TORCH Infections in Pregnancy

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

TORCH Infections in Pregnancy — Diagnosis & Prevention

TORCH infections (toxoplasmosis, other, rubella, cytomegalovirus, herpes simplex) cause stillbirth, growth restriction, brain and eye damage, and deafness. This guide covers diagnosis, timing of tests, treatment, delivery, newborn care, and prevention, using the TORCHES approach.

🎯 AT A GLANCE — TORCH INFECTIONS

TORCH stands for Toxoplasmosis, Other infections (syphilis, varicella, parvovirus B19, Zika, listeria, HIV, hepatitis B), Rubella, Cytomegalovirus (CMV), and Herpes simplex virus (HSV)

Shared fetal picture: growth restriction, microcephaly, intracranial calcification, hepatosplenomegaly, jaundice, petechiae, chorioretinitis, and deafness

Maternal illness is often mild or silent; the damage depends on the infection, the gestation at infection, and whether the baby is infected

Do not send a routine 'TORCH panel': test for a reason — exposure, symptoms, or an abnormal scan — and interpret IgM with avidity and PCR (polymerase chain reaction)

Prevention beats treatment: rubella immunity before pregnancy, hygiene and food safety, and screening for syphilis, HIV and hepatitis B in every pregnancy

🚨 ACT AT ONCE

Abnormal fetal scan — microcephaly, ventriculomegaly, periventricular calcification, hydrops, echogenic bowel, growth restriction, or abnormal liquor: test the mother and refer to fetal medicine

Non-immune woman exposed to chickenpox: varicella zoster immunoglobulin or acyclovir within days; chickenpox with breathlessness: intravenous acyclovir and admit

Genital herpes lesions or tingling in labour: caesarean section is advised; baby needs herpes evaluation

Rash with fever in a pregnant woman: rubella, parvovirus, measles, varicella, Zika — test and avoid contact with other pregnant women

🗺️ THE PATHWAY AT A GLANCE

1 · SuspectExposure, symptoms, or a scan finding; note the gestation and date of exposure

2 · TestIgG, IgM, and IgG avidity; paired samples 2–3 weeks apart for rubella or parvovirus

3 · ConfirmAmniotic fluid PCR, 4–8 weeks after maternal infection

4 · TreatSpecific drug or immunoglobulin if available; counsel on the outcome

5 · WatchSerial growth, brain, and Doppler scans; plan delivery and neonatal care

6 · PreventVaccinate, hygiene, safe food; suppress herpes from 36 weeks

STEP 1 · TOXOPLASMOSIS, RUBELLA, CMV — the classic three

🐈 TOXOPLASMOSIS

Topic	Details
Source	Undercooked meat, cat faeces, soil, and unwashed vegetables; primary infection in pregnancy only matters (earlier infection protects)
Mother	Usually silent; neck lymph nodes, fatigue, or low fever
Fetal risk	Transmission rises with gestation (about 15% at 13 weeks, 45% at 26, over 70% near term); damage is worst when infection is early
Fetal damage	Hydrocephalus, scattered intracranial calcification, chorioretinitis, seizures, stillbirth; many babies look normal and develop eye disease later
Diagnosis	IgG and IgM; high IgG avidity in early pregnancy excludes recent infection; amniotic fluid PCR from 18 weeks and at least 4 weeks after infection
Treatment	Spiramycin 1 g three times daily from diagnosis to reduce transmission; if the fetus is infected (after the first trimester): pyrimethamine + sulfadiazine + folinic acid under specialist care
Prevention	Cook meat thoroughly, wash vegetables and hands, wear gloves for gardening, avoid cat litter, no raw or cured meat

🔴 RUBELLA (GERMAN MEASLES)

Topic	Details
Mother	Mild fever, rash behind the ears, joint pain, lymph nodes; up to half are silent
Fetal risk	First 12 weeks: up to 80–90% infected with severe defects; 13–16 weeks: fewer, mainly deafness; after 20 weeks: rare
Congenital rubella syndrome (CRS)	Cataract, sensorineural deafness, heart defects (patent ductus arteriosus, pulmonary stenosis), microcephaly, growth restriction, 'blueberry muffin' rash, hepatosplenomegaly
Diagnosis	IgM, IgG seroconversion, avidity; PCR on throat or amniotic fluid; immune if IgG is 10 IU/mL or more
Treatment	None specific; immunoglobulin is not recommended; counsel early: infection before 16 weeks carries a high risk of defects, and termination is a legal option
Prevention	Measles–rubella (MR) vaccine before pregnancy; avoid pregnancy for 4 weeks after it; live vaccine is not given in pregnancy (accidental vaccination is not an indication for termination); vaccinate non-immune women after delivery

India (national immunisation schedule): MR vaccine at 9–12 months and 16–24 months (up to 5 years if missed); adolescent girls and women of reproductive age without immunity should be vaccinated before pregnancy

🧫 CYTOMEGALOVIRUS (CMV)

