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.
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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