Management of Abnormal TORCH Results :an update Through case studies

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  • 1. Management of Abnormal TORCH Results :an update Through case studies Dr. Sharda Jain Director :- Sec General : Delhi Gynae Forum
  • 2. “Awareness” Presentation ROI (Return on Investment) Is it worth it ?
  • 3. It take us 30-60 HOURS to create a presentation from scratch To perfect knowledge / skill and become an expert , it takes 10,000 HOURS
  • 4. TORCH Asymptomatic in Mothers Havoc in Offspring
  • 5. TORCH – Normal /Abnormal
  • 6. • Wrong concepts • Basics not clear ↓ • Unnecessary Treatment TORCH
  • 7. • Never ever order any Test which you can’t Interpret Evaluate & Manage
  • 8. Can I make difference ?
  • 9. What is our AIM !! • Basics • Decide whether the result is actually abnormal or not • Focus on each of the 4 components T,R,C and H and interpret separately through case studies.
  • 10. TORCH Basics 1.IgM - new 2. IgG - old
  • 11. Interpretation of TORCH results : Basics • IgM antibodies - Produced in acute / late phase of primary infection - appear immediately after infection and usually persist for 8-12 weeks may persist for 1-2 years - Igm not = fetal infection ----- Diag. workup needed • IgG antibodies appear after 1-2 weeks, fall within 1-2 months and persist lifelong
  • 12. • No exposure • Recent / Acute infection • Past infection Ig M Ig G No exposure - - Acute Infection + +/- Past Infection - + Interpretation of TORCH results : Basics +/-
  • 13. IgG AVIDITY • Assay measures the functional binding affinity of the IgG antibody in response to infection. • The maturation of antibody avidity over time can be used to discriminate between primary and non- primary infection. • HIGH AVIDITY is detected - Non-primary infection. • LOW AVIDITY - Primary infection
  • 14. Management of a pregnant woman with ABNORMAL RESULT of Toxoplasma Toxoplasma
  • 15. Frequency of transplacental Toxoplasma Transmission and severe congenital sequelae
  • 16. INTERPRETATION Toxoplasma IgG Toxoplasma IgM Toxoplasma IgG Avidity Interpretation / Recommendation Non Reactive Non Reactive Not applicable Infection unlikely Non Reactive Reactive Not applicable Repeat after 2-3 weeks for Toxoplasma IgG & IgM. Both positive – Acute infection IgG – ve ; IgM +ve – False positive Reactive Non Reactive High avidity Past infection Reactive Reactive Low avidity Recent infection Reactive Reactive High avidity Past infection
  • 17. Management of abnormal results Toxoplasma Case - 1 A 28 yr old woman with h/o Recurrent Abortions is advised TORCH profile. » She is Toxo IgM and IgG positive » → signifies recent infection Does she need treatment? » No. » the disease is self limiting and she is not pregnant Can Toxoplasmosis cause recurrent abortions? » No it can cause sporadic infection » As after acute infection the woman becomes toxo immune and is unlikely to reacquire infection unless immuno-compromised
  • 18. Management of toxoplasmosis during pregnancy : First trimester Case - II A 30yr primigravida treated case of infertility is detected to have acute toxoplasmosis at 10 wks pregnancy (Igm +Ve) Start spiramycin + advice USG USG: Foetal anomaly detected → counsel and advice MTP USG: No anomaly detected → ↓ counsel • 10-15% chances of fetal infection with a 40-60 % chance of being severe ( 6-10%) • Need for amniocentesis in second trimester and regular monitoring by monthly USG • Drug treatment through out pregnancy
  • 19. Management of toxoplasmosis during pregnancy : First trimester USG: No anomaly detected - counseling Woman does not want to continue : Do MTP Woman wants to continue : Involve a fetal medicine specialist Continue spiramycin Advice amniocentesis at 18 weeks No infection detected : Continue spiramycin + mthly USG Infection detected : Counsel regarding 6-10% chances of baby being affected offer MTP again MTP declined switch over to sulphadiazine + pyrimethamine (3wks) alternating spiramycin (3 wk) + USG every month
  • 20. Management of toxoplasmosis during pregnancy : Second Trimester Counseling • Chances of fetal infection 20 – 30% severe damage 10% • Start spiramycin • Advice USG and amniocentesis for any evidence of fetal infection/damage No fetal infection : Continue spiramycin + USG mthly Fetal infection present : May offer MTP if < 20 weeks or else start on sulphadiazine + pyrimethamine (3wks) alternating with spiramycin (3wks) +USG mthly
  • 21. Management of toxoplasmosis during pregnancy : Third trimester <37 wks : Manage as in 2nd trimester Start on Spiramycin Advice USG + amniocentesis > or = 37 wks : Deliver