Topic	Details
Importance	Commonest congenital infection (about 0.5–1% of births); most mothers are silent; spread by saliva, urine, and toys of young children
Fetal risk	Primary infection: about 30–40% transmission (higher later in pregnancy), but worse damage when early; non-primary (reactivation or reinfection): lower risk
Newborn	About 10–15% symptomatic (microcephaly, calcification, jaundice, petechiae, hepatosplenomegaly); 10–15% of silent infections develop sensorineural hearing loss
Diagnosis	IgG, IgM, and low avidity in recent infection; amniotic fluid PCR from 21 weeks and at least 6–8 weeks after infection; detailed scan and fetal MRI
Treatment	Valacyclovir 8 g daily early in primary infection may reduce transmission (off-label); hyperimmune globulin has not been shown to help; specialist care
Newborn	CMV PCR on urine or saliva within 3 weeks of birth; valganciclovir for symptomatic infants; hearing and eye follow-up
Prevention	Wash hands after nappy changes and wiping noses; do not share food, cups, or utensils with toddlers; do not kiss on the mouth

STEP 2 · HERPES, VARICELLA, PARVOVIRUS — viral infections with a clear action

🔥 HERPES SIMPLEX VIRUS (HSV)

Topic	Details
Risk to the baby	Mainly at delivery: first episode near term: 30–50%; recurrent lesions: under 3%; neonatal herpes: skin, eye and mouth, brain, or disseminated
First episode in pregnancy	Acyclovir 400 mg three times daily for 5–10 days (or valacyclovir 500 mg twice daily); take a swab and counsel
Suppression	Acyclovir 400 mg three times daily (or valacyclovir 500 mg twice daily) from 36 weeks to delivery for a history of genital herpes or a first episode in pregnancy
Delivery	Lesions or prodromal symptoms in labour, or a first episode within 6 weeks of delivery: caesarean section; avoid scalp electrodes and instrumental delivery
Newborn	Swabs and bloods if the mother has recent infection or lesions; intravenous acyclovir for suspected or proven neonatal herpes (14–21 days)
Breastfeeding	Safe unless there is a lesion on the breast; hand hygiene

🟠 VARICELLA (CHICKENPOX)

Topic	Details
Mother	Pneumonia in 10–20%, the main cause of maternal death; smokers and later gestation are at higher risk
Fetus	Congenital varicella syndrome (limb hypoplasia, skin scars, microcephaly, eye damage): about 0.4% before 13 weeks, 2% at 13–20 weeks; neonatal varicella if the mother's rash begins 5 days before to 2 days after delivery
Non-immune woman exposed	Varicella zoster immunoglobulin (VZIG) as soon as possible (best within 4 days, up to 10); or acyclovir days 7–14 after exposure
Chickenpox in pregnancy	Oral acyclovir 800 mg five times daily for 7 days if seen within 24 hours of the rash and from 20 weeks; intravenous acyclovir 10 mg/kg every 8 hours for pneumonia or severe disease
At delivery	Delay delivery to at least 7 days after the rash starts when possible; baby gets VZIG if the rash is within 5 days before or 2 days after delivery
Prevention	Live vaccine is not given in pregnancy: vaccinate non-immune women before pregnancy or after delivery, and avoid pregnancy for 4 weeks

🔵 PARVOVIRUS B19 (FIFTH DISEASE)

Topic	Details
Mother	Slapped-cheek rash, joint pain, or no symptoms; mild
Fetus	Red cell aplasia: anaemia, hydrops; loss in 5–10% (highest at 9–20 weeks); no malformations
Diagnosis	IgM and IgG, PCR; if infected, then fetal surveillance
Surveillance	Middle cerebral artery peak velocity (Doppler) and scan for hydrops every 1–2 weeks for 8–12 weeks; raised velocity (above 1.5 multiples of the median) means fetal anaemia
Treatment	Intrauterine blood transfusion for severe anaemia or hydrops (in a fetal medicine centre); good outcome after recovery
Prevention	Hand hygiene; no vaccine; exclusion from work is not required

STEP 3 · 'OTHER' INFECTIONS AND THE NEWBORN — screen, treat, and examine

🧬 OTHER CONGENITAL INFECTIONS

Infection	Key points
Syphilis	Screen every pregnant woman at the first visit; benzathine penicillin G; treat partner; see the dedicated sheet on reactive VDRL (Venereal Disease Research Laboratory test)
HIV	Test every pregnant woman; lifelong antiretroviral therapy and infant prophylaxis; see the dedicated sheet
Hepatitis B	Hepatitis B surface antigen (HBsAg) screening in pregnancy; vaccine at birth, within 24 hours (national schedule) and immunoglobulin for babies of HBsAg-positive mothers; tenofovir in late pregnancy for a high viral load
Zika virus	Mosquito-borne; microcephaly and brain damage; PCR in blood and urine; no treatment; avoid affected areas and use repellents and nets
Listeria	Unpasteurised dairy, soft cheese, deli and ready-to-eat foods; febrile illness, stillbirth, neonatal sepsis; blood cultures, amoxicillin or ampicillin
Others	Enteroviruses, lymphocytic choriomeningitis virus, malaria (see the dedicated sheet), Chagas disease

👶 THE NEWBORN WITH A SUSPECTED CONGENITAL INFECTION

Look for: small for dates, microcephaly, jaundice, petechiae or purpura, hepatosplenomegaly, cataract or white pupil, heart murmur, and failed hearing screen

