TORCH is an acronym widely used in maternal and fetal medicine to refer to a group of infections acquired in utero (during the birth process). These infections are a significant cause of fetal and neonatal mortality and an important contributor to childhood morbidity.

TORCH includes:

Once the mother is infected with a disease, the organism circulates in the mother’s blood and reaches the fetus by way of the placenta. In most cases, the maternal illness is mild, but the impact on the developing fetus can be severe enough to cause fetal loss or result in IUGR (intrauterine growth restriction), prematurity, or chronic postnatal infection.

The routine screening of pregnant women for TORCH infections varies geographically. In the United States, the American College of Obstetricians and Gynecologists recommends pregnant women be screened for syphilis and rubella at the initial prenatal visit. Asymptomatic newborns are not generally screened for congenital infections except for some areas that screen for toxoplasmosis or cytomegalovirus.

Toxoplasmosis

The “T” in TORCH is for toxoplasmosis, which is a disease caused by a parasitic protozoa and is usually acquired by a pregnant woman eating raw or poorly cooked meat or raw eggs, or by contact with the feces of infected cats (such as improper handling of a cat litter box).

The infant exposed prenatally may have one of the classic symptoms, such as chorioretinitis (inflammation behind the retina, which can progress to blindness), hydrocephalus (a buildup of cerebrospinal fluid in the brain), or intracranial calcifications, which are linked to mental retardation, seizures, or motor and developmental delays.

Most infants with congenital toxoplasmosis have no apparent abnormalities at birth, but signs present may include fever, hepatosplenomegaly, maculopapular rash, jaundice, thrombocytopenia, microcephaly, seizures, and generalized lymphadenopathy. Infants who do not receive treatment have an increased risk of long-term consequences.

To avoid infection with toxoplasmosis, pregnant women should avoid poorly cooked or raw meat (especially pork, beef, and lamb), wash fruits and vegetables thoroughly, avoid drinking unfiltered water, avoid contact with a cat litter box, wear gloves when gardening, and avoid garden areas frequented by cats.

Diagnosis of congenital toxoplasmosis can be done by blood test. Treatment is based on the gestational age at diagnosis. There are two antibiotics typically given to reduce the risk of congenital toxoplasmosis: spiramycin (given prior to 14 weeks gestation) and pyrimethamine-sulfadiazine (given at 14 weeks and beyond).

Other Agents

The “O” in TORCH stands for “other agents” and can include syphilis, varicella-zoster, HIV, hepatitis B, parvovirus B19, Zika virus, enteroviruses, and lymphocytic choriomeningitis virus.

Syphilis

Syphilis is a sexually transmitted bacterial infection that is transmitted from mother to fetus during pregnancy or at birth, resulting in congenital syphilis. Untreated early syphilis results in miscarriage, premature birth, stillbirth, deformities, developmental delays, or seizures.

Newborns with congenital syphilis may develop “snuffles,” in which the mucus is highly infectious, and a palmar or solar rash. As the child ages (after 2 years old), they develop Hutchinson’s teeth, which have notched incisors or widely spaced pegged teeth. They also develop a saddle nose, or collapse of the bony part of the nose. Frontal bossing is also seen; this is an unusually pronounced forehead.

Almost half of the fetuses infected with syphilis in utero do not make it to term or die soon afterward. Most children born with syphilis do not show symptoms of the disease for several weeks or months after birth. If left untreated, the disease becomes severe and affects the neurological and cardiovascular systems. A newborn with syphilis can be treated with antibiotics and if the mother is treated early in pregnancy, the infant is at minimal risk for infection.

Varicella-Zoster (VZV)

The varicella-zoster (VZV), also known as chickenpox, can be spread from a pregnant mother to her fetus through the bloodstream, known as congenital varicella. VZV can also spread from a mother to the fetus just prior to delivery, known as neonatal varicella infection. Most cases of congenital varicella syndrome occur in infants whose mothers were infected between 8 to 20 weeks gestation.

Characteristic findings include cutaneous scars, neurological abnormalities (intellectual disability, microcephaly), vision abnormalities (cataracts, chorioretinitis), limb abnormalities (atrophy, partial paralysis), gastrointestinal abnormalities (gastroesophageal reflux, stenotic bowel), and low birth weight. Neonates born to mothers who have VZV five days before to two days after delivery are at the greatest risk for severe disease and poor outcome.

