Ethical and psychological aspects regarding the infection with Toxoplasma gondii

during pregnancy
Roxana-Gabriela Cobzaru1,2, Ana-Maria Dumitrescu1, Magda Leon1,3, Mariana Luca1,2, Anca
Sava1,4, Luiza Ioni1, Carmen Rp1,2 , Danisia Haba1,5
1. Grigore T. Popa University of Medicine and Pharmacy, faculty of Medicine
2. Parasitology Department
3. Medical Semiology Department
4. Anatomy and Embriology Department
5. Radiology and Medical Imaging Department
Congenital toxoplasmosis represents a parasitic pathology, transmitted from mother to child
within the intrauterine life, following the maternal infection with Toxoplasma gondii (T.
gondii), during pregnancy. The transmission occurs accidentally in humans (intermediar
hosts) from the principal host which is the cat. The infection can be transmitted to the faetus
both during pregnancy and labor, and , ulteriorly, during the birth itself. The pregnant woman
develops a mild form of infection, thing which stands against fast recognition of disease, and
therefore tardive administration of treatment. The treatment with spiramycin, for example,
reduces the possibilities of transmitting the infection to the faetus, and its lack of initiation
determines the onset of the congenital infection. Therefore, among the first measures that
should be taken in determining toxoplasmosis within pregnancy and reducing its transmission
is monitoring the seroconversion in the case of a seronegative pregnant woman. Among the
important aspects with repercussions on the pregnant womans psychic and with ethical
significance is the premature birth of the child, that takes place in more than half of the cases
and the possible deterioration of the childs nervous, auditory, visual and tegumentary
systems, signs visible ever since birth. In this situation, the mother is confrunted with certain
dillemas, having to decide, once having the certainty of the infection with T. gondii and
knowing all the repercussions upon the future baby, whereas she is going to keep the
pregnancy or abort. In the case of abortion, there are taken into consideration its ethical
implications, highlighting the respect given to ethical principles and the importance of
medical decision within doctor-patient relationship. The fact that the mother may not know
about the infection, until the birth of a child with various pathologies, counts for the
psychological aspect of the situation, with the necessity of psychotherapy indicated by the
specialist and corresponding treatment. Severe episodes of depression, anxiety, panic attacks,
a lack of self-esteem and certain phobias may appear in the case of abortion, as well as in the
case of finding out the diagnosis by the time of late pregnancy, which could worsen things
anticipatedly. KEY WORDS: T.gondii, spyramicin, ethical principles, pregnancy,
psychotherapy.
Congenital toxoplasmosis represents a parasitic pathology, transmitted from mother
to child within the intrauterine life, following the maternal infection with Toxoplasma gondii
(T. gondii), during pregnancy. The transmission occurs accidentally in humans (intermediar
hosts) from the principal host which is the cat. The infection can be transmitted to the faetus
both during pregnancy and labor, and , ulteriorly, during the birth itself. According to several
studies more than a third of the global population has suffered from an infection with this