Tests: blood count and platelets, liver tests, CMV PCR on urine or saliva, cranial ultrasound, eye and hearing examination, and pathogen-specific tests (IgM, PCR)

Placenta: send for histology and PCR

Treat according to the infection: valganciclovir (CMV), acyclovir (HSV), penicillin (syphilis), pyrimethamine and sulfadiazine for up to 12 months (toxoplasmosis)

Follow-up: hearing, vision, growth, and neurodevelopment; counsel the parents on recurrence risk and prevention in the next pregnancy

⚠️ COMMON PITFALLS

Ordering a TORCH panel for every miscarriage or small baby without a clinical reason

Treating a single positive IgM as proof of recent infection — IgM can persist or be false positive; check avidity and repeat

Amniocentesis too early — PCR is falsely negative if done before the right interval after maternal infection

Giving a live vaccine (rubella, varicella) in pregnancy, or advising pregnancy within 4 weeks of it

Missing herpes lesions or prodrome at admission in labour, or forgetting 36-week suppression

Forgetting the newborn: hearing screen, eye examination, and CMV test

Memory Aid

TORCHES

Seven rules for congenital infections.

T

Toxoplasma — spiramycin early, PCR on amniotic fluid, cook meat and wash hands

O

Other — syphilis, HIV, hepatitis B screened in all; varicella and parvovirus have set plans

R

Rubella — vaccinate before pregnancy, never during; no treatment once infected

C

CMV — hygiene, PCR at 21 weeks or later, hearing follow-up

H

Herpes — suppress from 36 weeks, caesarean for lesions or prodrome

E

Evaluate the newborn — scan, hearing, eyes, urine CMV PCR

S

Serial scans — growth, brain and Doppler; test for a reason, not by panel

Remember: prevent, test for a reason, time the test, treat what can be treated, and examine the baby.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. The Indian national immunisation schedule (measles–rubella vaccine at 9–12 and 16–24 months; hepatitis B birth dose within 24 hours) was read from a Government of India schedule page; no Government of India protocol for the other TORCH infections was found. The remainder is from memory of the Royal College of Obstetricians and Gynaecologists (RCOG), the American College of Obstetricians and Gynecologists (ACOG), the Society for Maternal-Fetal Medicine (SMFM), and the Centers for Disease Control and Prevention (CDC). Check current guidance before use; thresholds, intervals and regimens vary between guidelines — follow local protocol, obtain consent, and involve a senior obstetrician in any high-risk case.

OBESITY AND PREGNANCY

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Obesity in Pregnancy

Obesity is now common in pregnancy and raises the risk to mother and baby, but careful planning reduces most of the harm. This guide covers the risks, preconception and booking care, antenatal care, the birth plan, and postpartum care, using the WEIGHT approach.

🎯 AT A GLANCE — OBESITY IN PREGNANCY

Obesity (BMI of 30 or more; 25 or more by Indian consensus) raises the risk of gestational diabetes, pre-eclampsia, caesarean birth, wound infection, blood clots, haemorrhage, stillbirth, and birth defects

Care starts before pregnancy: weight loss, 5 mg of folic acid daily from at least 1 month before conception through the first trimester and stopping any anti-obesity drug

Screen early for diabetes (HbA1c in early pregnancy) and test every woman at 24–28 weeks even if the early result was normal

Gain 5–9 kg if BMI is 30 or more (US Institute of Medicine range); do not advise weight loss in pregnancy, and focus on diet and activity

Plan the birth early: anaesthetic review for BMI of 40 or more, early venous access and epidural, antibiotic cover and blood clot prevention

Obesity alone is not a reason to fear the birth: good planning prevents most complications, and respectful, non-judgemental care helps women return

🚨 WATCH FOR

Sudden breathlessness, chest pain, or a swollen painful leg — suspect a blood clot or pulmonary embolism; start treatment and refer

High blood pressure or protein in the urine — pre-eclampsia is more common; use a large cuff so the reading is correct

Reduced fetal movements — movements are harder to feel in obesity; assess with cardiotocography and ultrasound the same day

Loud snoring with daytime sleepiness or pauses in breathing — possible sleep apnoea; plan anaesthesia carefully

Fever or discharge from a caesarean wound — wound infection is common; examine and treat early

🗺️ THE PATHWAY AT A GLANCE

1 · Before pregnancyWeight loss, 5 mg folic acid, review medicines, and plan 12–18 months after weight-loss surgery

2 · BookingWeight, height, BMI, blood pressure with a large cuff, HbA1c, risk assessment for blood clots

3 · From 12 weeksAspirin 150 mg if indicated; healthy diet and daily activity

4 · 18–22 weeksDetailed anomaly scan; views may be limited and repeated

5 · 24–28 weeksGlucose tolerance test for all; growth scan after 32 weeks

6 · 34–37 weeks to birthWeekly checks (from 34 weeks in class III, 37 in class II); anaesthetic and birth plan