  • 22. Drug Treatment for Toxoplasmosis Drug Dose Spiramycin 2-3 g/day (6-9 MIU/day) in divided doses Sulfadiazine 50-100 mg/kg/day Pyrimethamine 1mg/kg/day Folinic acid 0.1 mg/kg/dose twice a week
  • 23. Management of Rubella infection during pregnancy Rubella
  • 24. INTERPRETATION Rubella IgG Rubella IgM Rubella IgG Avidity Interpretation Non Reactive Non Reactive Not applicable Infection unlikely Reactive Non Reactive High avidity Past infection Reactive Reactive Low avidity Primary infection Reactive Reactive High avidity Non-primary infection; Low risk for in-utero transmission
  • 25. Case study : 1 Women presenting for pre-pregnancy counseling Rubella specific IgG Positive Negative Rubella immune At risk of rubella infection Adv: Rubella vaccine Advice not to conceive for 1mth
  • 26. Case Study : 2 26 yrs - I look vaccination on 25th day of my cycle Using CC, Now pregnancy test +ve Advice : No MTP
  • 27. Case Study : 3 Routine pregnant patients Screening of Rubella infection During pregnancy If rubella status UNKNOWN Order rubella specific IgG at early 1st trimester booking Negative Positive Woman educated Reassure on S/S of rubella
  • 28. Cold ,Fever & ? Rash at 5 weeks 1. IgG + ve 2. IgM Neg. – 2-3 weeks 3. Repeat IgM weekly for 2-3 weeks Case study : 4 A.If IgM Neg – Reassure B. If +ve – MTP
  • 29. Rubella IgG (as soon as possible after contact) IgG negative IgG positive Probably immune IgM positive IgM negative Rubella Repeat after 7-10 days Infection Repeat weekly for 4 weeks after last If no change If levels ↑ contact to refute the Woman Woman diagnosis Immune Rubella infected Confirmation of Rubella infection after EXPOSURE (Case study :- 5)
  • 30. Management of acute Rubella infection during pregnancy Depends essentially on • Gestational age at infection First trimester : Counsel Risk of infection 80 - 90% Risk of congenital malformation 90% before 11 wks 33% at 11-12 wks 11% at 13-14 wks Gabbe SG, Niebyl JR, Simpson JL, eds. Obstetrics-normal and problem pregnancies. 4th ed. New York: Churchill Livingstone, Inc.;2002:1328–30. Advice MTP
  • 31. Management of acute Rubella infection during pregnancy Second trimester : 13-16 wks Counsel Risk of infection 60% Risk of congenital defects 25- 50% Offer MTP/ prenatal diagnosis (Overall risk 15-30%) 17-20 wks Counsel Risk of infection 25% Risk of congenital defects - Negligible No intervention Third trimester : No intervention
  • 32. Management of CMV infection during pregnancy CMV Infection
  • 33. First decide whether primary or recurrent infection IgG avidity test If low  primary infection If high  recurrent infection Management of CMV infection during pregnancy
  • 34. Case Study A G3P0A2 presents at 10 weeks gestation with a report CMV Specific Ig G + Ig M + Interpretation: • Primary infection during the period since conception • Re-infection or reactivation of latent CMV IgG avidity testing High : Reactivation Low : Primary infection
  • 35. Maternal CMV Infection : Fetal Risks Primary Recurrent Fetal infection 40% < 10% CMID 2% 0 Perinatal death 0.4% 0 Delayed onset CMV 6% Rare • Can cause sporadic abortion and still birth
  • 36. Maternal CMV infection ≤ 20 weeks : Termination of pregnancy > 20 weeks : Prenatal diagnosis a) Amniocentesis (at least 6 weeks after seroconversion) • Viral culture • PCR b) USG CMV infection : Management decisions Primary
  • 37. If Patients Diagnosed to have CMV Infection in Pregnancy • Careful counseling about fetal risk • Consider invasive procedure to establish fetal risk • Check fetal growth and health • Consider MTP if early gestational age • No effective treatment • RVT for patients positive for human immunodeficiency Virus • Newborn with pediatric follow – up, if infection confirmed
  • 38. Termination not considered Couple counseling • Risk of transmission 0.5 – 1.5% • Symptomatic NN disease < 1% (hearing loss) USG every month PND if abnormal USG findings • No role of C.S. • Breast feeding not contraindicated Recurrent CMV infection : Management decisions
  • 39. INTERPRETATION CMV IgG CMV IgM CMV IgG Avidity Interpretation Non Reactive Non Reactive Not applicable Infection unlikely Reactive Non Reactive High avidity Past infection Reactive Reactive Low avidity Primary infection Reactive Reactive High avidity Non-primary infection; Low risk for in-utero transmission
  • 40. Management of Genital Herpes infection during pregnancy Genital Herpes infection PRENATAL :- symptomatic treatment of infection (primary or recurrent)
  • 41. Management of pregnant woman with Genital Herpes 1. Acyclovir therapy – Class C Indications : - All women with first episode in pregnancy 200mg five times a day x 5 d ? 7-14 days - All women with > 1 recurrence during pregnancy 200 mg four times a day x last 4 weeks 2. USG - 12 weeks 18-20 weeks for congenital abnormalities Amniocentesis if required 3. Abstinence/ use of condoms
