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J.-S. Yuk et al. / International Journal of Gynecology and Obstetrics 129 (2015) 169–177
http://dx.doi.org/10.1016/j.ijgo.2014.11.013 0020-7292/© 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
Cesarean delivery or induction of labor does not prevent vertical transmission of toxoplasmosis in late pregnancy Martine Wallon a,b, François Kieffer c, Cyril Huissoud d, François Peyron a,b,⁎ a
Department of Parasitology, Claude Bernard Lyon 1 University, Faculty of Medicine, Lyon, France Department of Parasitology, Hospital of the Croix Rousse, Lyon, France c Neonatal Unit, Armand Trousseau Hospital, Paris, France d Department of Gynecology and Obstetrics, Hospital of the Croix Rousse, Lyon, France b
a r t i c l e
i n f o
Article history: Received 22 August 2014 Received in revised form 14 October 2014 Accepted 10 December 2014 Keywords: Congenital toxoplasmosis Cesarean delivery Induction of labor
Toxoplasmosis during pregnancy can have deleterious effects on the fetus, ranging from severe neurologic or ophthalmologic lesions to fetal loss. In some cases, infection appears subclinical at birth but patients are at risk of developing chorioretinitis [1]. The stage of pregnancy at maternal infection is the main predictive factor for the risk of fetal toxoplasmosis and its severity [2]. For third trimester infections, the placental barrier is less efficient than at the beginning of pregnancy, and the risk of fetal infection reaches 58% [3]. Conversely, the severity of the disease is inversely related because the majority of newborns are asymptomatic. The management of maternal infections in the first and second trimesters is well codified, relying on amniocentesis to determine treatment with pyrimethamine and sulfonamides. The approach is less standardized for later maternal infections. Because of the high risk of
congenital infection, obstetricians might consider performing cesarean delivery or induction of labor to prevent the risk of vertical transmission by reducing the length of fetal exposure to the parasite. The present study reports a series of 10 infants born to mothers who became infected with Toxoplasma gondii between 33 and 39 weeks of pregnancy (median, 36 weeks) and for whom a cesarean delivery or induction of labor was performed between 38 and 40 weeks (median, 39 weeks) to protect the newborn from toxoplasmosis. The study covered the period from October 1994 to July 2012. Date of maternal infection was serologically confirmed in the department. No amniocentesis was performed and five women were treated with spiramycin (Table 1). The median delay between the estimated date of maternal infection and delivery was three weeks. Nine newborns were diagnosed with congenital toxoplasmosis, subclinical at birth in eight cases, and one had chorioretinitis. In third trimester infections, vertical transmission occurs rapidly after maternal infection and cesarean delivery or induction of labor, even when performed shortly after the estimated date of infection, is inefficient at preventing congenital toxoplasmosis. Another approach comprises presumptive treatment with sulfadiazine and pyrimethamine; however, at the end of pregnancy, 30% of children would be treated unnecessarily [2]. Amniocentesis allows parasitic detection by polymerase chain reaction, with sensitivity and specificity of 73.5% and 100%, respectively, during the third trimester [3], and should be performed whenever possible, with treatment prescribed only for positive cases. Toxoplasmosis in late pregnancy should be managed first by amniocentesis whenever feasible. Induction of labor or cesarean delivery does not prevent congenital toxoplasmosis. Compared with term births, early-term deliveries are associated with greater morbidity [4].
Table 1 Mode of delivery and outcome for 10 newborns whose mothers presented with a toxoplasmic infection during pregnancy. Patient
Gestational age at estimated time of maternal infection, wk
Maternal treatment
Gestational age at delivery, wk
Interval between maternal infection and delivery, wk
Type of delivery
Gender of neonate
Congenital toxoplasmosis
1 2 3 4 5 6 7 8 9 10
37 35 34 33 37 39 38 36 39 36
No No Spiramycin Spiramycin Spiramycin No No Spiramycin No Spiramycin
38 38 39 38 40 40 39 38 40 39
1 3 5 5 3 1 1 2 1 3
Cesarean Induction Induction Induction Induction Cesarean Induction Cesarean Cesarean Induction
F M F F F M M M F M
Yes Yes Yes Yes Yes Yes No Yes Yes Yes
⁎ Corresponding author at: Service de Parasitologie, Hôpital de la Croix Rousse, 103 Grande Rue de la Croix Rousse, 69317 Lyon, France. Tel.: +33 4 72 07 18 72; fax: +33 4 72 07 18 73. E-mail address: [email protected] (F. Peyron).
J.-S. Yuk et al. / International Journal of Gynecology and Obstetrics 129 (2015) 169–177
Conflict of interest The authors have no conflicts of interest.
References
177
[2] Wallon M, Peyron F, Cornu C, Vinault S, Abrahamowicz M, Kopp CB, et al. Congenital toxoplasma infection: monthly prenatal screening decreases transmission rate and improves clinical outcome at age 3 years. Clin Infect Dis 2013;56(9):1223–31. [3] Rabilloud M, Wallon M, Peyron F. In utero and at birth diagnosis of congenital toxoplasmosis: use of likelihood ratios for clinical management. Pediatr Infect Dis J 2010;29(5):421–5. [4] Sengupta S, Carrion V, Shelton J, Wynn RJ, Ryan RM, Singhal K, Lakshminrusimha S. Adverse neonatal outcomes associated with early-term birth. JAMA Pediatr Nov 2013;167(11):1053–9.