STEP 1 · KNOW THE RISKS — for the mother and the baby

⚠️ WHAT OBESITY CHANGES

Group	Risks
Mother, in pregnancy	Gestational and type 2 diabetes, high blood pressure and pre-eclampsia, blood clots, sleep apnoea, and miscarriage
Mother, in labour and after	Slower labour, caesarean birth, failed vaginal birth after caesarean, wound infection, postpartum haemorrhage, anaesthetic difficulty, and depression
Baby	Neural tube defects and some heart defects, large baby (macrosomia) and shoulder dystocia, stillbirth, preterm birth, low blood sugar, and later obesity
Why care is harder	Scans give poorer images, blood pressure cuffs and venous access are difficult, and fetal monitoring and movements are harder to assess
Indian cut-offs	Body fat is higher at a given BMI in Asian Indians, so risk starts earlier (overweight from 23, obesity from 25 in Indian consensus) (from memory; check the current Indian guidance)

STEP 2 · BEFORE PREGNANCY AND AT BOOKING — get the start right

📝 PRECONCEPTION AND FIRST VISIT

Topic	Advice
Weight loss before conception	Even a loss of 5–10% improves fertility and outcomes; help with diet, activity, and a weight management service
Folic acid	5 mg daily starting at least 1 month before conception and continuing through the first trimester (RCOG, for BMI of 30 or more)
Medicines	Anti-obesity drugs are contraindicated in pregnancy and should be stopped when pregnancy occurs or is planned; advise contraception while on them
After weight-loss surgery	Wait 12–18 months before conception; consultant-led care with nutritional checks and dietitian input
At booking	Measure weight and height, record BMI, use a large cuff for blood pressure, take a history of diabetes, blood pressure, sleep apnoea, and past clots
Early diabetes test	HbA1c is preferred in early pregnancy (accurate before 15 weeks); a value of 5.9% or more is linked to complications
Counsel without blame	Explain risks and the plan in a kind and practical way

STEP 3 · ANTENATAL CARE — nutrition, activity, tests, and prevention

🥗 DURING PREGNANCY

Topic	Advice
Weight gain	For BMI of 30 or more, about 5–9 kg in total (0.17–0.27 kg a week in the second and third trimesters); weight loss or very little gain should not be advised because small babies become more likely
Diet	Regular balanced meals, less sugar, refined cereals, and fried food; more vegetables, pulses, and fibre; no strict dieting
Activity	About 30 minutes of brisk walking on most days (about 150 minutes a week) unless there is a medical reason to stop
Diabetes screening	Oral glucose tolerance test at 24–28 weeks for every woman, even if the early HbA1c was normal
Aspirin	150 mg daily from 12 weeks until birth for a woman with more than one moderate risk factor (BMI 35 or more, first pregnancy, age over 40, family history, multiple pregnancy) (RCOG)
Vitamin D	Deficiency is common in obesity; supplementation is reasonable, though its benefit is uncertain
Blood clot risk	Assess at booking, if admitted, in labour, and after birth; BMI of 30 or more is a risk factor; give low molecular weight heparin when the score says so
Scans and surveillance	Detailed anomaly scan (views may be limited), growth scan after 32 weeks, and weekly fetal checks from 34 weeks in class III or 37 weeks in class II

STEP 4 · LABOUR AND BIRTH — plan early and prepare for difficulty

🏥 BIRTH PLAN

Topic	What to do
Anaesthetic review	Refer women with BMI of 40 or more in pregnancy; document the plan for labour and for caesarean
Place of birth	Class I and II obesity alone is not a reason to move to a specialist unit; class III and women with complications need a facility with senior obstetric, anaesthetic, and blood bank support
Timing	Obesity alone is not an indication for induction before 39 weeks; induction at term may reduce caesarean birth and should be discussed with the woman
In labour	Early intravenous access (a second cannula if BMI is 40 or more), early epidural, a larger bed and equipment, and expect a longer first stage
Large baby	Offer caesarean for estimated fetal weight of 4,500 g or more with diabetes, or 5,000 g or more without; suspected macrosomia alone is not a reason to induce
At caesarean	Antibiotic cover at a weight-adjusted dose (for example cefazolin 2 g, or 3 g at 120 kg or more; check local protocol), close subcutaneous fat if over 2 cm, and prevent blood clots
Third stage	Active management to reduce postpartum haemorrhage

STEP 5 · AFTER BIRTH — protect her future health

💛 POSTPARTUM CARE

Topic	Advice
Blood clots	Early walking and, after caesarean, low molecular weight heparin by weight for up to 6 weeks as the risk score advises
Breastfeeding	Start rates are lower and exclusive feeding is shorter; give specialist help and support
Mood	Depression risk rises with BMI; screen at follow-up visits
Contraception	Offer long-acting methods; combined pills add clot risk, and the patch may work less well at BMI of 30 or more
Diabetes follow-up	After gestational diabetes, test glucose at 6–12 weeks and then every year
Weight and next pregnancy	Support gradual weight loss and refer to weight management; counsel on preconception care
Child	Breastfeeding and healthy feeding reduce the risk of childhood obesity

⚠️ COMMON PITFALLS

Using a standard cuff and missing hypertension

Advising weight loss in pregnancy

Testing for diabetes only once or only at 28 weeks

Forgetting 5 mg folic acid and aspirin where indicated

Leaving the anaesthetic plan until she is in labour

Missing a blood clot risk assessment after caesarean

Blaming the woman instead of offering support

Memory Aid

WEIGHT

Six steps for obesity in pregnancy.