Congenital and neonatal varicella is treated by giving the newborn varicella-zoster immune globulin (Varizig) immediately after birth to lessen the severity of the disease. Pregnant patients without evidence of immunity who have been exposed to VZV should also receive Varizig. A pregnant woman with varicella may be treated with oral or IV acyclovir, an antiviral medication. If the woman was immunized or previously infected with varicella before pregnancy, antibodies were formed and will be transferred to the fetus. Neither the woman nor her fetus will become infected during the pregnancy.

HIV

Mothers with HIV may transmit the virus to their child during pregnancy, childbirth, or breastfeeding. With the appropriate antiretroviral therapy (ART), the risk of mother-to-child infection can be reduced to less than 1%, whereas the risk of transmission without treatment is 15%-45%. Antiretroviral therapy can be used before, during, and after pregnancy. Even if the woman is on ART, she should avoid breastfeeding because HIV can still be transmitted through breast milk.

Newborns should receive a 6-week course of AZT, and be tested for HIV at 2-3 weeks of life, again at 4-8 weeks, and again at 4-6 months of age. Most HIV babies appear healthy at birth, but if left untreated, the following signs or symptoms may develop within 2-3 months:

• Poor weight gain
• Repeated fungal mouth infections (such as thrush)
• Enlarged lymph nodes
• Multiple bacterial infections (such as pneumonia)
• Neurological problems

Hepatitis B

Hepatitis B is a viral infection that can be passed from a pregnant woman to her unborn infant, which may lead to acute or chronic liver disease, scarring, and/or cancer of the liver. A baby born to a mother with hepatitis B should receive a hepatitis B vaccine injection and hepatitis B immune globulin within 12 hours of birth. Prevention involves universal screening of pregnant women for HBsAg during each pregnancy.

Parvovirus B19

Parvovirus B19 is a common childhood illness characterized by a “slapped cheek” appearance from erythema infectiosum, also known as “fifth disease.” Parvovirus B19 infection during pregnancy may be associated with fetal loss or hydrops fetalis, with a greater risk when the infection occurs prior to 20 weeks gestation.

B19 is cytotoxic to fetal red blood cell precursors and may cause severe anemia. Hydrops fetalis is a life-threatening condition in which a fetus or newborn has abnormal edema in the tissue around the lungs, heart, or abdomen, or under the skin.

Zika Virus

Zika virus is a virus transmitted by mosquitoes, in which the greatest risk to the fetus occurs with an infection during the first or second trimester. Congenital Zika virus infection is associated with severe congenital anomalies, including microcephaly, facial disproportion, irritability, seizures, hypertonia and hyperreflexia, joint contractures, visual impairment, hearing loss, and brain abnormalities. There is no specific treatment for Zika virus infection and management involves caring for the symptoms.

Enteroviruses

Enteroviruses are transmitted person-to-person through fecal-oral contact and sometimes by respiratory secretions. When a pregnant woman is infected with an enterovirus, in most cases, the placental barrier has been shown to reduce the risk of fetal infection. However, if the infection occurs near term, the risk of pregnancy complications increases and there is an increased risk of vertical transmission to the newborn.

Infections of enterovirus in neonates can range from self-limiting (such as exanthema or viral meningitis) to severe and life-threatening, such as myocarditis or hepatitis, often presenting with encephalitis, hypotension, profuse bleeding, jaundice, and multiple organ failure.

Lymphocytic Choriomeningitis Virus

Lymphocytic choriomeningitis virus is transmitted to humans from exposure to the urine and feces of rodents. Congenital infection is characterized by chorioretinitis, micro- or macrocephaly, and neurologic issues including intellectual disability, seizures, and cerebral palsy.

Rubella

The “R” in TORCH stands for rubella. Rubella is a disease that is also called German measles, caused by the virus rubivirus. It causes mild flu-like symptoms and a rash on the skin, or no symptoms at all. Rubella can be passed from mother to fetus through the bloodstream during pregnancy. Rubella can cause miscarriage, stillbirth, premature birth, or congenital rubella syndrome, which causes birth defects such as:

• Patent ductus arteriosus
• Cataracts
• Deafness
• Intellectual disabilities
• Bone or growth problems
• Liver or spleen damage
• Or a “blueberry muffin rash”

Most damage is done to the developing fetus during the first trimester, whereas if the mother gets rubella towards the end of the second trimester, it is less likely to harm the fetus.

