2. AN OVERVIEW OF TORCH INFECTIONS
THE TORCH COMPLEX
TORCHcomplexisamedicalacronymforasetofperinatalinfections(i.e.infectionsthatarepassedfromapregnantwomantoherfetus).TheTORCHinfectionscanleadtoseverefetalanomaliesorevenfetalloss.Theyareagroupofviral,bacterial,andprotozoaninfectionsthatgainaccesstothefetalbloodstreamtransplacentallyviathechrionicvilli.Hematogenoustransmissionmayoccuratanytimeduringgestationoroccasionallyatthetimeofdeliveryviamaternal-to-fetaltransfusion.

3. Thecapitalization"TORCH”consistsof:
T–TOXOPLASMOSIS
O–Otherinfections(Syphilis,VaricellaZoster,ParvovirusB-19,Listerosis&CoxsackieVirus)
R–RUBELLA
C–CYTOMEGALOVIRUS
H–HERPESSIMPLEXVIRUS–2
HepatitisBmayalsobeincludedamong"otherinfections", butthehepatitisBvirusisalargevirusanddoesnotcrosstheplacenta,henceitcannotinfectthefetusunlesstherehavebeenbreaksinthematernal-fetalbarrier,suchascanoccurinbleedingduringchildbirthoramniocentesis.

4. TOXOPLASMOSIS
ToxoplasmosisisadiseasecausedbyanintracellularparasiteTOXOPLASMAGONDII. Humanacquisitionoftheinfectionoccursby:
•Oocystcontaminatedsoil,salads,vegetables.
•Ingestionofraworundercookedmeatcontainingtissuecysts(Sheep,pigsandrabbitsarethemostcommonmeatsources).
•Outbreaksoftoxoplasmosishavealsobeenlinkedtotheconsumptionofunfilteredwater.

6. •Serafromrandomlyselected345pregnantNepalesewomenaged16-36yearsand13womenwithbadobstetrichistory(BOH)weretestedforthepresenceofToxoplasmaantibodiesusingmicrolatexagglutination(MLA)andELISAmethods.
•Theoverallprevalencewas55.4%(191/345).
•Prevalencewasslightlyhigher(59.0%)inolderage-group(27-36years)comparedwithyoungerage-group(16-26years)(52.2%).
•InpatientswithanexistingHIVinfection,toxoplasmosisisanimportantoppurtunisticinfectionwithconsiderablemorbidityandmortalityespeciallyinthepregnantwomen.

7. CLINICALFEATURES:
•Inmostimmunocompetentindividuals,includingchildrenandpregnantwomen,theinfectiongoesunnoticed.
•Inapproximately10%ofthepatientsitcausesaself- limitingillness,mostcommonlyinthe25-35yearsagegroup.
•Painlesslymphadenopathy(LocalorGeneralised)isthemostcommonpresentingfeature.Cervicallymphnodesareinvolvedinparticular.Themesenteric,mediastinalortheretroperitonealnodesmayalsobeinvolved.
•Otherfeaturesinclude–Malaise,Fever,Fatigue,Musclepain,Sorethroatandheadache.

8. •Completeresolutionusuallyoccurswithinafewmonths, althoughsymptomsandlymphadenopathytendtofluctuateunpredictablyandsomepatientsdonotrecovercompletelyevenforayearormore.
•Sometimesthepatientmayalsodevelopencephalitis, hepatitis,pneumonitisandmyocarditis.
•Retinochoroiditisisnearlyalwaystheresultofcongenitalinfection.

9. CONGENITAL TOXOPLASMOSIS
•Acutetoxoplasmosis,mostlysubclinical,affects0.3-1%ofpregnantwomen,withanapproximately60%transmissionratetothefetuswhichincreaseswithincreasinggestation.
•Primarymaternalinfectioninpregnancy–
Infectionratehigherwithinfectionin3rdtrimester.
Fetaldeathhigherwithinfectionin1sttrimester.
•Congenitaldiseaseaffectsapproximately40%ofinfectedfetuses,andismorelikelytobeseverewithinfectionearlyingestation.
•Manyfetalinfectionsarealsosubclinicalatbirthbutthelong-termsequelaeincludehydrocephalus,microcephalyandretinochoroiditis.

