Standard Obstetric Care Research Articles

Effects of Periodontal Therapy on Rate of Preterm Delivery

It is unclear whether treatment of maternal periodontal disease will reduce the risk of preterm delivery. The results of 4 randomized single-center trials suggested that periodontal treatment during pregnancy may reduce preterm births. However, a randomized, multicenter clinical trial reported no difference between treatment and control groups for mean gestational age and preterm birth. This randomized, controlled clinical trial investigated the effects of treatment of periodontal disease on the incidence of preterm birth in women receiving standard obstetric care. Between 2004 and 2007 at 3 US sites, 1806 pregnant women with periodontal disease were randomized to either a periodontal treatment arm (n = 903), consisting of scaling and root planning early in the second trimester, or a delayed treatment arm (n = 903) that provided periodontal care only after delivery. The pregnancy and maternal periodontal status in all participants were followed to delivery and neonatal outcomes until discharge. The primary outcome was preterm birth defined as gestational age less than 37 weeks. The secondary outcome was gestational age less than 35 weeks. A total of 1760 evaluable patients were included in the final analysis. There were no differences at baseline in the treatment and control (delayed treatment) groups for any periodontal or obstetric measure. No statistically significant differences were found between the 2 groups in rates of preterm delivery or adverse events, or in major obstetric and neonatal outcomes. There were some differences among the individual study sites in effects of treatment on periodontal status. These findings demonstrate that periodontal therapy during pregnancy has no effect on rates of preterm delivery.

Serial Membrane Sweeping at Term in Planned Vaginal Birth After Cesarean

To estimate the effect of serial membrane sweeping on the onset of labor in women who planned vaginal birth after cesarean (VBAC). Women at term with one transverse lower segment cesarean delivery who were suitable for and who planned VBAC were approached to participate. Participants were randomly assigned to weekly membrane sweeping or weekly vaginal assessment for Bishop score until delivery. Participants and delivery providers were blinded to the allocated treatment. Standard obstetric care was given to all participants. The primary outcome was onset of labor which was defined as the presence of spontaneous regular and painful contractions that cause cervical dilation to at least 3 cm or prelabor rupture of membranes. Secondary outcomes included induction of labor and repeat cesarean delivery. One hundred eight women were randomly assigned to membrane sweeping and 105 to control. The spontaneous labor rate was 78.5% compared with 72.1% (relative risk [RR] 1.1, 95% confidence interval [CI] 0.9-1.3; P=.34), the induction of labor rate was 12.1% compared with 9.6% (RR 1.3, 95% CI 0.6-2.8; P=.66), and the all-cause cesarean delivery rate was 40.2% compared with 44.2% (RR 0.9, 95% CI 0.7-1.2; P=.58) for the membrane sweeping and control groups, respectively. Gestational age at delivery (mean+/-standard deviation) of 39.6+/-1.0 weeks for the membrane sweeping group compared with 39.6+/-0.9 weeks for the control group (P=.84) was no different. Serial membrane sweeping at term in women who planned VBAC has no significant effect on the onset of labor, pregnancy duration, induction of labor, or repeat cesarean delivery. ISRCTN, isrctn.org, ISRCTN55163179. I.

Effects of Periodontal Therapy on Rate of Preterm Delivery

To test the effects of maternal periodontal disease treatment on the incidence of preterm birth (delivery before 37 weeks of gestation). The Maternal Oral Therapy to Reduce Obstetric Risk Study was a randomized, treatment-masked, controlled clinical trial of pregnant women with periodontal disease who were receiving standard obstetric care. Participants were assigned to either a periodontal treatment arm, consisting of scaling and root planing early in the second trimester, or a delayed treatment arm that provided periodontal care after delivery. Pregnancy and maternal periodontal status were followed to delivery and neonatal outcomes until discharge. The primary outcome (gestational age less than 37 weeks) and the secondary outcome (gestational age less than 35 weeks) were analyzed using a chi test of equality of two proportions. The study randomized 1,806 patients at three performance sites and completed 1,760 evaluable patients. At baseline, there were no differences comparing the treatment and control arms for any of the periodontal or obstetric measures. The rate of preterm delivery for the treatment group was 13.1% and 11.5% for the control group (P=.316). There were no significant differences when comparing women in the treatment group with those in the control group with regard to the adverse event rate or the major obstetric and neonatal outcomes. Periodontal therapy did not reduce the incidence of preterm delivery. I.