There is no cure for congenital rubella syndrome, so prevention is the key.

Rubella can be prevented by getting the MMR (measles, mumps, rubella) vaccine, usually given in childhood. If the woman is non-immune, she may receive the vaccine at least 28 days prior to pregnancy or after delivery of the infant. Since it is a live virus, it cannot be given during pregnancy.

Cytomegalovirus (CMV)

“C” stands for cytomegalovirus (CMV) and is a virus that belongs to the herpes simplex virus group that may be inactive at times, but is an incurable, life-time infection. To the generally healthy adult, the virus normally produces no symptoms and most women have produced antibodies, which can be passed on to the fetus, providing protection. However, CMV is a major concern if a mother becomes first infected while pregnant because she has no antibodies to pass on to the fetus.

Symptoms in the mother are similar to mononucleosis (fever, swollen glands, fatigue, tonsillitis, and liver malfunction). The virus can be found in blood, saliva, urine, semen, cervical mucus, and breast milk and can be transmitted from the infected mother across the placenta to the fetus or by the cervical route during birth or by breastfeeding.

CMV has become the most common congenital viral infection and is the leading cause of nonhereditary sensorineural hearing loss. It can also cause other long-term neurodevelopmental disabilities, including intellectual disability, vision impairment, cerebral palsy, and seizures. Symptoms of congenital CMV may or may not be seen at birth, but may include premature birth, low birth weight, petechiae, liver or spleen enlargement, jaundice at birth, microcephaly (small head), hearing loss, and seizures.

When a newborn with symptomatic CMV is treated with an antiviral medication within the first month of life, it has been shown to improve long-term hearing and neurodevelopmental outcomes. Prevention is very important! The pregnant woman should practice good personal hygiene, especially hand washing after contact with diapers or saliva of toddlers (especially if they are in day care). Avoid sharing food or utensils. Avoid kissing young children on the mouth or putting their pacifier in your mouth; CMV can be transmitted by saliva.

Herpes Simplex Virus (HSV)

The final letter in the acronym is “H,” which stands for herpes simplex virus (HSV).

Herpes simplex virus infection can cause painful lesions in the genital area. Women who contract their first herpes infection near the time of birth have the highest risk of transmission to the newborn. Transmission of HSV to the fetus almost always occurs after the membranes rupture or during vaginal birth. Intrauterine placental transfer of infection is rare. Women who have genital herpes during pregnancy are given suppressive antiviral therapy starting at 36 weeks to reduce the risk of recurrence at labor. A cesarean delivery is performed to reduce the risk of neonatal transmission.

If HSV is transferred to the newborn, it is evidenced by one or more forms. Skin, eyes, and mouth (SEM) herpes involve external lesions on the infant but no internal organ involvement. Disseminated herpes (DIS) affects multiple organs, particularly the liver. Central nervous system (CNS) herpes is an infection of the nervous system and brain; the infant presents with seizures, tremors, lethargy, irritability, poor feeding, unstable temperature, and bulging fontanelles. Antiviral treatment of neonatal HSV improves survival and outcome.

As with all infections, prevention is the key! As a nurse, educating your pregnant patient about how to prevent TORCH syndrome infections is vitally important to her health and the health of her newborn.

Review

Now let’s go over some questions for review:

1. A baby boy is born at 38 weeks gestation and his newborn examination reveals fever, jaundice, chorioretinitis, and an unusually large head with a bulging anterior fontanel. Mom reports that she started caring for two cats several months ago. This baby most likely has:

1. Parvovirus B19
2. Enterovirus
3. Congenital toxoplasmosis
4. Congenital syphilis

 
2. A baby girl is delivered at 36 weeks gestation, weighing 5 lb 3 oz, and fails her newborn hearing screen. Further testing is warranted to determine if she has:

1. Congenital rubella
2. Congenital cytomegalovirus
3. Herpes simplex virus
4. Congenital Zika virus

 
That’s all for now. Thanks for watching, and happy studying!