10. INVESTIGATIONS:
•Intheimmunocompetentpatient–Serologyisoftendonewhileintheimmunocompromisedthediagnosisoftenrequiresthedirectdetectionofparasites.
•SABIN-FELDMANDYETEST(IndirectFluorescentAntibodyTest)–detectstheIgG–Antibody. Recentinfectionisindicatedbyafour-foldincreaseintitrewhilepeaktitresof1/1000ormorearereachedwithin2monthsofonsetofinfection.
•ThedetectionofToxoplasmaspecificIgM-Antibodymaybeusefulinconfirmingacuteinfections.However,falsepositivesorpersistenceofIgM-Antibodiesforyearsafterinfectionmakeinterpretationdifficult.NegativeIgM- Antibodyvirtuallyrulesoutacuteinfection.

11. Toxoplasma Gondii in fluorescent stain

12. •Duringpregnancyitishighlycriticaltodifferentiatebetweenrecentandpastinfection-thepresenceofhigh- avidityIgG-Antibodiesexcludesinfectionacquiredinthepreceding3-4months.
•Ifnecessary,thepresenceofToxoplasmaOrganismsinalymphnodebiopsycanbesoughtforbystainingsectionshistochemicallywithT.Gondii-AntiserumorbytheuseofPCRtodetectToxoplasma-specificDNA.

13. TREATMENT:
•Inimmunocompetentsubjects,uncomplicatedtoxoplasmosisisself-limitingandrespondspoorlytoanti- microbialtherapy.
•InPREGNANTWOMENwithanestablishedrecentinfection,SPIRAMYCIN(3gdailyindivideddoses)shouldbegivenuntilterm.
•Oncefetalinfectionisestablished,treatmentwithSULFADIAZINEANDPYRIMETHAMINEplusCALCIUMFOLINATEisrecommendedasSPIRAMYCINdoesnotcrosstheplacentalbarrier.

14. OTHER INFECTIONSVARICELLAZOSTER
•VaricellaZosterisamemberoftheherpesvirusfamily.
•VaricellaalsoknownasChickenpox,istheacuteprimarydisease.
•IncubationPeriod–15daysandiscommunicable2daysbeforeand5daysaftertheonsetofrash.
•AfteraninitialepisodeofinfectionwithVaricellaZosterleadingtoChickenpox,thevirusmaypersistinalatentstateintheposteriorrootgangliaofthespinalcordforyear.ReactivationresultsinHerpesZoster.

15. •Itishighlycontagious,self-limitingdiseaseofchildhoodthatistransmittedbyrespiratorydropletsorclosecontact.
•Itisusuallyacquiredby90%ofthepopulationbeforethereproductiveage,thusmostwomenareimmunebeforetheybecomepregnant.
•TheincidenceofVaricellainpregnancyis0.7/1000.
•CLINICALFEATURESincludevesiculareruptionsoftenonmucosalsurfacesfirstfollowedbyarapiddisseminationinacentripetalpattern.Newlesionsappearevery2-4daysandeachcropisassociatedwithfever.Therashprogressesfrommaculestovesiclesandthentopustulein24hours.

17. •Maternalvaricellainfectioninthefirst20weeksofpregnancycancauseVARICELLAEMBRYOPATHYalsocalledCongenitalVaricellaSyndromeinapproximately1-2%ofcasescharacterisedbyhallmarkcicatriciallesionsindermatomalpattern,limbhypoplasia,contracturesandcanalsoinvolvetheeyeandcentralnervoussystem.Theprognosisispoorifaninfantbeinfected.DiagnosisisbyPrenatalUltrasoundandMRImayshowOligohydramnios, IUGR,hydrops,limbdeformitiesandmicrocephaly.
•However,theriskofcongenitalvaricellasyndromeisnegligiblebecauseantibodiesinthematernalbloodpreventthevirusfromcrossingtheplacentaandinfectingthefetus.
•In1994,Endersandcolleaguesshowednoclinicalevidenceofinfectionininfantsbornto366womenwithVaricellaZosterinpregnancy.