Referrals during Labor in Midwifery Care

In 2008, 84% (459) of 548 women with pregnancies initially considered "low risk" requested to give birth under midwifery care at Japanese Red Cross Katsushika Maternity Hospital. Of these, 42% (191) were referred to obstetric care during labor at term; however, we found no evidence that midwifery primary obstetric care is less safe for women with "low-risk" pregnancy than is standard obstetric care. Therefore, we recommend that midwifery care be promoted with an international collaborative effort.

Aspects of psychosocial problems of patients with vesico-vaginal fistula

SummaryOur objective was to evaluate psychosocial problems among patients presenting with vesico-vaginal fistula (VVF), and their close relatives. All patients presenting with VVF and their spouses or attendant close relatives were administered a structured questionnaire followed by an in-depth interview. A total of 20 patients and 10 attendant relatives were interviewed. The average age of patients was 24.7 years, range 16–38 years. A total of 11 patients (55%) had their first marriage between the ages of 15–20 years, with one nulliparous, unmarried patient, who acquired VVF following infertility treatment with herbs. Of the interviewed respondents, 19 affirmed that prolonged labour was the cause of VVF, while four patients developed VVF sequel to unsupervised vaginal birth after a previous caesarean section. Reported medical problems were dermatitis (20%), foul smell of urine (15%), recurrent UTI (10%), infertility (5%), amenorrhoea (5%), in that order. Socially, 45% felt ostracised and 50% were economically impoverished by job loss. The divorce rate was 25%, with one case of remarriage and childbirth with an unrepaired VVF. Some 56.6% respondents suggested hospital delivery was a preventive measure, while 33.3% felt avoidance of premarital sex and early marriage would prevent VVF. VVF is still a major social and reproductive health problem and most patients and relatives understand the place of difficult childbirth in VVF formation. The need to empower patients to timely access standard maternity and emergency obstetric care is recommended.

Effect of Coital Activity on Onset of Labor in Women Scheduled for Labor Induction: A Randomized Controlled Trial

Coital activity at term reportedly is associated with shorter gestation and less need to induce labor because of prolonged pregnancy, but such findings have not been consistently affirmed. In this randomized study, 108 women scheduled to have nonurgent induction of labor at term (37 weeks' gestation or later) were randomly assigned to be advised to have vaginal intercourse with the goal of hastening the onset of labor. They were told that intercourse late in pregnancy was safe and could promote the onset of labor. The 102 women in a control group were neither encouraged nor discouraged to have coitus. Labor was induced by amniotomy if the cervix was favorable and by vaginal dinoprostone if it was unfavorable. All participants kept a coital and orgasm diary and received standard obstetrical care. The rate of reported coital activity was 60% in women advised to have sex and 40% in control women; the relative risk was 1.5, with a 95% confidence interval of 1.1 to 2.0. Nevertheless, rates of spontaneous labor did not differ significantly; they were 56% in the study group and 52% in control women. More than 80% of women who reported one or more episodes of vaginal sex after randomization also reported having at least one orgasm. The 2 groups did not differ significantly with regard to either the timing of admission for birth or spontaneous labor, or presentation at admission for birth. There also were no group differences in rates of cesarean delivery, maternal fever, or neonatal outcomes. These findings do not validate the practice of advising women scheduled for induction of labor at term to have vaginal intercourse in order to hasten the onset of labor.

Effect of Coital Activity on Onset of Labor in Women Scheduled for Labor Induction

To estimate the effect of coitus on the onset of labor. Women with a nonurgent labor induction at term were recruited. Women randomly assigned to the advised-coitus group were encouraged to have sex to promote the onset of labor. Controls were neither encouraged nor discouraged regarding coitus. Participants kept a coital and orgasm diary until delivery, and standard obstetric care was provided to both groups. Primary outcomes were reported coitus and spontaneous labor. Secondary outcomes included reported orgasms, initial Bishop score at the admission for induction, preterm rupture of membranes, use of dinoprostone, oxytocin, or epidural, meconium-stained amniotic fluid, cesarean delivery, maternal fever, and neonatal morbidity. One hundred eight and 102 women randomly assigned to advised-coitus and control groups, respectively, were available for analysis. Women assigned to the advised-coitus group were more likely to report coital activity before delivery (60.2% compared with 39.6%, relative risk 1.5, 95% confidence interval 1.1-2.0; P=.004), but the spontaneous labor rate was no different (55.6% compared with 52.0%, relative risk 1.1, 95% confidence interval 0.8-1.4; P=.68). Cesarean delivery rate and neonatal and other secondary outcomes were also not different. Among women scheduled for labor induction who were advised to have sex, the increase in sexual activity did not increase the rate of spontaneous labor. isrctn.org, http://isrctn.org, ISRCTN17998696

