|Year : 2013 | Volume
| Issue : 1 | Page : 62-66
Seroprevalence of toxoplasmosis in antenatal women with bad obstetric history
Suryamani Chintapalli, I Jyothi Padmaja
Department of Microbiology, Andhra Medical College, Visakhapatnam, India
|Date of Web Publication||25-Jun-2013|
Department of Microbiology, Andhra Medical College, Visakhapatnam - 24
| Abstract|| |
Background: The occurrence of fetal death is one of the tragedies that confront the physician providing obstetric care. Among the various agents associated with infections of pregnancy, viruses are the most important followed by bacteria and protozoa. Among protozoal infections in pregnancy, toxoplasmosis is reported to have a high incidence, sometimes causing fetal death. The study was intended to observe the seroprevalence of Toxoplasmosis in pregnant women presenting with bad obstetric history (BOH). Materials and Methods: A total of 92 antenatal women were included in the study (80 in the study group and 12 in control group). The study group comprised of antenatal women with BOH in the age group of 20-35 years. Antenatal women with Rh incompatibility, pregnancy induced hypertension, diabetes mellitus, renal disorders and syphilis were not included in the study. The control group included women in reproductive age group without BOH. All the samples were screened by enzyme linked immuno sorbent assay (ELISA) for Toxoplasma specific Immunoglobulin M (IgM) and Immunoglobulin G (IgG) antibodies. Results: Of the 80 antenatal women in the study group, 36 (45%) were seropositive for Toxoplasma specific IgG antibodies (P < 0.005), 16 (20%) were seropositive for Toxoplasma specific IgM antibodies (P < 0.005) and 8 (10%) were seropositive for both IgG and IgM antibodies (P < 0.005). Various predisposing factors for acquiring Toxoplasmosis such as contact with cats, contact with soil, food habits, illiteracy, socio-economic status and residential status were also studied. Conclusions: We conclude that toxoplasmosis during pregnancy causes congenital fetal infection with possible fetal loss. ELISA was found to be a sensitive serological test for diagnosis of Toxoplasmosis in pregnant women with BOH. Major cause of fetal loss in BOH cases in the study group was abortion.
Keywords: Antenatal women, assay, bad obstetric history, enzyme linked immunosorbent immunoglobulin G, intrauterine death, immunoglobulin M, toxoplasmosis
|How to cite this article:|
Chintapalli S, Padmaja I J. Seroprevalence of toxoplasmosis in antenatal women with bad obstetric history. Trop Parasitol 2013;3:62-6
| Introduction|| |
Toxoplasmosis is a zoonotic protozoal infection. It occurs during pregnancy as an acute infection that may cause damage to the fetus, which is one of the important reasons for bad obstetric history (BOH) in pregnant women.  Toxoplasma infection is known to be transmitted from cat's feces, often through contaminated vegetables, fruits and milk.
Diagnosis of Toxoplasma specific Immunoglobulin M (IgM) by enzyme linked immuno sorbent assay (ELISA) indicates recent infection as the cause of BOH in pregnant women leading to congenital malformations, abortions and still births. The detection of Toxoplasma specific immunoglobulin G (IgG) antibodies indicates chronic infection. 
Studies analyzing the role of maternal infection in the causation of BOH are less in number, probably due to lack of facilities in isolating etiological agents causing BOH and the prohibitive cost of commercial diagnostic kits. Most of the available information on Toxoplasmosis from India is in women with pregnancy wastage.
In view of the above observation, the present study was carried out on clinically suspected cases of toxoplasmosis in antenatal women. The study was intended to observe the sero prevalence of toxoplasmosis in pregnant women with BOH.
| Materials and Methods|| |
A total of 92 whole blood samples were collected from antenatal women attending their antenatal check-up. They were divided into two groups, namely the study group and the control group.
Women in reproductive age group with BOH such as; spontaneous abortions, missed abortions, intra uterine death (IUD), preterm deliveries, still births, congenital malformations, perinatal deaths, unexplained neonatal deaths, women having mentally retarded children in earlier pregnancies and unexplained seizures.
Patients with Rh incompatibility, pregnancy induced hypertension, diabetes mellitus, renal disorders and syphilis.
Women in reproductive age group without any BOH. Every case was studied by obtaining detailed history and data regarding clinical examination, history of lymphadenopathy, pyrexia of unknown origin, convulsions and visual disturbances which indicate symptomatic toxoplasmosis, was specifically elicited. Subsequently relevant investigations to exclude common etiological factors implicated in BOH were conducted which included blood grouping, Rh typing, complete hemogram, coagulation profile, fasting and post-prandial blood sugars and renal function tests. Thus only idiopathic fetal wastage was included in the present study.