18. DIAGNOSIS: Isprimarilyclinical,byrecognitionoftherash.Ifnecessary, itcanbeconfirmedbydetectionofantigen(DirectImmunofluroscence),PCRorbyVIRALCULTUREoftheaspiratedVesicularFluid. TREATMENT: ACYCLOVIR(800mg5timesdailyat4hourlyintervalsfor7days)orACYCLOVIR5mg/kg8hourlyIVuntilpatientisimprovingisaClass-CantiviralagentusedinthetreatmentofVaricellaZoster.OralAcyclovirhasbeenshowntosignificantlyreducesymptoms,durationandintensity.
•ManystudieshaveshowedthesafetyofAcycloviruseinpregnancy.In1993, CenterforDiseaseControlpublisheddatashowingnoriskoffetalabnormalitiesinpatientsexposedinthefirsttrimesterreceivingAcyclovir.
•ThenewerdrugslikeVALACYCLOVIRandFAMCYCLOVIRhaveabetterbio-availabilityandalessfrequentdosingthanAcyclovirwithsimilarefficacy.

19. PARVOVIRUSB-19INFECTION:
•ParvovirusB-19virusisasmallsinglestrandedDNAvirusandhasapredilectionforrapidlydividingcellsparticularlytheerythroblasts.Manyinfectionsaresub- clinical.
•IncubationPeriod–14-21days.
•CLINICALFEATURES:ProdromalFever,CoryzalSymptoms,andacharacteristic“Slapped-cheekrash”, ImpairedErythropoiesiscausingmildanemiaandpolyarthropathy.
•Trans-placentalfetalinfectioncanoccurduringthefirsttwotrimestersofpregnancywithanimpactonthefetalbonemarrow.Itcauses10-15%ofnon-immune(Non- Rhesusrelated)HYDROPSFETALIS.

21. TREATMENT:
•Infectionisusuallyself-limiting.
•SymptomaticrelieffromArthriticsymptomsmayberequiredbytheuseofanalgesics.
•PregnantwomenshouldavoidcontactwithcasesofParvovirus-B19infection.
•Ifexposed,SEROLOGYshouldbedonetoestablishwhethertheyarenon-immune.
•PassiveprophylaxiswithNORMALIMMUNOGLOBINhasbeensuggested.
•ThepregnancyshouldbemonitoredcloselybyUSG,sothatHydropsFetaliscanbetreatedbyFetalTransfusion.

22. SYPHILIS:
•Syphilisiscausedbyinfection,throughabrasionsintheskinormucousmembraneswiththespirochaeteTREPONEMAPALLIDUM.
•Inadultstheinfectionisusuallysexuallyacquired, howevertransmissionbykissing,bloodtransfusionandpercutaneousinjuryhavealsobeenreported.
•Infectionmayremainlatentthroughoutorclinicalfeaturesmaydevelopatanytime.
•Allwomenshouldhavesyphilisserologycarriedoutinthefirsttrimesterofpregnancyoratthefirstantenatalvisit.
•Womenatariskofacquiringsyphilisshouldhaveafurthertestinthe3rdtrimesterpreferablyat28-30weeks.

23. CONGENITALSYPHILIS–
•CongenitalSyphilisisrarewhereantenatalserologicalscreeningispractised.
•Treponemalinfectionmaygiverisetoavarietyofoutcomesafter4monthsofgestationwhenthefetusbecomesimmunocompetent:
1.MiscarriageorStill-birth,Prematureoratterm. 2.Birthofasyphiliticbaby(verysickbabywithhepatosplenomegaly,bullousrashandperhapspneumonia). 3.BirthofababywithlatentinfectionwhoeitherremainswellordevelopsCongenitalSyphilislaterinlife.

