TORCH Infections

I. STATEMENT OF PURPOSE
To provide Triage guidelines for the management and health education of pregnant women with TORCH exposures and infections.

II. INTRODUCTION
A. TORCH
is an acronym for a group of five infectious diseases:
Toxoplasmosis
Other (Hepatitis B)
Rubella (German measles)
Cytomegalovirus (CMV)
Herpes Simplex Virus (HSV)

B. Each disease may be teratogenic
1. Each crosses the placenta
2. Each may adversely affect the developing fetus
3. The effect of each varies, depending on developmental stage at time of exposure.

III. DESCRIPTION, ASSESSMENT, INTERVENTIONS AND HEALTH EDUCATIA. A.Toxoplasmosis
1. Description
     Caused by the protozoa Toxoplasma gondii.  More than 60 million people in the United States are      infected, but very few have symptoms.  Incidence of congenital Toxoplasmosis is 1 in 1000-8000        in U.S.

2. Transmission
    a. Ingestion of Toxoplasma eggs from soil
    b. Ingestion of raw or partially cooked meat, especially pork, lamb or   venison
    c.  Contact with infected cat feces.
    d. Transplacentally (if new infection occurs during pregnancy)
    e. Through organ transplant or transfusion- very rare
    f. Women with compromised immune systems are at risk for reactivation of a previous infection.

3. Physical Findings
    a. “Flu”-like symptoms
    b. Swollen lymph glands (posterior cervical)
    c. Muscle aches and pains lasting days to weeks.

4. Diagnostic findings
    serologic antibody testing, ELISA

5. Potential maternal and neonatal effects –
    a. Maternal effects- 90% of women are asymptomatic. Increased risk for miscarriage or premature          labor and delivery
    b. Neonatal effects – High risk gestational age is 10-24 weeks.  Sequelae can be neurological,                opthalmological, and cognitive.  IUGR, hydro- and microencephaly.  Severity varies, with earlier        exposure usually more severe.

6. Interventions
   a. Pregnant women with new infection and immuno-compromised women may be candidates for              treatment with pyrimethamine and sulfadiazine.

7. Health Education
    a. Women planning a pregnancy may be tested before pregnancy.  If the test is positive there is no           need to worry about passing a new infection to the baby.  Women who test negative can take               precautions.
    b. Wear gloves and wash hands carefully after handling soil.
    c. Cook meat thoroughly (until no longer pink inside and juices run clear)
    d. Wash hands and any equipment or surfaces that raw meat contacts thoroughly with warm water           and soap.
    e. Keep your cat inside and do not feed raw meat.  Avoid handling stray cats or new kittens that               may have eaten raw meat.  Have someone else change the litter box.
    f. References and Exhibits AWHONN , 2ND edition – Table 22-1, TORCH Disease CDC Fact              Sheet- Toxoplasmosis    

B. Hepatitis B (HBV)
1. Description –
    Hepatitis B (HBV) is a serious viral disease responsible for 4000 to 5000 deaths each year in the         U.S. due to cirrhosis and liver cancer.  Acute infection occurs in 1 to 2 pregnancies per 1000.             Estimated that 300 million people worldwide are chronically infected with HBV.

2. Transmission
    a. Incubation usually 50-180 days
    b. Mode of transmission  - Sexual contact - Perinatal - Transplacental - Contact with blood, stool           and saliva - Shared razors, toothbrushes, towels, and other personal items.
    c. At risk populations
          a. Southeast Asians, Eskimos, Africans, Chinese, Flipinos and  Indonesians
          b. Homosexuals
          c. IV drug users
          d. Hemophiliacs
          e. Transfusion or organ recipients
          f. Hemodialysis patients
          g. Household contacts of infected persons
          h. Persons with multiple and/or infected sexual partners
          i. Persons diagnosed with a STD
          j. Healthcare or safety workers

3. Physical Findings – Low-grade fever, nausea, anorexia, jaundice, hepatomegaly, and malaise.

4. Diagnostic findings –  + HbsAg , + HbeAg (7-14 days after exposure) See Interpretation of                 Hepatitis B Panel.

5. Potential Maternal and Neonatal Effects
    a. Maternal – Premature labor and delivery, cirrhosis and liver cancer
    b. Neonatal – Stillbirth. Infants infected at birth have a 90% chance of becoming chronically                  infected.

6. Interventions
   a. Maternal –  Pregnant women who are exposed to HBV should receive vaccine and HBIG.                   Pregnant women who are already infected  should eat well, get sufficient rest, avoid stress and           avoid alcohol.  Alpha interferon and lamivudine are not recommended during pregnancy.
   b. Neonatal  - Infants of infected women should receive HBV vaccine and HBIG.

