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.