24. •SyphilismaybedividedasEarlyorLatentSyphilis.
•CLINICALFEATURES:
•IncubationperiodofEarlySyphilisisusually14-28dayswithawiderangeof9-90days.
•Theprimarylesionorchancredevelopsatthesiteofinfectionusuallyonthegenitalareaandmayalsodeveloponthevaginalwallandthecervix.
•After6-8weeksthetreponemesdisseminatetoproduceamulti-systemdisease.Constitutionalfeaturessuchasfever, malaiseandheadachearecommon.Over75%patientspresentwitharashonthetrunkandlimbsthatlaterinvolvesthepalmsandsoles.
•Generalisednon-tenderlymphadenopathyispresentinover50%patients.

25. •Oftenfeaturessuchasmeningitis,cranialnervepalsies, hepatitis,gastritis,glomerulonephritisandanterior/posterioruveitisareseen. INVESTIGATIONS:
SEROLOGICAL TESTS FOR SYPHILIS
Non-treponemal( Non-specific)tests:
•VeneralDiseases Research Laboratory ( VDRL ) Test
•Rapid Plasma ReaginTest
Treponemal(Specific) antibody tests:
•Treponemalantigen-basedenzyme immunoassay (EIA) for IgGand IgM
•T. Pallidumhaemagglutinationassay (TPHA)
•T. PallidumParticle agglutination assay (TPPA)
•Fluorescent treponemalantibody-absorbed (FTA- ABS) test

27. TREATMENT:
•In early latent stage: single dose of 2.4 Million units Benzathine Penicillin G IMIn late latent stage: 3 doses of 2.4 million units of Benzathine Penicillin GIM is given. It is given once in a week.
•ERYTHROMYCINSTEARATEcanbegivenifthereisPenicillinhypersensitivity,butitcrossestheplacentapoorly.Thetreatmentofsyphiliscanbeconsideredadequateifitiscompletedbyatleast30daysbeforedeliveryorthereisadocumentef4-folddropinRPRtitre.

28. •ThenewbornbabymustthereforebetreatedwithacourseofPenicillinandconsiderationgiventore-treatingthemother.
•SuccesshasalsobeenachievedwithCEFTRIAXONE250mgIMfor10daysinmanycases.
All pregnant women testing positive for Syphilis should also be screened for HIV.

29. COXSACKIEVIRUSINFECTION:
•ThevirusisamemberofthePicornaviridaeandhaveasingle-strandedRNA.Itmaycauseclinicallyinapparentinfectioninthemotherbutmayprovefataltothefetusortheinfantbyincreasingcongenitalmalformations.
•Infectionisspreadfrompersontoperson.Thevirusispresentinsecretionsandbodyfluidsofinfectedpeople.
•FetaldeathmaybecausedbyviraemiaresultinginHepatitis,MyocarditisandEncephalomyelitisduetoplacentitisandclinicalchorioamnionitis.
•Thevirusmaybegrownfromtheamnioticfluidortheneonatalspinalfluid.PCRcandetect66-90%oftheinfection.

30. CLINICALFEATURES:CommonCold,Rash,diarrhoea, sorethroat.Severemanifestationsincludemeningitis, encephalitis,severechestpain,myopericarditis. TREATMENT:
•ThereisnospecificmedicationknowntokilltheCoxsackievirus.
•Fortunately,thebody’simmunesystemisusuallyabletodestroythevirus.
•SomereportssuggestthattheremightbeabenefittoIVImmunoglobulinwhichismadefromhumanserumandcontainsantibodies.
•TreatmentforMyocarditisissupportive.

32. LISTEROSIS:
•Recentsurveyshaveshownthat4%ofpregnantwomenharborLISTERIAMONOCYTOGENS,aGram-positivebacteriainthecervix.
•Trancplacentalinfectionscanoccurfromaninfectedmother.
•SuchpatientshaveInfluenzalikesymptoms,prematuredeliveryanddirtybrownamnioticfluid,fever,myalgia, choriamnionitisandabortions.
•BabiesborntothesemothersmaygetinfectedtransplacentallyorduringdeliverywithahighmorbidityandmortalityduetoPyogenicMeningitis.

