1. Toxoplasmosis & Chicken pox In Pregnancy
بنام خدا
Toxoplasmosis & Chicken pox
In Pregnancy

2. Toxoplasmosis in pregnancy
Introduction
a ubiquitous protozoan parasite
serological evidence of past infection(15-45% in industrially developed and 80% in another countries)
in neural and muscle tissue
retinochoroiditis is the most frequent manifestation

3. Toxoplasmosis in pregnancy
Sources of infection
the oocyst, which is shed only in cat feces
the tachyzoite
the bradyzoite(within tissue cysts)

4. Toxoplasmosis in pregnancy

5. Toxoplasmosis in pregnancy
Maternal infection
Incidence: 1 to 8 per 1000 pregnancy
Clinical manifestations:
Acute infection is usually asymptomatic
Nonspecific (fatigue, fever, headache, malaise, and myalgia)
Lymphadenopathy

6. Toxoplasmosis in pregnancy
MATERNAL INFECTION
Clinical differential:
acute Epstein-Barr virus infection, cytomegalovirus infection, HIV infection, syphilis, sarcoidosis, Hodgkin's disease, and lymphoma 

7. Toxoplasmosis in pregnancy
Diagnosis: a minimum of two blood samples at least two weeks apart showing seroconversion from negative to positive Toxoplasma-specific IgM or IgG
IgM antibodies…positive from 1-2 w to years
igG antibodies…positive from 6-8 w for 2-4 w
IgG avidity assay
Screening: Not recommended!

8. Toxoplasmosis in pregnancy
FETAL INFECTION
Risk factors:
advancing gestational age at the time of maternal seroconversion
mother”s immunity

9. Toxoplasmosis in pregnancy
Pathogenesis of fetal infection:
via plasenta
during the parasitemic phase
the transition from acute infective tachyzoite form to the dormant bradyzoite form contained in tissue cysts…therapeutic "window of
opportunity."

10. Toxoplasmosis in pregnancy
Fetal sequelae:
cerebral palsy, microcephaly, or bilateral blindness, or hydrocephalus or epilepsy
retinochoroiditis, or lymphadenopathy or hepatosplenomegaly

11. Toxoplasmosis in pregnancy
Fetal sequelae in sonograghy: 
intracranial hyperechogenic foci or calcifications
ventricular dilatation
Intrahepatic densities, increased thickness and hyperdensity of the placenta, ascites, and, rarely, pericardial and pleural effusions

12. Toxoplasmosis in pregnancy
Prenatal diagnosis:
purpose: decide whether to change prenatal treatment from spiramycine to a pyrimethamine-sulfonamide combination and terminate the pregnancy
Amniocentesis
PCR for T. gondii DNA in amniotic fluid
In placenta after delivvery:granulomatous villitis, cysts, plasma cell deciduitis, villous sclerosis, and chorionic vascular thromboses.

13. Toxoplasmosis in pregnancy
Prenatal treatment
spiramycin alone, spiramycin followed by pyrimethamine-sulfonamides, and pyrimethamine-sulfonamides alone
three-week course of spiramycin (1 g orally three times per day)
Pyrimethamine (25 mg once per day orally) and sulfadiazine (4 g/day orally divided into two to four doses) administered continuously until term.

14. Toxoplasmosis in pregnancy
Azithromycin
animal model and in humans with acquired immunodeficiency syndromes (AIDS)
reduces serious neurological sequelae of congenital toxoplasmosis, but no evidence of any effect on ocular disease, vision, or mother-to-child transmission of infection

15. Toxoplasmosis in pregnancy
Termination of pregnancy
the most infected babies have a good prognosis
PREVENTION:
avoid drinking unfiltered water
hand hygiene after touching soil
washing fruit and vegetables
avoid undercooked meat

16. Toxoplasmosis in pregnancy
Timing pregnancy after maternal infection:
delay of six months has been suggested

17. Varicella-zoster virus infection in pregnancy
Introduction
one of eight herpesviruses
infection in adults can lead to significant morbidity and mortality
transmitted by:
nasopharyngeal mucosa by droplets onto the conjunctival or nasal/oral mucosa
direct contact with vesicular fluids
rarely, the airborne spread

18. Varicella-zoster virus infection in pregnancy
Maternal varicella 
Incidence:1 to 5 cases per 10,000 pregnancies
the incidence of varicella is not higher in pregnant compared to nonpregnant adults, disease severity appears to be increased
Transmission can occur in utero, perinatally, or postnatally

19. Varicella-zoster virus infection in pregnancy
Maternal varicella 
 Primary infection:regional lymph nodes and tonsils and possibly ductal tissue of salivary glands, VZV exanthem
Uncomplicated varicella:rash of varicella, lesions in different stages of development, fever, malaise, and myalgia
oral acyclovir therapy (800 mg five times per day for seven days)

20. Varicella-zoster virus infection in pregnancy
Maternal varicella 
Complicated infection:meningitis, encephalitis, cerebellar ataxia, pneumonia, glomerulonephritis, myocarditis, ocular disease, adrenal insufficiency, and death
Varicella pneumonia:specially in who smoking or have more than 100 vesicles  
acyclovir (10 mg/kg every eight hours)

21. Varicella-zoster virus infection in pregnancy
Maternal varicella
DIAGNOSIS:clinical
doubt:PCR testing of skin scrapings
can also be cultured
Serologic testing is usually not necessary for diagnosis

22. Varicella-zoster virus infection in pregnancy
Congenital varicella
the incidence of congenital abnormalities 0.4 percent before the 12th w;two percent between weeks 13 and 20; only percent between weeks 21 to 28 of gestation

23. Varicella-zoster virus infection in pregnancy
Clinical features of congenital varicella syndrome:
●Cutaneous scars in a dermatomal pattern
●Neurological abnormalities (eg, mental retardation, microcephaly, hydrocephalus, seizures, Horner’s syndrome)
●Ocular abnormalities (eg, optic nerve atrophy, cataracts, chorioretinitis, microphthalmos, nystagmus)
●Limb abnormalities (hypoplasia, atrophy, paresis)
●Gastrointestinal abnormalities (gastroesophageal reflux, atretic or stenotic bowel)
●Low birth weight and intrauterine growth retardation

24. Varicella-zoster virus infection in pregnancy
Neonatal VZV infection:transmission from a mother to the fetus just prior to delivery
mothers who have clinical disease within five days before to two days after delivery 

25. Varicella-zoster virus infection in pregnancy
Congenital varicella
Prenatal diagnosis:
PCR testing of fetal blood or AF for VZV
ultrasonography for detection of fetal abnormalities
Postnatal diagnosis:
●History of maternal varicella infection during the first or second trimester of pregnancy
●Presence of compatible fetal abnormalities consistent with congenital varicella syndrome
●Evidence of intrauterine VZV infection

26. Varicella-zoster virus infection in pregnancy
POST-EXPOSURE PROPHYLAXIS :VZIG
is not needed among women who were immunized with varicella vaccine in the past
To decrease the risk of maternal infection and maternal morbidity
biologically plausible that might decrease viremia, leading to a lower risk of mother-to-child transmission

27. Varicella-zoster virus infection in pregnancy
no data on whether acyclovir is beneficial in reducing the risk of varicella after exposure during pregnancy
a single dose of intravenous immune globulin (IVIG) at 400 mg/kg
should be administered as soon as possible within 10 days of exposure

30. Toxoplasmosis & Chicken pox In Pregnancy
THANKS FOR YOUR ATTENTION