information on some of the top most deadliest and morbid infections.

1. 
TORCH Infections
Meredith Scannell, RN, CNM, MSN, MPH

2. Background
 Infections acquired in utero or during the birth process are
a significant cause of fetal and neonatal mortality.
 Most fetus if infected during the first trimester will suffer
congenital malformation
 Perinatal infections account for 2% - 3% of birth defects
which arise form a spectrum of organisms & have varying
modes of transmission
 Not all birth defects are routinely screened for during
prenatal care

3. TORCH Infections
 T=toxoplasmosis
 O=other (syphilis, Hepatitis, HIV)
 R=rubella
 C=cytomegalovirus (CMV)
 H=herpes simplex (HSV)
 Origin was based on 5
infections that presented
similarly, with rash and ocular
findings.
 First 4 are acquired antenately
 Herpes and hepatitis acquired
prenately or via delivery
 Term TORCH somewhat
obsolete as other disease are
important such as HIV

4. Toxoplasmosis

5. Toxoplasmosis - Transmission
 Caused by protozoan –
Toxoplasma gondii
 Domestic cat is the
definitive host with
infections via:
 Ingestion of cysts
(meats, garden
products)
 Contact with oocysts in
feces

6. Toxoplasmosis
 Acute infection usually asymptomatic
 1/3 risk of fetal infection with primary maternal
infection in pregnancy
 Infection transmission rate higher with in 3rd
trimester
 Fetal death higher with in 1st
trimester
 Abnormal growth

7. Clinical Manifestations - Maternal
 Most are asymptomatic at birth
 Mononucleosis type symptoms:
 Fatigue
 Headache
 Malaise
 Lymphadenopathy (7% of infected individual)
 Blood test reveals seroconversion

8. Clinical Manifestations - Infant
 Most (70-90%) are asymptomatic at birth
 Classic triad of symptoms:
 Chorioretinitis
 Hydrocephalus
 Intracranial calcifications
 Other symptoms include fever, rash, HSM,
microcephaly, seizures, jaundice, thrombocytopenia,
lymphadenopathy
 Initially asymptomatic infants are still at high risk of
developing abnormalities, especially chorioretinitis

9. Toxo Screening
 Prenatal testing with varied sensitivity
not useful for screening
 Neonatal screening with IgM testing
implemented in some areas
 Identifies infected asymptomatic
infants who may benefit from
therapy

10. Prevention andTreatment
 Treatment for pregnant
mothers diagnosed with acute
toxo
 Spiramycin daily
 Macrolide antibiotic
 Small studies have shown this
reduces likelihood of
congenital transmission (up to
50%)
 Symptomatic infants
 Pyrimethamine (with
leucovorin rescue) and
sulfadiazine
 Treatment for 12 months
total
 Prevetion
 Wash hands before eating,
after handleing raw mean
 Wash hands after contact
with cat feces
 Wash hands if in contact
with soil
 Cook meat adequately

11. Syphilis

12. Syphilis
 Syphilis is a systemic infection caused by the
spirochete Treponema pallidum
 Transmitted via sexual contact
 Placental transmission as early as 6wks gestation
 Typically occurs during second half
 Mom with primary or secondary syphilis more likely to
transmit than latent disease
 Large decrease in congenital syphilis since late
1990s
 In 2002, only 11.2 cases/100,000 live births reported

13. From MMWR –From MMWR –
Aug 2004Aug 2004

14. From MMWR – Aug
2004

15. Clinical Manifestations
 Fetal:
 Stillbirth
 Neonatal death
 Low birth weight
 Hydrops fetalis
 Congential Malformations
 Active congenital syphilis in
the neonate
 Long-term sequelae, such as
deafness and neurologic
impairment
 SAB after 4th
months when
the spirochetes cross the
placenta
 Repeated late abortion
 Intrauterine death in 25%
 Perinatal mortality in 25-
30% if untreated

16. Clinical Manifestations
Congenital syphilis Hutchinson Teeth Lores
•2/3 of affected live-born infants are
asymptomatic at birth
•Clinical symptoms split into early or late

17. Diagnosing Syphilis
Maternal
 Available serologic testing
 RPR/VDRL: nontreponemal test
 Sensitive but NOT specific
 RPR/VDRL screen in ALL pregnant women
early in pregnancy and at time of birth
 This is easily treated

18. Treatment
 Penicillin G is THE drug of choice for ALL syphilis
infections
 Maternal treatment during pregnancy very
effective (overall 98% success)
 Treat newborn if:
 They meet CDC diagnostic criteria
 Mom was treated <4wks before delivery
 Mom treated with non-PCN med
 Maternal titers do not show adequate response
(less than 4-fold decline)

19. Rubella

20. Rubella
 Single-stranded RNA virus, spread via respiration
 Vaccine-preventable disease
 No longer considered endemic in the U.S.
 Mild, self-limiting illness
 Infection earlier in pregnancy has a higher probability of affected
infant within the first 16 weeks
 Risk of fetal infection 50-60% 1st
month
 Risk of fetal infection 22% in 2nd
month
 Risk of fetal infection 6-10% in 4th
month

21. Copyright ©2006 American Academy of PediatricsMeissner, H. C. et al. Pediatrics 2006;117:933-935
Reported rubella and CRS: United States, 1966-2004

