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Toxoplasmosis

Often pregnant mothers are warned to keep away from cats for fear of Toxoplasmosis, which spreads to human through cat feces. This can lead to severe health issues for the unborn baby. As a cat ingests an infected small animal such as a rodent, the protozoa invade cells of the cat's intestine. The parasite undergoes several developmental changes to become infective and gets released into the environment in cat feces. This parasite can invade another animal or human, as it buries into skeletal muscles, heart muscles and the brain. It forms cysts, and can stay there throughout her entire life. It is quite rare for humans to get Toxoplasmosis as house cats are not allowed outside and do not carry this parasite; wild cats or those that live outside and hunt are most likely to host toxoplasmosis parasite.


How does Toxoplasmosis spread ?

Toxoplasmosis can spread through:

Food, especially uncooked meats, pork, lamb which may carry toxo cysts.


  • Directly from cat feces

  • From contaminated water, from soil or water with toxo from kitty litter or feces - feral cats or trash disposal may be responsible.

  • Blood transfusion

  • Organ transplantation

  • Mother-to-child transmission, congenital infections

Though the parasite is not infectious until 1 to 5 days after being excreted by an infected cat, it can survive in the environment or litter box for over a year.


Symptoms of Toxoplasmosis

Most infected with the parasite toxoplasmosis show no signs or symptoms. Approximately 10 to 20% of patients will develop flu-like symptoms that can last several weeks or more. Some develop swollen glands, such as in the neck - cervical lymph nodes. Confusion, lack of coordination, seizures, trouble breathing and blurred vision are some other signs of toxoplasmosis. These symptoms can last for a month or more and resolve on their own. Those with weakened immune system are at a risk of developing:


  • Brain inflammation, causing headaches, seizures, confusion and coma

  • Lung infection, which can cause cough, fever, shortness of breath

An infected fetus may exhibit symptoms mild or quite serious. It can lead to miscarriage, stillbirth or birth abnormalities including enlargement or smallness of head. Toxoplasmosis in an unborn baby can be life threatening for the baby soon after birth. It can also infect the baby's eyes and lead to temporary or permanent loss. While most newborns with congenital toxoplasmosis appear normal at birth, it can develop signs and symptoms as they age. Hence, it is important to check the baby's brain and eyes.


Causes

The parasite causing Toxoplasmosis is T.gondii, which survives in contaminated meat that is raw or not thoroughly cooked. Drinking contaminated water, or in some rare cases, blood transfusion or a transplanted organ can cause toxoplasmosis. The parasite exists in feces and mostly found in feces of cat. This means, it can be found in some unwashed produce contaminated with manure. Wash your produce thoroughly to prevent toxoplasmosis.

In the US, although the parasite is found in nearly all warm-blooded animals, cats are the only hosts. The parasite's eggs only reproduce sexually in cats. And interestingly, cats do not show any symptoms of toxoplasmosis, though they are hosts. Those humans who ingest the parasite become infected with toxoplasmosis. This happens, most likely, when cleaning out a litter box without washing hands properly afterward. Pregnant woman are at an increased risk of passing toxoplasmosis to their unborn child and hence, it is important to ask someone else to take care of cat litter box during pregnancy. Protect hands with gloves and change cat litter box daily. And remember, the parasite is not infectious until one to five days, after it is shed.


Risk factors

Toxoplasmosis, though can infect anybody, is more severe in people whose immune systems are weakened, such as those with HIV. The infection can particularly be worrisome in pregnant woman.

Diagnosis

To diagnose Toxoplasmosis clinically could be difficult. A swollen lymph node may be the key to diagnosis, and diagnosis can be made if blood sample is sent specifically for toxoplasmosis. The blood test looks for antibodies against Toxoplasmosis and this specific antibody can help clinicians estimate when the infection occurred. Other diagnosis, though less common, includes microscopic examination of tissues or body fluids for presence of this parasite. Toxoplasma DNA in amniotic fluid is used to determine if the fetus is infected.


Treatment

Most healthy people recover without any treatment. Pregnant women and infants are usually treated with drugs – a combination of pyrimethamine (Daraprim) and sulfadiazine. Pyrimethamine is also used to treat malaria. Sulfadiazine is an antibiotic. Alternate regimens are available for those with drug allergies. If the disease is persistent, and it involves the eyes or internal organs, or the patient is suffering from HIV or AIDS, they need to continue these medications for life.


Treatment for pregnant mothers

During pregnancy, the treatment is somewhat different. The course of treatment depends upon whether the unborn child is infected and if so, the severity of the infection. Most likely, an antibiotic is prescribed depending upon how far she is in pregnancy and to reduce the likelihood of transmission to the fetus. A combination of drugs is generally used during second or third trimesters. If her unborn baby has toxoplasmosis, then pyrimethamine and sulfadiazine may be considered as a treatment. However, these drugs do have significant side effects on the mother and fetus and are used only as a last resort. Potential side effects include bone marrow that helps produce blood cells and liver toxicity.


Prevention tips


  • Washing fresh produce of fruits and vegetables before consumption.