Cluster Randomized Trial of an Active, Multifaceted Educational Intervention Based on the WHO Reproductive Health Library to Improve Obstetric Practices

The hypothesis underlying this study was that hospital obstetrical practices can be improved by interactive workshops that promote the use of evidence-based measures based on the World Health Organization's Reproductive Health Library (RHL). The RHL is an annually updated electronic publication featuring Cochrane reviews in the area of reproductive health along with expert commentary, practical guidance documents, and various aids such as educational videos. Participating in the trial were 22 hospitals in Mexico City and 18 in northeast Thailand, whose maternity units conducted more than a thousand deliveries each year, and which had no direct affiliation with a university or other academic or research facility. Three workshops were held during a 6-month period: the first provided information about the project and principles of evidence-based decision-making; the second focused on RHL content; and the third concerned how best to implement desired changes. A stratified cluster randomized design took country, type of hospital, and number of births per year into account. The chief outcome measures were changes in 10 clinical practices as recommended in the RHL, implemented within 4 to 6 months after the third workshop. The intervention failed to influence targeted practices in any consistent or substantive way. Three of the 10 practices (iron/folate supplementation, postnatal uterotonic use, breast feeding on demand) already were part of the practice regimen, and it proved impractical to measure external cephalic version. Selective rather than routine episiotomy was performed more often in the intervention hospitals than in control hospitals. In Mexico, antibiotics tended to be used more at the time of cesarean delivery. No significant differences were documented in companionship during labor, the use of magnesium sulfate to treat eclampsia, corticosteroid treatment of women delivering before 34 weeks' gestation, or the use of vacuum extraction. Awareness of the RHL increased substantially following the intervention at both study sites, as did its use. Despite the efficacy of active educational measures in expanding access to the RHL and promoting its use, this study failed to demonstrate lasting or substantial changes in reproductive medical practices. Within a 10- to 12-month time frame, at least, access to current knowledge of such practices apparently does not assure that they will become part of standard obstetrical care.

Are women really asking for it?

Childbirth educators and doulas express frustration that the vast majority of women choose standard obstetric care for labor and birth, even though the evidence shows that this care increases the likelihood that they will experience unnecessary intervention and morbidity. Women are preparing for childbirth by reading and taking classes, but they are unprepared for this reality. What responsibility do doulas and childbirth educators have in alerting women of the risk?

"Near-miss" obstetric events and maternal deaths in Sagamu, Nigeria: a retrospective study

AimTo determine the frequency of near-miss (severe acute maternal morbidity) and the nature of near-miss events, and comparatively analysed near-miss morbidities and maternal deaths among pregnant women managed over a 3-year period in a Nigerian tertiary centre.MethodsRetrospective facility-based review of cases of near-miss and maternal death which occurred between 1 January 2002 and 31 December 2004. Near-miss case definition was based on validated disease-specific criteria, comprising of five diagnostic categories: haemorrhage, hypertensive disorders in pregnancy, dystocia, infection and anaemia. The near-miss morbidities were compared with maternal deaths with respect to demographic features and disease profiles. Mortality indices were determined for various disease processes to appreciate the standard of care provided for life-threatening obstetric conditions. The maternal death to near-miss ratios for the three years were compared to assess the trend in the quality of obstetric care.ResultsThere were 1501 deliveries, 211 near-miss cases and 44 maternal deaths. The total near-miss events were 242 with a decreasing trend from 2002 to 2004. Demographic features of cases of near-miss and maternal death were comparable. Besides infectious morbidity, the categories of complications responsible for near-misses and maternal deaths followed the same order of decreasing frequency. Hypertensive disorders in pregnancy and haemorrhage were responsible for 61.1% of near-miss cases and 50.0% of maternal deaths. More women died after developing severe morbidity due to uterine rupture and infection, with mortality indices of 37.5% and 28.6%, respectively. Early pregnancy complications and antepartum haemorrhage had the lowest mortality indices. Majority of the cases of near-miss (82.5%) and maternal death (88.6%) were unbooked for antenatal care and delivery in this hospital. Maternal mortality ratio for the period was 2931.4 per 100,000 deliveries. The overall maternal death to near-miss ratio was 1: 4.8 and this remained relatively constant over the 3-year period.ConclusionThe quality of care received by critically ill obstetric patients in this centre is suboptimal with no evident changes between 2002 and 2004. Reduction of the present maternal mortality ratio may best be achieved by developing evidence-based protocols and improving the resources for managing severe morbidities due to hypertension and haemorrhage especially in critically ill unbooked patients. Tertiary care hospitals in Nigeria could also benefit from evaluation of their standard of obstetric care by including near-miss investigations in their maternal death enquiries.