  • 42. Role of Cesarean Section • No lesion, no caesarean • Caesarean section at term for women with first episode within 6 weeks of EDOD • Caesarean section in patients with active HSV infection and ruptured membranes irrespective of duration of ROM Management of pregnant woman with Genital Herpes
  • 43. Labor and Delivery contd.. • Counseling about the benefits of cesarean section in preventing fetal infection with membrane rupture is difficult – take a call • Avoid fetal electrodes if possible Management of pregnant woman with Genital Herpes
  • 44. Neonatal Care • Breast feeding contraindicated only in the presence of breast lesions • Frequent hand washing • Avoid kissing the baby • Healthcare workers / family members with active HSV avoid direct contact Management of pregnant woman with Genital Herpes
  • 45. Take home messages • Women with past infection with rubella / toxoplasma are unlikely to have reinfection/ recurrence whereas reinfection/recurrences with CMV and HSV are common • Remember TORCH infections never cause recurrent abortions/stillbirths/preterm births but can explain sporadic events
  • 46. Take home messages • Early diagnosis and treatment of toxoplasmosis and HSV improve fetal prognosis • Cesarean section is useful for women with HSV in the presence of lesions • All females should be vaccinated against rubella at 18 months and a booster at 12 years of age • All women planning a pregnancy and with rubella status unknown should be vaccinated and advised not to conceive for 1 mth • All infected newborns should be followed up closely for delayed sequalae
  • 47. Take home messages • Always reconfirm the positive tests from a reference lab • Acute maternal infection does not always imply fetal infection • Counseling of the couple regarding the risk of fetal infection and risk of fetal damage is important • Offer MTP/ prenatal diagnosis involve a fetal medicine specialist
  • 48. Return on Investment
  • 49. Return on Investment 450%
  • 50. Give your Comments Please
  • 51. • A healthy woman 35years G1P0A1 came for pre-pregnancy counseling • She was advised for TORCH test after her first abortion five year back. Tox IgG was positive , rest were negative. • She was given spiramycin for 3 weeks and advised not to become pregnant till IgG – negative and repeated tests were done at six monthly interval, for last five years. • Patient continued to take OCP for five years, waiting for titre to become negative. Real case scenario No.1 TOXO
  • 52. Real Case scenario : 2 • A pregnant woman of “8” weeks pregnancy with history of previous three abortions, was advised for TORCH test by an obstetrician. • It showed rubella IgG positive and rest were negative. She was advised for termination of pregnancy as fetus is at risk of rubella syndrome. • She then consulted an another obstetrician for second opinion – Who started Acyclovir, thrice daily; to be continued throughout the pregnancy. • She came for consultation at 32 weeks of gestation and was advised to stop acyclovir. But patient was not convinced to stop the treatment as she developed the faith that rubella treatment had saved her pregnancy. Rubella
  • 53. Real Case scenario : 3 • Third gravida , healthy female with two living issues came for booking at 2 months of pregnancy. • Her first pregnancy was uneventful with healthy baby. • During second pregnancy she had fever with rashes at 3½ months gestation , which lasted for four months. No investigation was done. Her first USG was done at 30 weeks revealed moderate hydrocephalous with oligo - hydramnios . so TORCH titer was done. CMV IgG & IgM was positive. Too late for termination. Baby had mental retardation and seizures. CMV
  • 54. Real Case scenario : 4 • Second gravida , with history of one missed abortion and secondary infertility for two years came for consultation. • TORCH test was advised by her obstetrician after her first abortion. IgG for Rubella & HSV was positive, • She was given Rubella vaccination & acyclovir 400mg twice dailly for TWO years. Repeat titers were done and revealed same result. • She was advise for elective LSCS in her next pregnancy Rubella , HSV
  • 55. Real Case scenario : 5 • Primi gravida - 5 weeks spontaneous abortion - Rubella IgG Positive ., Igm negative - Rubella vaccination given • Conceived again IgG Rubella +ve , Pregnancy terminated • Conceived again after 2 years, repeat rubella Ig G done – found +ve , advised termination. • COMMENT Rubella