parasite, seroprevalence being differently distributed across regions and depending on the
socio-economic status. Most of newborns with congenital toxoplasmosis do not show any
clinical signs of infection at birth, but those who developed clinical abnormalities, undetected
initially, though, are found with pathologies of the nervous, visual, auditory, respectively
tegumentary tissues later on in childhood (1, 2).
The pregnant woman develops a mild form of infection, if the infection has occurred
in the esrly phases of gestation, thing which stands against fast recognition of disease, and
therefore tardive administration of treatment. The treatment with spiramycin, for example,
reduces the possibilities of transmitting the infection to the faetus, and its lack of initiation
determines the onset of the congenital infection. Therefore, among the first measures that
should be taken in determining toxoplasmosis within pregnancy and reducing its transmission
is monitoring the seroconversion in the case of a seronegative pregnant woman, that has been
around cats short time before pregnancy or during pregnancy. Therefore, even though
education should play a major role in preventing the spread of congenital toxoplasmosis, this
lacks most of the times. This justifies the necessity of improved systematic serological
programmes that stand for the early prevention of congenital toxoplasmosis and
administration of treatment (1, 2, 3).
Primarily, the congenital toxoplasmosis initiates in women infected with T. gondii
within gestation , when the parasite crosses the placenta and transmits the infection to the
offspring. Although rare, there are some exceptions from this first type of infection: the case
of women who primarily get infected just before the conception, the ones who got already a
chronic infection with the parasite and get double infection with a different strain, as well, and
the case of immunocompromised persons ( women suffering from AIDS, for example). It is
important to mention that not always the infection of the placenta can lead to fetal
toxoplasmosis, but, that, when it happens, it cannot be without its infection first, known as the
parasitemic phase. The gestational age of the mother has a very important impact on the
incidence disease (3, 4).Therefore, the earlier the infection occurs within gestation, the more
probably it is that the faetus will develop the disease, being the inversed situation when the
infection had already occurred in the mother before getting pregnant. In literature, there have
been mentions regarding this issue, stating that most of stillbirths, abortions, brain necrosis
and hydrocephalus developed in faetuses whose mothers where infected with T. gondii earlier
in gestation, an exception being represented by the infection that occurs in the third semester
of pregnancy, with more agressive strains. The pathological clinical developments affecting
the nervous, visual and auditory systems are: microcephaly, hydrocephalus and retardation in
the case of nervous system affection, retinochoroiditis and retinal damage in the case of the
visual system, seizures in the case of the tegumentary system and in the case of the auditory
system (3). These all are very dangerous pathologies to develop within a faetus and involve
serious thinking of bioethical principles within the decision to keep the baby or abort. The doctor
patient relationship which is absolutely marked by confidentiality and security of the patients
confessions and personal data comes in the rescue of the situation in order to come to the right
medical decision. Therefore there is a contradiction between the bioethical principle of nonmaleficience and the one of beneficience, and that is where one of the most important questions
and issues come from. Because it is right to have your own baby, but in cases such as retardation,
hydrocephalus or microcephalus, especially the pathologies involved by the damage of the
nervous system , the cahnces that the baby enjoys a normal healthy life and does not become a
burden for his family are very low. Of course, little chances of a better life for the child exist due to
certain postnatal treatment, but there is little evidence though of the efficacy of some prenatal
treatment. The informed consent comes only from the patient only after she is presented all the
risk factors involved by keeping the pregnancy and all the positive aspects regarding the

confrunting situation, and after the medical decision, the mother is helped with abortion, if it has
been decided so, this being respected the bioethical principle of respect for autonomy (5).
The psychological issue involved by the matter is one of great importance as well, due to
the contradiction between the desire of having a baby and avoiding giving birth to someone who
wouldnt be able to live a proper life, thus harming not only youself as a mother, but also the rest
of the family involved and create a burdon to society, not mentioning the possible costs involved
by raising-up a child with so many pathologies and needs. It is a difficult situation for the mother
who may not even have been aware of the infection untill a later stage of it. The role of
psychotherapy is a complex one as it helps the taking of medical decison, as well, and orientates
the mother towards her next steps. It is helpful not only within pregnancy, but also before and
mainly after in case of abortion, as to avoid depression, anxiety, panic attacks, a feeling of selfesteem and suicidary acts (5).
Congenital toxoplasmosis remains an important trigger for both medical and existential
issues, a true challenge for systematic prevention programmes that involve serological testing in
seronegative pregnant women, that have been surrounded by cats or live in rural areas and a
continuous field of further investigation.

References:
1. David H. M. Joynson,Tim G. Wreghitt , Toxoplasmosis: A Comprehensive Clinical Guide,
New York, USA, Cambridge University Press, 2001;
2. Louis M. Weiss,Kami Kim, Toxoplasma Gondii: The Model Apicomplexan. Perspectives
and Methods, London, UK, Academic Press, 2007;
3. Asgari Q., Fekri M., Monabati A., Kalantari M., Mohammadpour I., Molecular
Genotyping of Toxoplasma gondii in Human Spontaneous Aborted Fetuses in Shiraz,
Southern Iran Iran J Public Health. 2013; 42(6): 620625;
4. SDLP Subasinghe, Karunaweera N.D., Kaluarachchi A., Abayaweera CA, Gunatilake MH,
Ranawaka J., Toxoplasma gondiiseroprevalence among two selected groups of pregnant
women, Sri Lankan Journal of Infectious Diseases 2011; Vol.1(1): 9-17;
5. Abortion Risks: A list of major psychological complications related to abortion, accesible
on http://afterabortion.org/2011/abortion-risks-a-list-of-major-psychological-complicationsrelated-to-abortion/, accesed on 06.05.2014;