Methods of sample collection
A total of 92 whole blood samples were collected using sterile disposable syringes. Under aseptic precautions, 5ml of blood was withdrawn by venepuncture. After centrifugation, clean serum was transferred into provials and was preserved at −20°C.
Processing of serum samples
All the samples were screened for Toxoplasma specific IgG and IgM antibodies by ELISA. (EUROIMMUN IgM and IgG) manufactured by Medizinische Labordiagnostica, Germany.
The antigen coated is lysate of sonicated gamma irradiated tachyzoites. Patient's serum was added and any antibodies to Toxoplasma antigens present in the serum would bind to these antigens. The microwells were washed to remove unbound serum proteins. Antibodies conjugated with Horseradish Peroxidase enzyme and directed against human IgM and IgG were added which would in turn bind to any human IgM and IgG present. The microwells were washed to remove unbound conjugate, and then chromogen/substrate was added. In the presence of peroxidase enzyme the colorless substrate was hydrolyzed to a colored end product. The color intensity was proportional to the amount of antibodies present in the patient serum.
Photometric measurement of the color intensity was measured using 450 nm filter within 30 min by adding the stop solution.
Calculation of results
The ratios were calculated according to the following formula.
Interpretations of results are as follows:
Ratio < 8.0: Negative
Ratio < 8.0-1.0: Borderline
Ratio > 1.0: Positive
A positive result indicates presence of IgM or IgG antibodies to Toxoplasma gondii.
A negative result indicates no immunity to Toxoplasma. These individuals are presumed to be susceptible to a primary infection.
The same procedure was also repeated for IgG antibodies.
| Results|| |
Out of 80 antenatal women in the study group 36 (45%), were seropositive for Toxoplasma specific IgG (P < 0.005), 16 cases (20%) were seropositive for Toxoplasma specific IgM antibodies (P < 0.005) and 8 cases (10%) were seropositive for both IgG and IgM (P < 0.005). In the control group, 1 sample each was seropositive for IgM and IgG antibodies [Table 1].
|Table 1: Correlation between IgG and IgM seropositivity among bad obstetric history and control groups (n=92)|
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The majority of seropositive cases in the study group were in the age group 20-24 years (49.99%).Among the seropositive cases IgG seropositivity was more in 20-24 years as compared 30-34 years [Table 2].
|Table 2: Seroprevalence of toxoplasma immunoglobulin G and immunoglobulin M in different age groups among bad obstetric history cases (n=80)|
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IgG seropositivity was high among antenatal women of low socioeconomic status (83.87%) ( P < 0.05), illiterates (80%) ( P > 0.05), from rural area (78.12%) with non-vegetarian food habits (72.34%)( P < 0.05). IgM seropositivity was high among antenatal women with high socioeconomic status (80%) ( P < 0.05), with the history of contact with cats (60%) ( P < 0.05) and with the history of contact with soil (38.7%) ( P > 0.05) [Table 3].
There was gradual increase of seropositivity for Toxoplasma infection with increasing parity for both IgG and IgM antibodies. These roprevalence was more in Gravida VI (87.5%) for IgG and (62.5%) for IgM antibodies [Table 4].
The predominant clinical condition responsible for BOH with Toxoplasma infection was abortions in 20 cases (38.46%) followed by IUD (24.99%), still births (28.5%), hydrocephalus and anencephalus [Table 5].
|Table 5: Clinical spectrum of seropositive bad obstetric history cases (n=52)|
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Ten seropositive cases in the present study were treated with spiramycin. Six of them were given prolonged therapy and four of them treated with interval therapy. Out of these 10 cases eight gave birth to live children [Table 6].
|Table 6: Percentage seropositivity of toxoplasmosis in different study groups in India|
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| Discussion|| |
Increasing evidence is available which shows that infection by Toxoplasma induces foetal loss in women. This agent has predilection for nucleated cells of muscle, intestinal epithelium and placenta. It can be congenitally acquired by transfer through the placenta, if the mother contracts the disease during pregnancy, causing abortions, stillbirths, congenital malformations.  The disease can be diagnosed by serology. Demonstration of Toxoplasma specific IgM antibodies indicates recent infection and detection of Toxoplasma specific IgG antibodies indicates chronic infection.