33. INVESTIGATIONS :
•DiagnosisismadebyBlood/CSFCulture,apositivefluoroscentantibodytestandcultureofstomachcontent, liquor. TREATMENT:
•ThemosteffectiveregimenconsistsofIVAMINOPENICILLIN(AMOXYCILLIN/AMPICILLIN)+ANAMINOGLYCOSIDE.
•PatientsallergictoPenicillinmaybegivenacombinationofSulfamethoxazole/Trimethoprim.
•Dietaryprecaution:Pregnantwomenareadvisedtoavoidhigh-riskproductslikeundercookedchicken,fish,rawvegetablesandsoftcheese.

34. RUBELLA :
•Rubella,commonlyknownasGermanmeasles,isadiseasecausedbytherubellavirusatogavirusthatisenvelopedandhasasingle-strandedRNAgenome.
•Thisdiseaseisoftenmildandattacksoftenpassunnoticed.Thediseasecanlastonetothreedays. Childrenrecovermorequicklythanadults.
•InfectionofthemotherbyRubellavirusduringpregnancycanbeserious;ifthemotherisinfectedwithinthefirst20weeksofpregnancy,thechildmaybebornwithcongenitalrubellasyndrome(CRS),whichentailsarangeofseriousincurableillnesses.Spontaneousabortionoccursinupto20%ofcases.Thevirushasteratogenicpropertiesandiscapableofcrossingtheplacentaandinfectingthefetuswhereitstopscellsfromdevelopingordestroysthem.

35. •Acquired(i.e.notcongenital)rubellaistransmittedviaairbornedropletemissionfromtheupperrespiratorytractofactivecasesandreplicatesinthenasopharynxandlymphnodes.
•Thevirusmayalsobepresentintheurine,Faecesandontheskin.Thereisnocarrierstate:thereservoirexistsentirelyinactivehumancases.
•Thediseasehasanincubationperiodof2to3weeks.
•Inmostpeoplethevirusisrapidlyeliminated.However,itmaypersistforsomemonthspostpartumininfantssurvivingtheCRS.Thesechildrenareasignificantsourceofinfectiontootherinfantsand,moreimportantly,topregnantfemalecontacts.

36. CLINICAL FEATURES :
•Germanmeaslescausessymptomsthataresimilartotheflu.Theprimarysymptomofrubellavirusinfectionistheappearanceofarash(exanthem)onthefacewhichspreadstothetrunkandlimbsandusuallyfadesafterthreedays.
•Thefacialrashusuallyclearsasitspreadstootherpartsofthebody.Othersymptomsincludelowgradefever, swollenglands(suboccipital&posteriorcervicallymphadenopathy),jointpains,headacheandconjunctivitis.Theswollenglandsorlymphnodescanpersistforuptoaweekandthefeverrarelyrisesabove38degreescentigrate.Therashdisappearsafterafewdayswithnostainingorpeelingoftheskin.
•.

37. CONGENITAL RUBELLA SYNDROME
•Congenitalrubellasyndrome(CRS)ischaracterizedby:
Intrauterinegrowthrestriction
Intracranialcalcifications
Microcephaly
Cataracts
Cardiacdefects(mostcommonlypatentductusarteriosusorpulmonaryarterialhypoplasia).
Neurologic disease (with a broad range of presentations, from behavior disorders to meningoencephalitis)
Osteitisandhepatosplenomegaly

39. •Mostofthesecomplicationsdevelopininfantsborntomotherswhoacquirerubellainfectionduringthefirst16weeksofpregnancy.
•90%ofinfantspresentwithsomefindingofcongenitalrubellaifinfectionoccurswithinthefirst12weeks,and20% presentwithcongenitaldiseaseiftheinfectionoccursbetweenweeks12and16.
•Cataractsresultswheninfectionoccursbetweenthethirdandeighthweekofgestation,deafnessbetweenthe3rdand18thweek,andheartabnormalitiesbetweenthe3rdand10thweek.

40. DIAGNOSIS:
•RubellavirusspecificIgMantibodiesarepresentinpeoplerecentlyinfectedbyRubellavirusbuttheseantibodiescanpersistforoverayearandapositivetestresultneedstobeinterpretedwithcaution.
•Thepresenceoftheseantibodiesalongwith,orashorttimeafter,thecharacteristicrashconfirmsthediagnosis.