Vesico-vaginal fistula in Eastern Nigeria

SummaryOur objective was to examine the epidemiological determinants of vesico-vaginal fistula in Eastern Nigeria, and maternal characteristics and sociocultural factors predisposing to vesico-vaginal fistula. The case-records of 74 patients with vesico-vaginal fistula were reviewed. The mean age of the patients was 34.1 years and the mean age at occurrence of fistula was 30.1 years. A total of 24 women (32.4%) presented within 6 months of fistula formation. They were mainly multipara, housewives, subsistence farmers and still living with their husbands. A total of 68 (91.9%) developed a fistula following prolonged obstructed labour. Juxta-cervical fistula was the most common, 33 (44.6%) followed by juxta-urethral 11 (14.9%). The other associated morbidity included chronic vulval excoriation, cervical damage and amenorrhoea. Fetal wastage was high with 53 (77.9%) stillbirths and four (5.9%) early neonatal deaths. Vesico-vaginal fistula is still a major problem in the developing countries and a reflection of standard of obstetric care currently available to our women.

Rapid HIV Type 1 Testing of Women Presenting in Late Pregnancy with Unknown HIV Status in Lima, Perú

We studied the feasibility and acceptability of HIV-1 testing using rapid serological assays in pregnant women presenting in late pregnancy without prior HIV-1 testing. Pregnant women presenting to the emergency room at the Instituto Materno-Perinatal in Lima, Peru, were offered on-site rapid HIV-1 testing. Consenting women were provided HIV counseling and had samples taken for rapid detection of antibodies in the blood and oral secretions. Women testing HIV-1 seropositive by one or both assays were offered standard HIV obstetrical care including antiretrovirals. Between October 2000 and August 2001, 3543 women were tested for HIV-1 antibodies through the rapid testing protocol. Twenty-seven women tested positive by one or both assays. Standard EIA results were negative for two of the 27 women and EIA results were not available for an additional three women. Seventeen of the 19 women (89%) for whom delivery information is available received antiretroviral therapy prior to delivery. Eighty percent of the women treated with nevirapine received the drug at least 1 hr prior to delivery. Study personnel reported problems with performing the rapid assays for less than 1% of the samples and the majority of the women did not express a preference for either the oral fluid or blood sample collection. While HIV-1 testing early in pregnancy is preferable, rapid HIV-1 testing in late pregnancy or at delivery is feasible, acceptable to most women, and allows for timely intervention to reduce maternal-child transmission.

Editor's Choice

Editor's Choice

Aromatherapy classes help promote natural childbirth

Women are demanding more choice and control in their childbirth experience, and often look to complementary therapies for alternatives or adjuncts to standard obstetric care. The essential oils used in aromatherapy are now widely available, often in products such as bath oils, cosmetics and massage oils. As many of these aim to promote relaxation, they are a popular choice for pregnant women anticipating labour.

Amnioinfusion in term labor with low amniotic fluid due to rupture of membranes: a new indication