W

Weigh and measure early — BMI at booking and a large blood pressure cuff

E

Eat well and keep active — gain 5–9 kg if BMI is 30 or more; no dieting

I

Identify diabetes early — HbA1c early and a glucose test at 24–28 weeks

G

Give folic acid 5 mg and aspirin 150 mg — when indicated

H

Hospital plan — anaesthetic review, early IV access and epidural, antibiotic cover

T

Thromboprophylaxis and after-birth support — heparin as scored, breastfeeding, mood, contraception

Remember: plan early, check often, and care without blame.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Checked against public sources: a 2026 American Academy of Family Physicians editorial (weight-gain ranges, diabetes screening, delivery timing, anaesthesia, and postpartum points) and a news summary of the second edition of the Royal College of Obstetricians and Gynaecologists guideline (folic acid, aspirin, thromboprophylaxis, anaesthetic review, delivery, and bariatric surgery). The ACOG bulletin and Indian guidance could not be opened. The Indian BMI cut-offs, antibiotic doses, activity advice, and weight-loss figures are from memory: check current guidelines. Weight-gain targets come from US data and may not suit Asian women; thresholds, intervals and regimens vary between guidelines — follow local protocol and involve a senior obstetrician in any high-risk case.

The Anaemia in Pregnancy: Indian Perspective

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Anaemia in Pregnancy: Indian Perspective

Anaemia affects about half of pregnant women in India and is largely preventable and treatable. This guide covers the burden and causes, diagnosis, prevention under Anaemia Mukt Bharat, treatment by severity, and care at birth, using the HEMES approach.

🎯 AT A GLANCE — ANAEMIA IN PREGNANCY: INDIAN PERSPECTIVE

About one in two pregnant women in India is anaemic: 52.2% in the National Family Health Survey (NFHS-5, 2019–21), up from 50.4% in NFHS-4

Anaemia in pregnancy is a haemoglobin below 11 g/dL: mild 10–10.9, moderate 7–9.9, severe below 7 (WHO categories)

Iron deficiency is the commonest cause, but sickle cell disease, thalassaemia, malaria, worms, and vitamin B12 or folate deficiency are common in India and must be looked for

Anaemia Mukt Bharat gives every pregnant woman iron and folic acid for at least 180 days, tests haemoglobin, and treats by severity

Intravenous iron (iron sucrose or ferric carboxymaltose) can be a first-line treatment when anaemia is found late or tablets are not taken

Severe anaemia raises the risk of heart failure, haemorrhage, preterm birth, low birth weight, and maternal death, so find it early and treat it fully

🚨 ACT NOW IF

Haemoglobin below 7 g/dL — refer to a First Referral Unit or district hospital

Haemoglobin below 5 g/dL, or breathlessness at rest, rapid pulse, swelling, or signs of heart failure — emergency admission, oxygen, and careful blood transfusion

Severe anaemia after about 34–36 weeks — admit and plan delivery and transfusion in a facility with blood available

Anaemia with fever — test for malaria (rapid test) in endemic areas such as Odisha

Antepartum or postpartum bleeding in an anaemic woman — treat early; she tolerates blood loss poorly

🗺️ THE PATHWAY AT A GLANCE

1 · Before pregnancyAdolescent and pre-conception iron and folic acid; treat anaemia early

2 · Booking (first visit)Haemoglobin, blood group and Rh, sickle cell and haemoglobinopathy screening (HPLC), malaria test where needed

3 · From the 4th monthOne iron and folic acid tablet daily for at least 180 days; albendazole once after the first trimester; calcium

4 · Every visit and the 9th of each monthCheck haemoglobin and symptoms (Pradhan Mantri Surakshit Matritva Abhiyan)

5 · Treat by severityOral iron, intravenous iron, or transfusion; recheck haemoglobin

6 · Birth and afterFacility delivery, active management of the third stage, and iron and folic acid for 180 days after birth

STEP 1 · KNOW THE BURDEN AND CAUSES — why it is so common in India

📊 BURDEN AND CAUSES

Topic	Details
Nutritional causes	Low iron intake, a mostly cereal diet, and poor absorption (tea with meals, phytates); vitamin B12 deficiency is common in vegetarians; folate deficiency adds to it
Reproductive causes	Early marriage and pregnancy, short birth intervals, many pregnancies, and heavy periods
Infections and worms	Hookworm, malaria, chronic infections, and tuberculosis
Inherited causes	Sickle cell disease and trait, beta-thalassaemia trait, and other haemoglobin disorders (common in western Odisha and tribal populations)
Social causes	Poverty, low education, food customs that give women less food, poor access to care, and low use of tablets
Effects on mother	Tiredness, infection, pre-eclampsia, heart failure, postpartum haemorrhage, and death
Effects on baby	Preterm birth, low birth weight, poor growth, and later iron deficiency