41. TREATMENT :
•Rubellainfectionsarepreventedbyactiveimmunisationprogramsusinglive,disabledvirusvaccines.Twoliveattenuatedvirusvaccines,RA27/3andCendehillstrains, areeffectiveinthepreventionofadultdisease.
•ThevaccineisnowusuallygivenaspartoftheMMRvaccine.TheWHOrecommendsthefirstdoseisgivenat12to18monthsofagewithaseconddoseat36months. Pregnantwomenareusuallytestedforimmunitytorubellaearlyon.Womenfoundtobesusceptiblearenotvaccinateduntilafterthebabyisbornbecausethevaccinecontainslivevirus.

42. •ThereisnospecifictreatmentforRubella;however, managementisamatterofrespondingtosymptomstodiminishdiscomfort.
•Treatmentofnewlybornbabiesisfocusedonmanagementofthecomplications.
•Congenitalheartandcataractscanbecorrectedbydirectsurgery.
•Managementforocularcongenitalrubellasyndrome(CRS)issimilartothatforage-relatedmaculardegeneration,includingcounseling,regularmonitoring, andtheprovisionoflowvisiondevices,ifrequired.
•Rubellainfectionofchildrenandadultsisusuallymild,self- limitingandoftenasymptomatic.TheprognosisinchildrenbornwithCRSispoor.

43. CYTOMEGALOVIRUS INFECTION :
•CMVisadouble-strandedDNAherpesvirusandrepresentsthemostcommoncongenitalviralinfection.
•TheCMVseropositivityrateincreaseswithage. Geographiclocation,socioeconomicclass,andworkexposureareotherfactorsthatinfluencetheriskofinfection.
•CMVinfectionrequiresintimatecontactthroughsaliva, urine,and/orotherbodyfluids.
•Possibleroutesoftransmissionincludesexualcontact, organtransplantation,transplacentaltransmission, transmissionviabreastmilk,andbloodtransfusion(rare).

44. •Primary,reactivation,orrecurrentCMVinfectioncanoccurinpregnancyandcanleadtocongenitalCMVinfection.
•Transplacentalinfectioncanresultinintrauterinegrowthrestriction,sensorineuralhearingloss,intracranialcalcifications,microcephaly,hydrocephalus, hepatosplenomegaly,delayedpsychomotordevelopment,thrombocytopeniaand/oropticatrophy.
•VerticaltransmissionofCMVcanoccuratanystageofpregnancy;however,severesequelaearemorecommonwithinfectioninthe1sttrimester,whiletheoverallriskofinfectionisgreatestinthe3rdtrimester.
•Theriskoftransmissiontothefetusinprimaryinfectionis30%-40%.

46. •Thetransmissionratetothefetusisbetween30-50% accordingtotheOrganizationofTeratologyInformationService(OTIS).
•Ofthosebabieswhobecomeinfected,only10-15%showsignsofcongenitalCMVafterprimarymaternalinfection.
•CongenitalCMVaffectsabout0.2-2.5%ofbabiesworldwide.
•Ofthese,only1-10%ofthebabiesbornwiththeCMVinfectionwillhavesymptomsatbirthandanother10-15% maynotshowanysymptomsatbirth,butstillmayhavelongtermaffectssuchashearinglossandlearningdisabilities.

48. DIAGNOSIS & MANAGEMENT :
•Serologic testing in women with suspected Cytomegalovirus (CMV)
•Amniocentesis
•Ultrasonography
•Quantitative polymerase chain reaction (PCR) for viral DNA in amniotic fluid
•Fetal magnetic resonance imaging (MRI) (considered but not recommended)
•Intravenous treatment with CMV-hyperimmune globulin
•Ganciclovirtreatment.