Objective: The null hypothesis was that the use of intrapartum amnioinfusion to induce term labor because of premature rupture of membranes when labor was complicated by low amniotic fluid volume due to vaginal loss would not improve fetal heart rate patterns, decrease the incidence of operative delivery, or improve neonatal acid–base status. Study design: 200 term pregnancies with low amniotic fluid due to vaginal loss were randomly chosen to receive intrapartum amnioinfusion or standard obstetric care without amnioinfusion. Fetal heart rate pattern, method of delivery and neonatal acid–base status were compared with Student's t test, chi-squared analysis, Mann–Whitney U- or Fisher's exact test. Results: When amnioinfusion was used, the fetuses had lower rates of variable (74 vs 91%, P<0.01) or late (26 vs 58%, P<0.001) decelerations. Spontaneous deliveries were more frequent (77 vs 59%, P<0.01) and cesarean sections less frequent (3 vs 10%, P<0.05). Mean umbilical arterial (7.24±0.07 vs 7.21±0.08, P<0.01) and venous (7.31±0.06 vs 7.28±0.08, P<0.01) pH were significantly higher in newborns with amnioinfusion, and babies in this group had lower rates of neonatal acidemia of arterial (22 vs 36%, P<0.005) or venous (13 vs 26%, P<0.005) origin. Conclusions: Amnioinfusion improved fetal heart rate pattern, lowered the incidence of operative delivery, and improved neonatal acid–base status in term labor complicated by low amniotic fluid due to vaginal loss.

Emergency hysterectomy in modern obstetric practice Changing clinical perspective in time

Emergency hysterectomy in obstetric practice is generally performed in the setting of life-threatening hemorrhage. A retrospective review based on hospital data of 67 patients undergoing emergency peripartum hysterectomy over 10 years was undertaken. Comparison of two different time periods regarding the incidence and the indications of obstetric hysterectomies was made. The number of patients with hysterectomy in the first 5 years of the study period (1985-1989) was 43 and during the last 5 years (1990-1994) it was 24. The incidence of hysterectomy during 1985-1989 was 1 in 2495 deliveries and the most common indication for hysterectomy was uterine atony (42%) followed by placenta accreta (25.5%) and uterine rupture (21%). On the other hand, the incidence of hysterectomy during 1990-1994 was 1 in 4228 deliveries and the ranking of indications of hysterectomy was slightly different from group 1 as mostly placenta accreta (41.7%) followed by uterine atony (29.2%). The maternal mortality rate was 4.5% in this series. This study showed that over the last decade the incidence of emergency hysterectomy in obstetric practice has declined in our clinic due to availability of high standard obstetric care and more liberal use of cesarean section at risk deliveries, better controlled use of oxytocin and internal iliac artery ligation.

Hypnosis and conversion of the breech to the vertex presentation

To evaluate the effectiveness of hypnosis to convert a breech presentation to a vertex presentation. Prospective case series compared with historical, matched comparison group. One hundred pregnant women whose fetuses were in breech position at 37 to 40 weeks' gestation and a matched comparison group of women with similar obstetrical and sociodemographic parameters derived from databases for other studies from the same time period and geographical areas. The intervention group received hypnosis with suggestions for general relaxation with release of fear and anxiety. While in the hypnotic state women were asked for the reasons why their baby was in the breech presentation. As much hypnosis was provided as was convenient and possible for the women until they were delivered of the baby or the baby converted to the vertex position. A successful conversion for the intervention group was scored when the baby spontaneously converted to the vertex position before delivery or successful external cephalic version. The conversion rate of the intervention group was compared with the comparison group who received standard obstetrical care without the opportunity for hypnosis. Parametric testing of statistically significant differences in the rate of conversion between the two groups. Eighty-one percent of the fetuses in the intervention group converted to vertex presentation compared with 48% of those in the comparison group. This difference was statistically significant. Motivated subjects can be influenced by a skilled hypnotherapist in such a manner that their fetuses have a higher incidence of conversion from breech to vertex presentation. Psychophysiological factors may influence the breech presentation and may explain this increased frequency of conversion to vertex presentation.

No effect of birth centre care on either duration or experience of breast feeding, but more complications: findings from a randomised controlled trial