In this study out of 80 cases in the study group 16 (20%) were seropositive for Toxoplasma specific IgM antibodies, 36 cases (45%) were seropositive for Toxoplasma specific IgG antibodies. In Andhra Pradesh, the results of the present study are comparable to the observations made by Dr. Sankar 2004, who reported a seropositivity of 38% for IgG and Yasodhara et al., who reported a seropositivity of 18.3% for Toxoplasma specific IgM antibodies.  [Table 5] summarizes similar studies which have determined the seropositivity for Toxoplasma specific antibodies. In the present study the values are comparatively higher when compared with other studies done by indirect fluorescent antibody test and indirect haemagglutination. The high seropositivity rate obtained in the present study can be attributed to the high sensitivity of the test system used to detect Toxoplasma antibodies. 
Out of 80 cases in the study group, eight cases (10%) were seropositive for both IgG and IgM antibodies with possible recent infection in the last 12 months. Eight cases (10%) were seropositive for IgM antibodies alone, which indicates acute infection. 28 cases (35%) were seropositive for IgG antibodies only which indicates chronic infection. Thirty six cases (45%) were seronegative for both IgG and IgM antibodies which shows that the BOH was not due to Toxoplasma infection, but may be due to other infections like CMV (cytomegalovirus), Herpes simplex and Rubella. 
Out of 12 cases in the Control group, one was seropositive for IgG antibodies which may be due to exposure to Toxoplasma infection in the past.Also, one patient in the control group was positive for IgM antibodies which probably denote a subclinical infection.
Out of 52 seropositive cases in the study group the highest incidence of toxoplasmosis was observed in the age group 20-24 years, 26 cases (49.99%). It was observed that the seropositivity for Toxoplasma specific IgG antibodies increased from the age group 20-24 years 61.53% (16 out of 26) to 85.71% (6 out of 7) in 30-34 year age group. Mittal et al., in their study revealed that the lowest rate of antibody acquisition occurred in the age group 15-20 years and it was increased with increase in age profile.  This is in agreement with the present study.
In our study abortions constituted the major clinical case of pregnancy wastage when compared to still births, IUD, congenital malformations like hydrocephalus, anencephaly.  The second major presenting condition was IUD, 12 cases (23.07%) of which nine (74.99%) were seropositive for IgG and three were seropositive for IgM antibodies. There were seven still births (13.46%) and 10 preterm labour cases (19.23%).
IgG seropositivity was more in still births, IgM seropositivity was more in preterm labour cases. 
There is evidence that active Toxoplasma infection can occasionally persist from one pregnancy to the next and such infection may be the cause repeated miscarriages or still births.  It appears that in such cases, T. gondii may encyst in the uterine endometrium and is stirred into activity by the process of placentation. This may lead to low grade local endometritis which may persist. T. gondii has been isolated from abortus in one case of miscarriage. Hence it is essential to test for both IgG and IgM antibodies, as chronic infection can also lead to fetal wastage.
From this study it is observed that illiteracy, poverty, overcrowding, lack of hygiene and associated environmental factors play a crucial role for the high incidence of Toxoplasmosis. The study also shows that, women who had contact with the soil ( P < 0.005) and those with non-vegetarian food habits have high levels of IgG antibodies ( P < 0.005).  This shows that unique environmental factors in various communities, eating habits have s on the transmission of this infection. The socio-epidemiological aspects of toxoplasmosis are the important contributing factors for the spread of the disease.
Early diagnosis and treatment have an effective role in reducing transmission of infection from mother to baby.  Ten seropositive cases in the present study were treated with Spiramycin. Four of them were treated with interval therapy (Spiramycin 3 million IU International units twice a day for 3 weeks) and six of them with prolonged therapy during pregnancy (Spiramycin 3 million IU twice a day for 3 weeks, with 2 weeks drug free period) same treatment was continued till parturition. Outcome of these cases was excellent after treatment with Spiramycin. Of the 10 cases, 80% had healthy live children. ,,
Toxoplasmosis is amenable to treatment. Early detection with repeated serological examination and treatment in all pregnancies can reduce the hazard substantially.
| Acknowledgments|| |
This study would not have been possible without the expert guidance of Dr. I. Jyothipadmaja and Dr. P. Balamurali Krishna. We convey our sincere thanks to the Superintendant of Government Victoria Hospital for women and children Dr. B.S. Krishnamma for providing the study samples. We also like to thank Dr. Varalakshmi, Dr. Perala. Balamuralikrishna, Dr. G. Ratnakumari, Dr. Arunasree, Dr. Lakshmi, Dr. Bharathi, Dr. Siva Kalyani, Dr. Parvathi and Dr. Sankar for their valuable inputs in the study. We would also thank the counselors, colleagues, paramedical staff and technicians of PMTCT (Prevention of mother to child transmission) for their work and help contributed to the study.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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