49. HERPES SIMPLEX VIRUS -2 INFECTION :
•Herpessimplexvirus(HSV)infectionisoneofthemostcommonviralsexuallytransmitteddiseasesworldwide.Theprimaryinfectionofthemothermayleadtosevereillnessinpregnancyandmaybeassociatedwithvirustransmissionfrommothertofoetus/newborn.
•Sincetheincidenceofthissexuallytransmittedinfectioncontinuestoriseandbecausethegreatestincidenceofherpessimplexvirusinfectionsoccurinwomenofreproductiveage,theriskofmaternaltransmissionofthevirustothefoetusorneonatehasbecomeamajorhealthconcern.

50. •Apregnantwomanwhoacquiresgenitalherpesasaprimaryinfectioninthelatterhalfofpregnancy,ratherthanpriortopregnancy,isatgreatestriskoftransmittingthesevirusestohernewborn.
•AdditionalriskfactorsforneonatalHSVinfectionincludetheuseofafoetal-scalpelectrodeandtheageofthemother<21years.
•HerpesSimplexVirus-2isaDNAvirusthatbelongstoAlphaherpesvirinaefamily.
•HSV-2ismostcommonlyfoundinthelumbosacralganglia.
•ThemostimportantHSVinfectionduringpregnancyistheprimarygenitalHSVinfection.

51. •PrimaryHSVinfectionsinpregnantwomencanresultinmoreseverediseasesthanthatinnon-pregnantones.
•Inparticular,gingivostomatitisandvulvovaginitisherpeticatendtowardsdissemination.Asaresult,womencandevelopdisseminatedskinlesionsassociatedwithvisceralinvolvementsuchashepatitis,encephalitis, thrombocytopenia,leucopoeniaandcoagulopathy.
•AlthoughdisseminatedHSVinfectionisuncommoninpregnancy,themortalityisabout50%.Inparticular, pregnantwomenwithprimarymucousmembraneinfectionduringthe3rdtrimester,haveanincreasedriskfordisseminationandtheycouldtransmitHSVtotheirbabiesduringvaginaldelivery.

52. •ThegreatmajorityofrecurrentgenitalherpesisduetoHSV-2becausethisvirusreactivatesmorefrequentlythanHSV-1.
•RecurrentepisodesofHSVinfectionarecharacterizedbythepresenceofantibodyagainstthesameHSVtypeandtheherpesoutbreaksareusuallymild(7–10days)withlessseveresymptomsthanthefirstepisode.
•Prodromalsymptoms(itching,tingling,neuralgia)mayoccurhoursordaysbeforearecurrentherpesepisode.
•Theapparentlyasymptomaticphasesbetweenclinicaloutbreaksofgenitalherpesareimportant,sinceHSVcanreactivateperiodicallyinlatentlyinfectedcellsofsensorygangliatravellingviatheneuronalaxonsbacktothegenitalmucosa,withoutclinicalsignsorsymptoms.Thismechanismisknownasasymptomaticvirusshedding.

53. •AsymptomaticsheddinghasbeenshowntobehigherinwomenwithHSV-2infectioncomparedwiththosewithHSV-1.
•Althoughthereisasmallriskofverticaltransmission, recurrentgenitalherpesmustberegardedasthemostcommoncauseofneonatalinfectionsandthepassagethroughaninfectedbirthcanalisthemostprobablerouteoftransmission.
•Inrecurrentinfectionsassociatedwithclinicalsymptoms, theriskofneonataldiseaseisreduceddramaticallybyCaesareansection.

55. DIAGNOSIS :
•Clinicaldiagnosisofgenitalherpesislimitedinaccuracy. First,HSVisonlyoneofseveraldiseasescharacterizedbygenitalulcers.Moreimportantly,manypersonsareunawarethattheirsymptomsarethoseofherpes.
•Thetypicallesionsmaynotappear,andrecurrencesmaybeatdifferentlocationsalongadermatome.Womenmayexperienceonlyprodromalsymptoms,suchasburningortingling;havesingleulcers,fissures,orerosion;orexperienceerythemaoredemaastheprimarysymptom.
•AvailabletestsforherpesincludebothcultureandPCR- DNAtestingforviralshedding,andtheuseofbloodteststoscreenforpreviousexposure.