Objective: to study the effect of birth centre care on the duration of breast feeding, breast feeding complications, and women's experiences of breast feeding. Design: randomised controlled trial. Setting: in-hospital birth centre at South Hospital, Stockholm, and standard obstetric care in the Greater Stockholm area. Subjects: 1230 women with expected date of birth between October 1989 and February 1992, interested in participating in a birth centre trial, and meeting medical low-risk criteria. 617 women were allocated to the experimental group offered birth centre care (EG), and 613 to the control group offered standard obstetric care (CG). Main outcome measures: duration of breast feeding, breast feeding complications such as sore nipples, engorgement, milk stasis, and mastitis, and women's experiences of breast feeding. Findings: no difference was found between EG and CG in the duration of breast feeding. Ninety-three per cent in both groups were breast feeding exclusively two months post partum. The average number of months of breast feeding, exclusively or partly, when investigated one year after the birth was 8.6 in EG and 8.5 in CG. No difference was observed in women's experiences of breast feeding, but rather more women in EG than in CG reported sore nipples, 36% and 30% respectively (p = 0.03), and milk stasis, 26% and 19% respectively (p = 0.002). Conclusions: birth centre care had no effect on the duration of breast feeding, or on women's experiences of breast feeding. Prenatal attitudes were probably more significant predictors of these outcomes than differences in the two modes of maternity care in this population of highly breast feeding-motivated women. The larger proportion of sore nipples and milk stasis in the EG might have been due to earlier discharge, or to midwives less skilled in assisting with breast feeding at the birth centre than in the postpartum wards.

Amnioinfusion during labor complicated by particulate meconium-stained amniotic fluid decreases neonatal morbidity

OBJECTIVE: Our purpose was to evaluate the efficacy of prophylactic amnioinfusion in decreasing neonatal morbidity associated with labor complicated by particulate meconium-stained amniotic fluid and to assess potential complications of this procedure. STUDY DESIGN: One hundred five laboring pregnant women with particulate (moderate or thick) meconium by subjective clinical analysis were randomly assigned to receive amnioinfusion or to receive standard obstetric care without amnioinfusion. Patients with any antepartum complications, other than the presence of meconium, were excluded from the study. Statistical analyses consisted of the two-tailed and paired Student t tests, Pearson χ 2 test, and Wilcoxon nonparametric test. Significance was set at p < 0.05. RESULTS: The study included 47 patients in the study group and 58 patients in the control group. A significantly greater proportion of study patients demonstrated decreased meconium concentration between rupture of membranes and delivery (46 of 46 vs 15 of 58, p < 0.001). The relative dilution of meconium consistency by objective analysis was significantly different between the study group and the control group (77.1% decrease vs 9.3% increase, p < 0.001). The proportion of neonates with meconium below the vocal cords was reduced in the study group (two of 47 vs 36 of 58, p < 0.001). Umbilical artery pH was increased in the study group neonates (7.29 ± 0.01 vs 7.25 ± 0.009, p < 0.05). The rate of neonatal acidemia was reduced in the study group (4 of 45 vs 12 of 50, p < 0.05). The rate of meconium aspiration syndrome was reduced in the study group (1 of 47 vs 8 of 58, p < 0.05). Maternal and neonatal morbidity rates were similar. CONCLUSION: Prophylactic amnioinfusion should be considered a possible addition to the intrapartum management of patients with particulate meconium-stained amniotic fluid. (AM J OBSTET GYNECOL 1994;170:842-9.)

Evaluation of the Possibilities for Preventing Congenital Toxoplasmosis

Little is known about the best way to prevent congenital toxoplasmosis. Until recently, the major effort was directed at preventing the disease during pregnancy by the application of hygienic measures (primary prevention). With the advent of detecting congenital toxoplasmosis antenatally, another method for reducing the incidence of congenital toxoplasmosis becomes possible (secondary prevention). In this study, we evaluate these two methods for the prevention of congenital toxoplasmosis. For 12 consecutive years, we studied the incidence of congenital toxoplasmosis in 11,286 consecutive pregnant women. The impact of primary prevention was studied by measuring the reduction in seroconversion when hygienic measures were systematically applied. Primary prevention reduces the seroconversion rate during pregnancy by 63% (P = 0.013). The effect of secondary prevention was studied in 76 pregnant women at risk of delivering a child with congenital toxoplasmosis. Secondary prevention by means of serological screening combined with prenatal diagnosis detected congenital toxoplasmosis correctly in eight infected fetuses. Secondary prevention reduced the incidence of congenital toxoplasmosis an additional 40%. This reduction would predominantly be seen in the group of mildly to severely affected fetuses. From this study, the effectiveness of primary prevention is obvious. Health education on how to avoid toxoplasmosis during pregnancy should become standard obstetric care. Adequate serological screening and prenatal diagnosis can be helpful in reducing further the incidence of congenital toxoplasmosis. Whether or not screening for toxoplasmosis during pregnancy should be combined with primary prevention depends on the importance of congenital toxoplasmosis as a health problem in a given geographic area.