and questioning the rationale for screening The hallmark clinical features of congenital rubella syndrome CRS are cataracts, sensorineural hearing loss, and congenital heart disease, consisting of patent ductus arteriosus or septal defects.
The measurement of antibodies in the serum is important for the determination of the immune status, especially the screening of young women in prenatal care — Table 1 Table 1. Rubella antibody detection 15 Preventing these adverse pregnancy outcomes is the focus of rubella vaccination programs.
ToRCH infections in pregnancy: approach and management
Collected data suggest that a cytomegalovirus infection can be severe only when the virus hits the fetus in the embryonic or early fetal period.
Congenital CMV infection may have various outcomes, from intrauterine death to clinically asymptomatic infections Primary infections in the mother have a much greater clinical impact on the fetus than reactivated infections or exogenous reinfections. An optimal approach to CMV infection in pregnancy should probably Wise Woman Clinic Research primary prevention in seronegative pregnant women, identified by pre-pregnancy or early pregnancy screening Proposed management for CMV-infected fetus 20 Laboratory testing for CMV is needed in particular clinical conditions, such as abnormal ultrasound findings Hematological disorders such as neutropenia and thrombocytopenia are rare in CMV-infected fetuses, although CMV is occasionally associated with mild fetal anemia If the IgG avidity index is determined later during pregnancy after weeks of gestationthe sensitivity is drastically reduced A high avidity index during the first weeks of gestation can be considered a good indicator of past infection The diagnosis of maternal primary infection remains tricky because the interpretation of IgG avidity test may be difficult Amniocentesis with amplification of the viral genome in the amniotic fluid by PCR is reliable for the diagnosis of fetal infection, but there American american Rican dating two factors Wise Woman Clinic Research take into account: gestational age and the time interval weeks between maternal seroconversion and amniocentesis The treatment of symptomatic non-pregnant woman with antiviral agents results in favorable clinical outcomes.
There is also some evidence that valaciclovir 8 g daily; 2 g four times Wise Woman Clinic Research day treatment of mothers carrying an infected fetus from the time of prenatal diagnosis range weeks up until delivery is feasible, safe and might be effective.
Symptomatic fetuses were defined by the presence of measurable extracerebral or mild cerebral ultrasound symptoms In contrast to the success of rubella vaccines that induce antibody responses similar to those measured following the infection with wild rubella virus, research is ongoing to clarify the role of treatments for cytomegalovirus Herpes simplex virus HSV Herpes simplex viruses Wise Woman Clinic Research 1 and 2 are simplexviruses in the Alphaherpesvirinae subfamily and important pathogens with a latent carrier restricted to humans.
The virus evades the immune response within the sacral ganglion and cannot be eliminated. HSV at the time of labor and delivery causes neonatal herpes, a rare infection, long-term neurologic impairment and high mortality rates in neonates. Genital HSV contributes to increased risk of HIV acquisition and transmission, and pregnant women should therefore receive the highest priority for HIV prevention 27, The seroprevalence in women is approximately twofold higher than in men, and seroprevalence increases with age and the number of sexual partners.
In USA and northern Europe, the changing epidemiology of genital herpes has been associated with HSV-1, now causing the majority of first-episode genital herpes in women under the age of 26 27, First-episode primary genital herpes is more severe than first-episode non-primary genital herpes.
In general, non-primary HSV-1 is rare. Primary herpes may be associated with early miscarriage Despite the low incidence during the intrauterine period, they are significant because of potentially fatal consequences such as fetal death or neurological disorders, the development of encephalomalacia especially in temporal regionsencephalitis, intracranial calcification and microcephaly, microphthalmia and optic nerve atrophy Recommended regimens in non-pregnant women: aciclovir mg orally, three times a day, for days, or aciclovir mg orally, five times a day, for days, or famciclovir mg orally, three times a day, for days, or valacyclovir 1 g orally, twice a day, for days.
Unlike famciclovir and valacyclovir, aciclovir has poor oral bioavailability; frequent high doses are needed for adequate antiviral activity The use of continuous aciclovir to suppress recurrent herpes throughout pregnancy is inadvisable Caesarean section should be performed if an active primary or recurrent herpes outbreak is suspected at delivery, in order to prevent neonatal transmission. Current guidance from the Royal College of Obstetricians and Gynaecologists and The Centre for Disease Control is to treat at the time of infection for days with mg oral aciclovir, three times a day, followed by a suppressive dose of mg of aciclovir, once a day, from 36 weeks of gestation until delivery 34, Conclusions Congenital infections with toxoplasmosis, rubella, cytomegalovirus and herpes simplex cause variable degrees of cerebral abnormality and fetal damage, with worldwide distribution and a high clinical importance Since guidelines on prenatal management have cautious approach, priorities for research include: a improving estimates regarding the immunologic changes that occur as pregnancy progresses and the interplay of infection, pregnancy, and the fetus and placenta; b concerns about false-positive test results to establish the acute primary infection and distinguish Wise Woman Clinic Research from past chronic infection, in evaluating the risk of fetal transmission; c determining the applicability of national screening programs; d potential risks associated with ToRCH coinfections, which may be able to lead to more complicated pregnancy outcomes 1,9,11, Conflict of interests: The authors declare no conflict of interests.
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Benoist G, et al. Management of pregnancies with confirmed cytomegalovirus fetal infection.
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In utero treatment of congenital cytomegalovirus infection with valacyclovir in a multicenter, open-label, phase II study. Am J Obstet Gynecol. Koelle DM, et al. Sci Rep. Johnston C, Corey L.