[1] Montoya JG, Liesenfeld O. Toxoplasmosis. Lancet 2004;363(9425):1965–76.
http://dx.doi.org/10.1016/j.ijgo.2014.10.026 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
J.-S. Yuk et al. / International Journal of Gynecology and Obstetrics 129 (2015) 169–177
http://dx.doi.org/10.1016/j.ijgo.2014.11.013 0020-7292/© 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
Cesarean delivery or induction of labor does not prevent vertical transmission of toxoplasmosis in late pregnancy Martine Wallon a,b, François Kieffer c, Cyril Huissoud d, François Peyron a,b,⁎ a
Department of Parasitology, Claude Bernard Lyon 1 University, Faculty of Medicine, Lyon, France Department of Parasitology, Hospital of the Croix Rousse, Lyon, France c Neonatal Unit, Armand Trousseau Hospital, Paris, France d Department of Gynecology and Obstetrics, Hospital of the Croix Rousse, Lyon, France b
a r t i c l e
i n f o
Article history: Received 22 August 2014 Received in revised form 14 October 2014 Accepted 10 December 2014 Keywords: Congenital toxoplasmosis Cesarean delivery Induction of labor
Toxoplasmosis during pregnancy can have deleterious effects on the fetus, ranging from severe neurologic or ophthalmologic lesions to fetal loss. In some cases, infection appears subclinical at birth but patients are at risk of developing chorioretinitis [1]. The stage of pregnancy at maternal infection is the main predictive factor for the risk of fetal toxoplasmosis and its severity [2]. For third trimester infections, the placental barrier is less efficient than at the beginning of pregnancy, and the risk of fetal infection reaches 58% [3]. Conversely, the severity of the disease is inversely related because the majority of newborns are asymptomatic. The management of maternal infections in the first and second trimesters is well codified, relying on amniocentesis to determine treatment with pyrimethamine and sulfonamides. The approach is less standardized for later maternal infections. Because of the high risk of
congenital infection, obstetricians might consider performing cesarean delivery or induction of labor to prevent the risk of vertical transmission by reducing the length of fetal exposure to the parasite. The present study reports a series of 10 infants born to mothers who became infected with Toxoplasma gondii between 33 and 39 weeks of pregnancy (median, 36 weeks) and for whom a cesarean delivery or induction of labor was performed between 38 and 40 weeks (median, 39 weeks) to protect the newborn from toxoplasmosis. The study covered the period from October 1994 to July 2012. Date of maternal infection was serologically confirmed in the department. No amniocentesis was performed and five women were treated with spiramycin (Table 1). The median delay between the estimated date of maternal infection and delivery was three weeks. Nine newborns were diagnosed with congenital toxoplasmosis, subclinical at birth in eight cases, and one had chorioretinitis. In third trimester infections, vertical transmission occurs rapidly after maternal infection and cesarean delivery or induction of labor, even when performed shortly after the estimated date of infection, is inefficient at preventing congenital toxoplasmosis. Another approach comprises presumptive treatment with sulfadiazine and pyrimethamine; however, at the end of pregnancy, 30% of children would be treated unnecessarily [2]. Amniocentesis allows parasitic detection by polymerase chain reaction, with sensitivity and specificity of 73.5% and 100%, respectively, during the third trimester [3], and should be performed whenever possible, with treatment prescribed only for positive cases. Toxoplasmosis in late pregnancy should be managed first by amniocentesis whenever feasible. Induction of labor or cesarean delivery does not prevent congenital toxoplasmosis. Compared with term births, early-term deliveries are associated with greater morbidity [4].
Table 1 Mode of delivery and outcome for 10 newborns whose mothers presented with a toxoplasmic infection during pregnancy. Patient
Gestational age at estimated time of maternal infection, wk
Maternal treatment
Gestational age at delivery, wk
Interval between maternal infection and delivery, wk
Type of delivery
Gender of neonate
Congenital toxoplasmosis
1 2 3 4 5 6 7 8 9 10
37 35 34 33 37 39 38 36 39 36
No No Spiramycin Spiramycin Spiramycin No No Spiramycin No Spiramycin
38 38 39 38 40 40 39 38 40 39
1 3 5 5 3 1 1 2 1 3
Cesarean Induction Induction Induction Induction Cesarean Induction Cesarean Cesarean Induction
F M F F F M M M F M
Yes Yes Yes Yes Yes Yes No Yes Yes Yes
⁎ Corresponding author at: Service de Parasitologie, Hôpital de la Croix Rousse, 103 Grande Rue de la Croix Rousse, 69317 Lyon, France. Tel.: +33 4 72 07 18 72; fax: +33 4 72 07 18 73. E-mail address: [email protected] (F. Peyron).
J.-S. Yuk et al. / International Journal of Gynecology and Obstetrics 129 (2015) 169–177
Conflict of interest The authors have no conflicts of interest.
References
177
[2] Wallon M, Peyron F, Cornu C, Vinault S, Abrahamowicz M, Kopp CB, et al. Congenital toxoplasma infection: monthly prenatal screening decreases transmission rate and improves clinical outcome at age 3 years. Clin Infect Dis 2013;56(9):1223–31. [3] Rabilloud M, Wallon M, Peyron F. In utero and at birth diagnosis of congenital toxoplasmosis: use of likelihood ratios for clinical management. Pediatr Infect Dis J 2010;29(5):421–5. [4] Sengupta S, Carrion V, Shelton J, Wynn RJ, Ryan RM, Singhal K, Lakshminrusimha S. Adverse neonatal outcomes associated with early-term birth. JAMA Pediatr Nov 2013;167(11):1053–9.
[1] Montoya JG, Liesenfeld O. Toxoplasmosis. Lancet 2004;363(9425):1965–76.
http://dx.doi.org/10.1016/j.ijgo.2014.10.026 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
