Systematic screening and Rx of toxoplasmosis during pregnanc
The present article is an Editorial written by Dr. Jose G. Montoya in the recent issue of American Journal of Obstetrics & Gynecology.

In this issue of the Journal, Mandelbrot et al report findings of the first randomized clinical trial (RCT) ever performed on the treatment of acute toxoplasma infection during pregnancy. Treatment of acute toxoplasma infection during gestation is aimed at preventing mother-to-child transmission (MTCT) and to minimize clinical sequelae in already infected offspring (CSIo).

According to the authors, a placebo-controlled RCT was not possible because most investigators who were surveyed at the time believed that such RCT would be unacceptable, given that spiramycin has been used for this indication in France for >30 years. For this reason, the Toxogest was designed as an RCT to compare the upfront use of spiramycin vs pyrimethamine/sulfadiazine/folinic acid (PS) in women confirmed to have seroconverted during their second trimester of gestation or later.

Their hypothesis was that PS would be superior to spiramycin. One hundred fifty-one women were randomly assigned to spiramycin or PS. The time of maternal infection, which is one of the most powerful factors that influences the likelihood of vertical transmission and clinical sequelae in the offspring, was estimated to have occurred between 13 and 25 weeks of gestation (WG) in their participants.

The time of maternal infection was determined accurately by choosing the midpoint between the last negative and the first positive Toxoplasma immunoglobulin G finding in the setting of monthly screening. Women could not be enrolled in their first trimester because PS is considered unsafe for the fetus during this period; their study did not have any women enrolled past 25 WG for maternal infection, which may have been a good thing because, in the third trimester, spiramycin is known to be less effective and because the comparison would have been unfair for spiramycin.

Unfortunately, Toxogest had to be terminated prematurely because of low enrollment and lack of additional funding. Given the fact that recruitment fell short of the projected sample size, did we learn anything new from Toxogest results? Fortunately, I believe the answer is an unqualified yes.

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