7. Health Education
   a. Hepatitis B vaccination is the best prevention.
   b. The proper and consistent use of latex condoms may prevent sexual transmission.
   c. Do not use IV drugs. Never share needles, syringes, water or “works”.
   d. Do not share personal items that may have blood on them – razors, toothbrushes.
   e. Consider the risks before getting a tattoo or piercing.
   f. Health care workers should use BSP and safe handling of sharps.

8. References and Exhibits  AWHONN, 2nd edition, Table 22-1, TORCH Disease CDC Fact Sheet - Viral Hepatitis B Interpretation of the Hepatitis B Panel

C. Rubella (German measles)
1. Description
    Rubella is a mild childhood illness that can pose a serious threat to the fetus, if a mother contracts       the illness during pregnancy.  Most women of childbearing age are immune to rubella, either               through vaccination or previous illness, but 2 in 10 are thought to be susceptible.

2. Transmission
   a. Incubation – 2 to 3 weeks
   b. Highly contagious
   c. Spread through nasopharyngeal secretions
   d. Transplacental transmission likely.

3. Physical Findings –
    Rash (lasting about 3 days), swollen glands, low-grade fever, joint pain, headache, loss of appetite,     sore throat and hepatomegaly.  Often asymptomatic.

4. Diagnostic findings-
    ELISA, Isolation of virus from urine or endocervical secretions.  Fluorescent antibody (FA)  or         complement fixation (CF) test.

5. Potential Maternal and Neonatal Effects
   a. Maternal – Infection can cause miscarriage and stillbirth.  The risk of congenital rubella                     syndrome is highest (up to 90%) when exposure is between 11 and 20 weeks gestation.
   b. Neonatal - About 25 percent of neonates whose mothers contracted rubella during the first                 trimester are born with one or more birth defects – blindness, cataracts, hearing loss, heart                 defects, mental retardation, movement disorders, and development of diabetes during childhood or       later.  Some infected babies have short-term health problems – diarrhea, LBW, feeding problems,       pneumonia, meningitis, anemia, red-purple spots on faces and bodies and enlarged spleen and             liver.  Neonates with congenital rubella infection are contagious and should be isolated.

6. Interventions
a. Maternal – Mild analgesics, rest and support.
b. Neonatal - No specific treatment for congenital rubella treatment.  Eye or cardiac defects may be corrected or improved with surgery.  Careful screening for problems and special education are indicated.

7. Health Education
   a. Vaccination of non-immune women before pregnancy is the best prevention.
   b. The rubella and MMR (measles, mumps, rubella) vaccines are not recommended during                      pregnancy.  A woman should wait 28 days after vaccination to attempt conception (although the          risk to an inadvertent pregnancy during this time is very small).  Breastfeeding women may be            vaccinated.
   c. Pregnant women who are non-immune for rubella should avoid anyone with rubella or the                  symptoms of rubella.

8. References and Exhibits AWHONN,  2nd edition, Table 22-1 TORCH March of Dimes Facts             Sheets - Rubella

D. Cytomegalovirus (CMV)
1. Description
    Cytomegalovirus is the most common congenital infection at birth in the U.S.  Each year about           40,000 babies (1%) are infected.  Fortunately, most babies are not harmed, but about 8,000 babies       per year develop lasting disabilities from CMV.

2. Transmission
    a. Incubation – unknown.  CMV is in the herpes family and like herpes can reactivate.
    b. CMV is very common in young children (perhaps 70% of children between 1 and 3 years of age         in childcare will be excreting CMV).
    c. Transmission can occur through contact with saliva, urine, feces, blood, and mucous.  It can also         be transmitted sexually and through transfusion and organ donation.
    d. Transplacental transmission tends to be most serious.
    e. Infants who are infected during birth or from breastfeeding rarely have serious problems from             the infection.

3. Physical Findings
    Sore throat, fever, body aches, fatigue and hepatomegaly.  Most infections are asymptomatic.

4. Diagnostic findings
    a. Maternal - ELISA, fluorescent antibody (FA), complement fixation (CF), seroconversion to              +IgM, and isolation of the virus by culture.
    b. Prenatal  - Affected infant’s may demonstrate the following ultrasound findings: microcephaly,           hydrocephalus, necrotic cystic or calcified lesions in the brain, liver or placenta, IUGR,                     oligohydramnios, ascites, pleural or pericardial effusion, hypoechogenic bowel and hydrops. -             Amniocentisis with culture or DNA identification. -Cordocentesis can be used to document                 presence and severity of disease.
     c. Newborn – virus isolation is the optimal method of documenting CMV infection.  Specimens             can be taken from urine, nasopharnyx, conjunctiva and spinal fluid.