STEP 2 · DIAGNOSE AND CLASSIFY — find the type and the cause

🔬 DIAGNOSIS

Test	What it tells
Haemoglobin at booking and each visit	A digital haemoglobinometer or a laboratory count (anaemia is below 11 g/dL); some guidelines use 10.5 in the second trimester
Blood count and smear	Small pale red cells (microcytic hypochromic) suggest iron deficiency or thalassaemia trait; large cells suggest vitamin B12 or folate deficiency; look for malaria parasites
Haemoglobin HPLC or electrophoresis	Finds sickle cell disease or trait and thalassaemia trait; test the partner when the woman is a carrier
Ferritin	Below 30 mcg/L suggests iron deficiency; use it when the cause is unclear or the response is poor
Stool and urine tests	Stool for ova (worms) and urine for infection
Malaria test	Rapid test or smear in fever or in endemic areas
Symptoms and signs	Pallor, tiredness, breathlessness, rapid pulse, swelling, and a systolic murmur; a pale tongue and nails are unreliable alone

Do not give iron blindly to a woman with thalassaemia or sickle cell disease; give iron only if iron deficiency is shown, and give folic acid 5 mg a day in sickle cell disease

STEP 3 · PREVENT — the Anaemia Mukt Bharat approach

💊 PREVENTION

Measure	Details
Iron and folic acid	One tablet daily (60 mg elemental iron and 500 mcg folic acid) from the 4th month (14–16 weeks) for at least 180 days and another 180 days after birth; take with water or vitamin C, away from tea, milk, and calcium by 2 hours
Deworming	Albendazole 400 mg once, after the first trimester
Calcium	Calcium supplementation from about 14 weeks as per national guidance; take at a different time from iron
Diet	Green leafy vegetables, legumes, jaggery, ragi, eggs, fish, and meat where eaten; fruit rich in vitamin C; cook in iron utensils
Fortified foods	Iron-fortified rice and salt in government programmes (supplementary nutrition and mid-day meal)
Behaviour change	ASHA home visits, group counselling, and family involvement
Six interventions (Anaemia Mukt Bharat)	Iron and folic acid supplementation, deworming, behaviour change, testing and treatment with digital methods, fortified foods, and action on non-nutritional causes (malaria, haemoglobin disorders, and fluorosis)

STEP 4 · TREAT BY SEVERITY — oral, intravenous, or transfusion

🩺 TREATMENT

Haemoglobin	What to do
Mild (10–10.9 g/dL)	Counsel, check the diet, give the daily iron and folic acid tablet, and recheck in 1 month
Moderate (7–9.9 g/dL)	Treatment doses of oral iron (the programme advises two tablets a day, about 120 mg elemental iron); treat worms and malaria; recheck in 1 month; a rise of less than 1 g/dL after 2 months means refer for another cause or for intravenous iron
Intravenous iron	Iron sucrose or ferric carboxymaltose can be a first-level treatment for anaemia found late in pregnancy, poor tolerance, or poor adherence; give from the second trimester, in a facility with resuscitation equipment, after a test dose or observation; the total dose is calculated from the weight and the haemoglobin deficit
Severe (below 7 g/dL)	Refer to a First Referral Unit or district hospital; find the cause; intravenous iron if the woman is stable
Blood transfusion	For haemoglobin below 5, heart failure, heavy bleeding, or severe anaemia close to term; give packed red cells slowly with a diuretic if needed, and monitor
Folic acid and vitamin B12	Folic acid 5 mg a day and vitamin B12 injections or tablets when deficiency is shown
Response	Haemoglobin should rise about 1 g/dL in 2–4 weeks; if not, review adherence, cause, and absorption

Avoid intravenous iron in the first trimester and in anyone with a past severe reaction; iron tablets for severe anaemia close to term are too slow

STEP 5 · BIRTH AND AFTER — protect her from haemorrhage

🏥 DELIVERY AND POSTPARTUM CARE

Topic	Advice
Place of birth	Facility delivery with blood available when haemoglobin is below 8–9; plan transfer early
In labour	Keep the woman rested, give oxygen if breathless, avoid fluid overload, and have blood cross-matched
Third stage	Active management (oxytocin, controlled cord traction, uterine massage) and treat any bleeding without delay
After birth	Check haemoglobin at 24–48 hours or before discharge; give iron and folic acid for 180 days; intravenous iron if low and not improving
Family planning	Advise a gap of at least 2 years and offer contraception
Newborn	Delayed cord clamping for 1–3 minutes; exclusive breastfeeding; iron supplements as per the programme

⚠️ COMMON PITFALLS

Not testing haemoglobin at every visit or relying on pallor

Giving the same tablets to every woman for months without a recheck or a search for another cause

Missing sickle cell disease or thalassaemia and giving iron without proof of deficiency

Waiting for tablets to work in late pregnancy instead of using intravenous iron or transfusion

Poor counselling on tablets: side effects, taking them with tea or calcium, and stopping early

Forgetting malaria, worms, and vitamin B12

Leaving an anaemic woman to deliver at home or without blood available

Memory Aid

HEMES

Five steps for anaemia in pregnancy.