56. MANAGEMENT :
•TheAmericanCongressofObstetriciansandGynecologists(ACOG)recommendsthatwomenwithactiverecurrentgenitalherpesshouldbeoffered–
•Suppressiveviraltherapyfrom36weeksuntildelivery
Valacyclovir500mgorallyBDOR
Acyclovir400mgorallyTDS.
•Transplacentalinfectionofthefetusisrareduringpregnancy.IntrauterineHSVinfectionhasuncommonlybeenassociatedwithskinlesions,chorioretinitis, microcephaly,hydranencephaly,andmicrophthalmia.

57. •WhileprimaryHSVinfectionsinthefirsttrimesterareassociatedwithhigherratesofspontaneousabortionandstillbirth,infectionlaterinpregnancyappearsmorelikelytobeassociatedwithpretermlabororgrowthrestriction.
•Ofgreatestconcernistheriskofprimaryinfectionacquiredatbirthwhichcouldleadtoherpeticmeningitis.Theinfectionrateis34to80%forinfantsbornvaginallyduringaprimaryinfection.
•Cesareansectionisrecommendedforallwomeninlaborwithactivegenitallesionsorprodromalsymptomssuchasvulvarpain. ForpatientswithpretermprematureruptureofmembranesremotefromtermcomplicatedbyrecurrentmaternalHSVinfection,therisksofprematurityshouldbeweighedagainsttheriskofneonatalHSVdiseaseinconsideringexpectantmanagement.Prophylactictreatmentwithantiviralagents(eg,acyclovir)maybeconsideredifexpectantmanagementischosen.

59. THE TORCH TEST :
•TheTORCHtestisusedtoscreenpregnantwomenandnewbornsforantibodiestotheinfectiousdiseasesincludedinthepanel,ifeitherthemotherornewbornhassymptoms.Thebloodtestcandetermineifthepersonhashadarecentinfection,apastinfection,orhasneverbeenexposed.
•ThetestisorderedwhenapregnantwomanissuspectedofhavinganyoftheTORCHinfections.Theseinfectionscanbeseriousiftheyoccurduringpregnancybecausetheycancrosstheplacentafromthemothertothedevelopingfetusandcancausecongenitaldefectsinthenewborn.

60. •Resultsareusuallygivenaspositiveornegative, indicatingthepresenceorabsenceofIgGandIgMantibodiesforeachoftheinfectiousagentstestedforwiththepanel.A"normal"resultisnegative(undetectable)IgMantibodyinthebloodofthemotherornewborn.
•PresenceofIgMantibodiesindicateseitheracurrentorrecentinfection.ApositiveIgMresultinanewbornindicateshighlikelihoodofinfectionwiththatorganism. IgMantibodiesproducedinthemothercannotcrosstheplacenta,sopresenceofthistypeofantibodystronglysuggestsanactiveinfectionintheinfant.PresenceofIgGandabsenceofIgMantibodyinaninfantmayreflectpassivetransferofmaternalantibodytothebabyanddoesnotindicateactiveinfectioninthatinfant.

61. •Likewise,thepresenceofIgMantibodyinapregnantwomansuggestsanewinfectionwiththevirusorparasite.
•FurthertestingmustbedonetoconfirmtheseresultssinceIgMantibodymaybepresentforotherreasons.
•IgGantibodyinthepregnantwomanmaybeasignofpastinfectionwithoneoftheseinfectiousagents.Bytestingasecondbloodsampledrawntwoweekslater, thelevelofantibodycanbecompared.
•IfthesecondblooddrawshowsanincreaseinIgGantibody,itmayindicatearecentinfectionwiththeinfectiousagent.

62. REFERENCES
•Davidson’s Principles & Practice of MEDICINE -21stedition
•Novak’s Textbook of Obstetrics –10thedition
•TORCH Infections in Pregnancy –VeenaGupta –JaypeePublication –2ndedition.
•William’s Textbook of Obstetrics –23rdedition
•Article on Torch infections in Pregnancy –THE BRITISH MEDICAL JOURNAL (BMJ)
•Article on TORCH INFECTIONS in Pregnancy –AMERICAN COLLEGE OF OBSTETRICS & GYNAECOLOGY (ACOG)