  • Making sure that meat is properly cooked by following safe kitchen practices especially when cooking meat - 70 degrees Celsius for 10 minutes to kill the parasite.

  • Washing utensils that are used to handle raw meat

  • Washing hands after cleaning cat litter.

  • Wearing gloves when gardening to avoid contact with feces in the soil.

  • Keeping outdoor sand boxes covered to keep out infected cats.

  • Avoid drinks that include un-pasteurized goat's milk and raw eggs.

  • Pregnant women should stay away from cat litter box and preferably can ask someone else to do the cleaning.

Transplacental

Transplacental infections are those that can cross the placental barriers. Typically infections such as HIV, hepatitis, herpes, toxoplasmosis and rubella. These transplacental infections can result in fetal malformation and abnormalities in skin, blood or organs.


Stillbirth

A baby who is born without any signs of life at or after 24 weeks of pregnancy is defined as still birth. It could have been during late pregnancy, called intrauterine death or could have died during labor or birth, called intrapartum death. Though stillbirth is uncommon, it cannot be said as rare.


Possible Causes

Genetic factors or

How the placenta works or

Age and lifestyle of the parent and

Infection.


Out of these, problem with the placenta or placental insufficiency is probably the most common cause of a baby dying in the womb. Though the exact reason for placenta not functioning properly is not understood, the blood vessels that connect a mother to her baby could become constricted. This may result in a drop in nutrients and oxygen to the baby, causing growth problems and hence death.

Reduced blood flow to the baby via the placenta could be due to pregnancy illness called Preeclampsia.

About 10 % of the babies are still born due to genetic or chromosomal defects. This happens when the placenta separates from the womb causing placental abruption.

Sometimes health condition of the mother such as diabetes, and rare infections such as flu, group B streptococcus, listeriosis or toxoplasmosis can cause the loss of baby in the womb.


The risk of stillbirth is more in older women. This risk appears to be highest at around 41 weeks. That is why in some hospitals, an older mother-to-be is sometimes recommended to have labor induced few weeks before due date. It is very rare that a baby may be stillborn at the very end of pregnancy. This could be due to problems with the placenta wearing out. If you are several weeks past the due date, the placenta may not work as well as it did earlier. Hence, induced labor is recommended by about 41 weeks. Lifestyle factors such as obesity, heavy drinking and smoking in pregnancy increase the risk of a baby being stillborn. Smoking again, can restrict a baby's growth as it reduces the supply of oxygen to the baby via the placenta.


Stillborn during labor or birth

It is quite rare for a baby to die unexpectedly during labor or birth. Most of the times, stillborn babies are lost when they are still in the womb. If the baby is large, in rare instances, his/her shoulders may get stuck as he/she leaves the birth canal, severely reducing the flow of oxygen to the baby. While most babies recover well, sometimes the shoulder dystocia can result in a baby being stillborn. Another cause is problems in the umbilical cord which could result in loss of oxygen to the baby. Either the cord can slip through the cervix or becomes wrapped around a baby's neck.


Diagnosis

Fetal behavior and changes in fetal movements or sleep-wake cycles can indicate if there is any fetal distress. Decreased or cessation of fetal activity is an indication of fetal distress or even death. Medical examination including a non-stress test is recommended. Obstetricians recommend the use of a kick chart to assist in detecting any changes. Fetoscopy/doptone, ultrasound or electronic fetal monitoring aid in confirming fetal distress or death. In case the fetus is alive but inactive, extra attention is given to the placenta, and umbilical cord during ultrasound examination to ensure that there is no dearth of oxygen supply and nutrients to the baby.


What happens if the baby dies in the womb ?

The sad reality is that even after the baby dies, the mother has to go through with the birth, as it is better for her health and physical recovery. It is rare for a stillborn baby to be born by cesarean section. In most cases, the labor will have to be started artificially induced. While some parents would want to have the induction as soon as possible, some others would prefer to wait a day to two to see what happens if the labor starts by itself. In case the mother is infected, they will advise the labor induced straightway.


Whether induced or natural labor, the midwife or doctor will administer effective morphine-based pain relief. In case of twins or more, and the death of one baby occurs, the doctor normally advises not to have an induction of labor. Other issues such as whether or not the babies share a placenta, and at what stage the loss occurred should be viewed. The doctor would give the best shot for the live baby or babies to develop and mature a bit longer in the womb. The babies can then be born at the same time, when it is best for the mother's health.


A post mortem examination is done to:

1. Identify a cause or causes for death

2. Provide information about the baby's development

3. Information about health problems to combat future pregnancy.

4. Officially confirm the baby's gender.


Not all parents agree to get a post mortem done and it is only carried out with prior written consent of the parents. Post mortem could also be refused for personal, religious or cultural reasons or for any other personal reasons which the parents may not want to disclose.


Implications for next pregnancy

The decision to try for another baby can be difficult for some mothers, whereas, there is an overwhelming urge to get pregnant again as soon as possible in some others. Depending upon the cause of the stillbirth, the doctor should be able to work together to reduce the risk of it happening again.


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Bibliography / Reference

Collection of Pages - Last revised Date: October 22, 2019