H

Haemoglobin at every visit — test at booking and recheck; below 11 g/dL is anaemia

E

Enrol on iron and folic acid — one tablet daily from 14–16 weeks for 180 days, plus albendazole

M

Manage by severity — oral iron, intravenous iron, or transfusion; refer below 7 g/dL

E

Evaluate the cause — sickle cell, thalassaemia, malaria, worms, vitamin B12 and folate

S

Safe delivery and follow-on — facility birth with blood, active third stage, 180 days of iron after birth

Remember: find it early, treat it fully, and prepare for bleeding before the birth.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Checked against public sources: the NFHS-5 and NFHS-4 prevalence figures (a data article), the WHO haemoglobin categories, the Anaemia Mukt Bharat statements that at least 180 iron and folic acid tablets are given and that intravenous iron sucrose or ferric carboxymaltose may be a first-level treatment, and referral of haemoglobin below 7 g/dL (a trial protocol that cites the Ministry guidance). The Ministry of Health and Family Welfare guideline itself could not be opened. Tablet strength, deworming, calcium, intravenous iron conditions, transfusion indications, and delivery advice are from memory of Indian and international guidance: check the current Anaemia Mukt Bharat guideline before use. Doses and thresholds must be set by the treating obstetrician; thresholds, intervals and regimens vary between guidelines — follow local protocol and involve a senior obstetrician in any high-risk case.

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Genetic Screening and NIPT

Genetic screening gives a chance, not a diagnosis, and non-invasive prenatal testing (NIPT) is its most accurate form for common chromosome conditions. This guide covers carrier screening, screening test options, how NIPT works, what to do with the result, and counselling and the law, using the GENES approach.

🎯 AT A GLANCE — GENETIC SCREENING AND NIPT

Genetic screening estimates the chance of a condition; diagnostic testing (chorionic villus sampling or amniocentesis) confirms it

Non-invasive prenatal testing (NIPT) measures cell-free DNA in the mother’s blood; it can be done from 10 weeks and carries no risk of miscarriage

For Down syndrome it detects over 99% with a false-positive rate under 0.1–0.5%, better than the combined test or quadruple test

NIPT is still a screening test: a positive result needs confirmation by a diagnostic test before any decision about the pregnancy

In western Odisha, screening for sickle cell disease and thalassaemia at booking, with partner testing, is the most useful genetic screening and should never be missed

NIPT is a screening test, so say “chance”, not “diagnosis”, and keep fetal sex undisclosed as the PCPNDT Act requires

🚨 DO NOT MISS

High-chance NIPT result — never advise termination on NIPT alone; offer chorionic villus sampling or amniocentesis, with a genetic counsellor

No result (low fetal fraction) — do not simply reassure; it can be linked to trisomy 13 or 18 or triploidy, so counsel and consider a diagnostic test

Abnormal anomaly scan or thick nuchal translucency (3.5 mm or more) with a low-chance NIPT — offer a diagnostic test with microarray

Both parents carriers of sickle cell, beta-thalassaemia, or the same condition — offer early prenatal diagnosis by chorionic villus sampling at 11–13 weeks

Any request to disclose or hint at fetal sex — refuse; it is prohibited by the PCPNDT Act

🗺️ THE PATHWAY AT A GLANCE

1 · Before or at bookingFamily history, consanguinity, previous affected child; carrier screening (HPLC for haemoglobinopathies) for both partners

2 · CounsellingExplain what screening can and cannot tell; written consent

3 · 10–14 weeksNIPT (from 10 weeks), or combined test (nuchal translucency, PAPP-A, free beta-hCG at 11–13+6 weeks)

4 · 15–20 weeksQuadruple test if first-trimester screening was missed

5 · 18–22 weeksDetailed anomaly scan for every woman

6 · High chanceChorionic villus sampling (11–14 weeks) or amniocentesis (from 15 weeks), then genetic counselling

STEP 1 · UNDERSTAND GENETIC SCREENING — what is offered and when

🧬 TYPES OF GENETIC SCREENING

Type	What it does
Carrier screening	Finds healthy people who carry a gene change; in India, HPLC for sickle cell and beta-thalassaemia is the key test, and the partner should be tested if the woman is a carrier
Aneuploidy screening	Estimates the chance of trisomy 21, 18, or 13 (combined test, quadruple test, or NIPT)
Structural screening	Anomaly scan at 18–22 weeks finds many major anomalies; it is offered to all
Diagnostic testing	Chorionic villus sampling or amniocentesis with karyotype or chromosomal microarray gives a definite answer for chromosome conditions
Who should be offered	Every pregnant woman should be offered screening; women with higher risk (age 35 or over, previous affected pregnancy, abnormal scan, family history) are offered diagnostic testing directly

STEP 2 · COMPARE THE SCREENING TESTS — choose with the woman

🧪 SCREENING OPTIONS FOR DOWN SYNDROME

Test	Timing	Approximate detection for trisomy 21
Combined first-trimester test	11–13+6 weeks	About 85–90% at a 5% false-positive rate; nuchal translucency, PAPP-A, free beta-hCG, and maternal age
Quadruple test	15–20 weeks	About 80% at a 5% false-positive rate; AFP, hCG, uE3, inhibin A
NIPT (cell-free DNA)	From 10 weeks	Over 99% with a false-positive rate under 0.1–0.5%
Contingent approach	Combined test first, NIPT only for the intermediate-risk group	Lower cost, with most of the benefit of NIPT
Practical point	Where NIPT is unaffordable	The combined test with a good nuchal translucency scan remains a sound choice