22. Clinical Manifestations
 Microcephaly
 Cerebral palsy
 Sensorineural hearing loss (50-75%)
 Cataracts and glaucoma (20-50%)
 blindness
 Cardiac malformations (20-50%)
 Neurologic (10-20%)
 Others to include growth retardation, bone
disease, HSM, thrombocytopenia, “blueberry
muffin” lesions

23. Diagnosis
 Maternal IgG may represent immunization or
past infection
 Can isolate virus from nasal secretions
 Less frequently from throat, blood, urine, CSF
 Serologic testing
 IgM = recent postnatal or congenital infection
 Rising monthly IgG titers suggest congenital infection

24. Treatment
 Acute infection – droplet precautions
 Prevention…immunize, immunize, immunize! (before or after
pregnancy)
 20% of women of child bearing age do not possess rubella
anitbody
 Avoid pregnancy for 3 months after vaccination
 Supportive care only with parent education

25. Cytomegalovirus (CMV)

26. Clinical Manifestations
 1:100 babies are born with this congenital infection
 90% of newborns are asymptomatic at birth
 Symptomatic infection
 Small for Gestational dates
 Hepatospleenomegaly
 Petechiae
 Jaundice
 >80% develop long term complications
 Hearing loss, vision impairment, developmental delay

27. Diagnosis
 Maternal IgG shows only past infection
 Infection common – this is useless
 Viral isolation from urine or saliva in 1st
3weeks of
life
 Afterwards may represent post-natal infection
 Viral load and DNA copies can be assessed by PCR
 Less useful for diagnosis, but helps in following viral
activity in patient
 Serologies not helpful given high antibody in
population

28. Treatment
 Ganciclovir x6wks in symptomatic infants
 Studies show improvement or no progression of hearing
loss at 6mos
 No other outcomes evaluated (development, etc.)
 Neutropenia often leads to cessation of therapy
 Treatment currently not recommended in
asymptomatic infants due to side effects

29. Herpes Simplex (HSV)

30. Herpes Simplex (HSV)
 HSV1 or HSV2
 Primarily transmitted through infected maternal genital tract
 Rationale for C-section delivery prior to membrane rupture
 Primary infection with greater transmission risk than
reactivation

31. Clinical Manifestations
 Most are asymptomatic at birth
 3 patterns of ~ equal frequency with symptoms
between birth and 4wks:
 Skin, eyes, mouth (SEM)
 CNS disease
 Disseminated disease (present earliest)
 Initial manifestations very nonspecific with skin
lesions NOT necessarily present

32. Presentations of congenital HSV

33. Diagnosis
 Culture of maternal lesions if present at delivery
 Cultures in infant:
 Skin lesions, oro/nasopharynx, eyes, urine, blood,
rectum/stool, CSF
 CSF PCR
 Serologies again not helpful given high prevalence of
HSV antibodies in population

34. Treatment
 High dose acyclovir 60mg/kg/day divided q8hrs
 X21days for disseminated, CNS disease
 X14days for SEM
 Ocular involvement requires topical therapy as well

35. Varicella Zoster

36. Varicella Zoster
 Herpes Virus in a DNA virus
 Highly contagious & transmitted by respiratory droplets & by direct
personal contact with vesicle fluid.
 Complicates 3 in 1,000 pregnancies
 Incubation period-10-21 days. Infectious 48 hrs before the rash - vesicle
crust over.
 If primary infection occurs in the first trimester 4.9% risk of congenital
vaircella
 Infection acquired in the last 10 days of pregnancy result in variable
congential infection with neonatal mortality as high as 34%

37. Varicella
Maternal
 Greater morbidity
 Pneumonia
 Up 10% of pregnant
women
 Severity increases later in
gestion
 Encephalatis
 Hepatitis
 Under 20 weeks gestation
 No increase in SAB
Fetal
 1-2% of maternal infections
 Characterised by skin
scarring
 eye defects,
 hypoplasia of limbs
 neurological
abnormalities
 microcephaly

38. FetalVaricella

39. Varicella
 Serology (IgG and IgM).
 Screening: Routine screening generally not recommended
 Prevention: If pregnant woman (with no history of previous
chickenpox) is exposed, perform STAT Varicella IgG. Exposed
neonate should receive VZIG prophylaxis.

40. Treatment and Prevention
 In non-immune adult who plans to become pregnant - Live
attenuated varicella vaccine is safe & effective in preventing
chickenpox
 If nonimmune - Give VZIG within 10 days of exposure
 Avoid contact with susceptible individual.
 Symptomatic treatment
 Oral acyclovir reduces the duration of symptoms if started
within 24 hours of development of rash.

41. Herpes Zoster (Shingles)
 Caused by reactivation of a latent varicella zoster virus
infection
 Can occur years or decades after illness with chickenpox
 Generally associated with normal aging and with anything that
causes reduced immunocompetence
 Lifetime risk of 32% in the United States
 Estimated 1 million cases zoster diagnosed annually in the U.S.
 ***Vaccine Contraindicated in Pregnancy***

42. Questions?

43. References
 Gilbert, R., Gras, L., & European Multicentre Study on
Congenital Toxoplasmosis. (2003). Effect of timing and type of
treatment on the risk of mother to child transmission of
Toxoplasma gondii. BJOG: an international journal of obstetrics
and gynaecology, 110(2), 112.