5. Potential Maternal and Neonatal Effects
   a. Maternal – Most infections are asymptomatic
   b. Neonatal – Infection is most likely to occur with primary maternal infection.  Approximate                  congenital infection rate of 1%.  Of these, 10 % will be symptomatic, of which 25 % will have            fatal disease and 90% of the survivors will have serious sequelae- IUGR, microcephaly, CNS            abnormalities, hydrocephaly, periventricular calcification, deafness, blindness, and mental                  retardation.  A small percentage of newborns asymptomatic at birth will also develop late                    sequelae.

6. Interventions
    a. Maternal – treat symptoms
    b. Neonatal - no satisfactory treatment available.  Infant is contagious and should be isolated.

7. Health Education
    a. Women can reduce their risk of CMV by practicing universal precautions and careful hand                washing, especially after any contact with saliva, urine, feces, blood and mucous.
    b. Avoid sharing glasses or eating utensils.
    c. Medical or day care workers may consider  being tested prior to pregnancy to determine if they           have had CMV, as they would then have little cause for concern.
8. References and Exhibits AWHONN, 2nd edition, Table 22-1 TORCH March of Dimes Fact Sheets – Cytomegalovirus in Pregnancy
Gibbs RS and Sweet RL. Evaluating and Treating Obstetric & Gynecologic Infections. Gardiner-Caldwell SynerMed, 1995.

E. Herpes Simplex Virus (HSV)
1. Description
    Herpes is caused by the herpes simplex viruses, which are similar to the viruses that cause                 chickenpox and shingles.  After the initial infection, the herpes simplex viruses can hide within           nerve cells and later launch new attacks.  There are 2 main kinds of herpes simplex virus (HSV):         type I, which is usually associated with cold sores around the mouth; and type 2, which is usually       associated with genital sores.  However, either type can infect either the mouth or genitals and both     can be passed on to the newborn.  Approximately 45 million Americans have genital herpes with         about 1,000 newborn infections occurring each year.
2. Transmission
    a. Incubation – 2 to 10 days
    b. Intimate mucocutaneous exposure- intercourse, mouth to genital contact or kissing in the                     presence of a cold sore.
    c. Passage through an infected birth canal
    d. Ascending infection in the presence of ROM
    e. Transplacental infection – happens rarely with an initial maternal infection during pregnancy
    f. Contact with virus-containing saliva.

3. Physical Findings
    Painful, genital lesion. Often form in clusters of blisters that break leaving a painful ulcer.                 Frequently will experience a “prodrome” – burning, itching, numbness, tingling before the blisters       appear (thought to be contagious during this stage, too).  Usually the lesions will recur in the same     area.  Recurrence generally becomes less frequent with time.  Primary infections may include fever,     malaise, myalgia and lymphadenopathy.

4. Diagnostic findings
    a. Tissue culture-swab specimen from vesicles
    b. Pap smear of lesion c. Visualization of a blister or ulcer-like, painful lesion by experienced                 clinician.

5. Potential Maternal and Neonatal Effects
     a. Maternal – Women with a primary infection during the pregnancy  may be at increased risk for            PTD and LBW infant.
     b. Neonatal -  Infants of women with the primary infection occurring  during the pregnancy are at           greatest risk.  Potential sequelae include: skin, mouth or eye lesions with potential permanent             damage to the nerves or eyes.  HSV in the newborn often can spread to the brain and other                 internal organs (approximate 50% mortality).  About 50% of the survivors develop mental                 retardation, cerebral palsy, seizures, blindness or deafness.

6.   Interventions
     a.   Women with prodromal symptoms or an active lesion (still in blister or ulcer stages) will be               counseled to have cesarean delivery.  The greatest
          protection to the fetus is if this is accomplished before ROM greater than 4 hours.
      b. Anti-viral drugs can shorten the duration of a herpes attack, alleviate symptoms and reduce the           number of attacks.  Oral acyclovir is sometimes used in late pregnancy to decrease the need for           cesarean birth.
      c. Acyclovir and vidarabine are used to treat neonatal HSV – more successful with localized                   infection than one that has spread to brain and other internal organs.

7.Health Education
     a. Encourage women with a history of genital herpes to avoid “triggers” (heat, friction,                         intercourse, peanuts, chocolate, fever or stress), especially during the later part of pregnancy.
     b. Recommend condoms or abstinence in pregnant women without HSV who have partners with              HSV.
     c. Encourage careful hand washing to prevent spread of HSV to others or to other parts of the               body
    d. People with active cold sore lesions should avoid kissing others, especially newborns.
    e. Educate women of the importance of reporting prodromal symptoms or lesions to their care                providers with suspected labor or ruptured membranes.