Detection rates are from studies of single pregnancies and vary with the laboratory; read the performance stated in your laboratory’s report

STEP 3 · KNOW NIPT IN DETAIL — how it works and what it can and cannot do

🩸 NON-INVASIVE PRENATAL TESTING

Topic	Details
How it works	Cell-free DNA in the mother’s blood comes mainly from the placenta (fetal fraction about 4–10% or more, from 10 weeks); the laboratory counts chromosome fragments to find extra or missing copies
Sample	One blood tube from the mother; no fasting; result in about 1–2 weeks
What it screens	Trisomy 21, 18, and 13; some laboratories add sex chromosome conditions and selected microdeletions, which are less reliable
What it does not find	Single gene conditions, structural anomalies, neural tube defects, most small deletions, and mosaicism that is confined to the placenta
Positive predictive value	Depends on how common the condition is: for trisomy 21 it is high in older women, but lower in young women, and lower again for trisomy 13 and 18 and sex chromosome conditions (about 50–60% at age 25 and over 90% at age 40 for Down syndrome; approximate)
Causes of a false result	Confined placental mosaicism, a vanished twin, maternal chromosome change, maternal cancer, organ transplant, recent blood transfusion, or low fetal fraction
Twins and IVF	Can be used in twins for trisomy 21 with slightly lower accuracy; not suitable after donor egg from a different woman without advice, or with a vanished twin
No result	Occurs in about 1–5%; more often with higher maternal weight or early sampling; repeat once if the fetal fraction is low, and offer other testing if it fails again

Scientific bodies (ACOG, ACMG) now support offering NIPT to all pregnant women, but a screening test must always be paired with counselling and diagnostic confirmation (recommendations differ between countries)

STEP 4 · ACT ON THE RESULT — what to do next

📋 RESULT AND ACTION

Result	What to do
Low chance	Reassure that the chance is very low but not zero; continue the anomaly scan and routine care
High chance	Counsel the same day, offer chorionic villus sampling (11–14 weeks) or amniocentesis (from 15 weeks); the woman decides whether to proceed
No result	Review dating and weight, repeat once, and offer a scan review or diagnostic test
Discordant findings	Normal NIPT with abnormal scan means diagnostic testing with microarray
Diagnostic procedure	Karyotype and, where available, chromosomal microarray; fetal loss risk is low (about 0.1–0.3% or less), done by an experienced operator under ultrasound
After a procedure	Anti-D immunoglobulin to Rh-negative women; advise rest for the day and warning signs (bleeding, fluid loss, fever)
Confirmed abnormality	Refer to a fetal medicine or genetic team; discuss outcome, options, and support

STEP 5 · COUNSEL, CONSENT AND THE LAW — do it properly

💬 COUNSELLING AND LEGAL POINTS

Topic	Advice
Counselling before testing	Explain what is tested and what is not; that the result is a chance; the possible results; cost; and the right to decline
Counselling style	Non-directive, in a language she understands, and with her partner if she wishes
Consent	Written, informed consent before NIPT and before any invasive test
PCPNDT Act	Sex determination and disclosure are prohibited; testing should be done in registered centres and laboratories, with the required forms; laboratories must not report fetal sex (check the current rules and your laboratory’s policy)
MTP Act	Termination is lawful within the limits of the Medical Termination of Pregnancy Act (as amended in 2021); beyond the usual limit, a medical board decides for substantial fetal abnormality (confirm the current provisions)
Privacy	Keep results confidential; share only with the woman unless she agrees
Support	Offer follow-up counselling, and a team for care of a child with Down syndrome if she continues

⚠️ COMMON PITFALLS

Calling NIPT a diagnostic test and advising termination on it alone

Skipping the anomaly scan because the NIPT was normal

Missing carrier screening for sickle cell and thalassaemia and not testing the partner

Sending blood too early (before 10 weeks) or without confirming dates

Reading a sex chromosome result without counselling or disclosing fetal sex

Offering the tests without pre-test counselling or without consent

Forgetting anti-D after a diagnostic procedure in an Rh-negative woman

Memory Aid

GENES

Five steps for genetic screening and NIPT.

G

Gather the history — family history, consanguinity, carrier screening for both partners

E

Explain — screening gives a chance; diagnosis gives an answer

N

NIPT or combined test — NIPT from 10 weeks; nuchal translucency at 11–13+6 weeks

E

Establish the diagnosis — chorionic villus sampling or amniocentesis if the chance is high

S

Support and stay within the law — non-directive counselling, PCPNDT and MTP Acts

Remember: NIPT screens, it does not diagnose; confirm before acting, and never disclose fetal sex.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary drawn from memory of guidance from the American College of Obstetricians and Gynecologists (ACOG), the American College of Medical Genetics and Genomics (ACMG), the International Society for Prenatal Diagnosis, the Fetal Medicine Foundation, and Indian law and practice; no source was read for this sheet. Performance figures, predictive values, and timing are approximate and vary between laboratories and studies. The PCPNDT Act and MTP Act points are from memory: check the current Acts, rules, and your laboratory’s policy. Test choice and result handling must be set by the senior obstetrician with a genetic counsellor; thresholds, intervals and regimens vary between guidelines — follow local protocol and involve a senior obstetrician in any high-risk case.