What are the guidelines for managing TORCH (Toxoplasmosis, Other, Rubella, Cytomegalovirus, Herpes) infection in pregnancy?

Guidelines for the Management of TORCH Infections in Pregnancy

Pregnant women should be screened for TORCH infections based on risk factors, with targeted interventions for each specific pathogen to prevent maternal-fetal transmission and reduce morbidity and mortality. 1

General Screening Approach

• Selective screening is recommended rather than universal screening for most TORCH pathogens
• Screen women at higher risk for primary infections during pregnancy
• Routine universal screening is not recommended for low-risk pregnant women 2

Management of Specific TORCH Infections

Toxoplasmosis

Screening and Diagnosis

• Screen pregnant women with risk factors for primary Toxoplasma gondii infection 2
• Suspected recent infection should be confirmed at a toxoplasmosis reference laboratory 2
• If acute infection is suspected, repeat testing within 2-3 weeks 2

Prevention

• Counsel pregnant women on preventive measures:
  • Cook meat to appropriate temperatures (at least 63°C/145°F for whole cuts, 71°C/160°F for ground meat) 3
  • Freeze meat at -20°C/-4°F for at least 48 hours 3
  • Wash hands after handling raw meat 3
  • Avoid contact with cat feces; if unavoidable, wear gloves 3
  • Change cat litter boxes daily (preferably by someone else) 3
  • Wash hands after gardening or contact with soil 3
  • Avoid drinking unpasteurized goat milk 3

Treatment

• If maternal infection confirmed but fetal infection unknown, offer spiramycin for fetal prophylaxis 2
• If fetal infection confirmed, offer combination of pyrimethamine, sulfadiazine, and folinic acid 2
• For immunocompromised or HIV-positive women, screening is recommended due to risk of reactivation 2

Cytomegalovirus (CMV)

Screening and Diagnosis

• For suspected primary CMV infection, obtain CMV IgG and IgM titers with IgG avidity testing 1
• Consider amniocentesis for confirmatory testing if results suggest primary infection 1
• Amniocentesis with PCR for CMV DNA is most sensitive when performed after 21 weeks gestation and >6 weeks from maternal infection 1

Monitoring

• Schedule regular ultrasound examinations to monitor for signs of fetal infection 1
• Recommend third-trimester ultrasound for reassessment if echogenic bowel is present 1

Rubella

Prevention

• Ensure rubella immunity before pregnancy through vaccination 1
• For pregnant patients with positive rubella titers, counsel regarding risks to fetus based on gestational age at infection 1

Herpes Simplex Virus (HSV)

Treatment

• For primary or recurrent genital herpes:
  • Acyclovir 200 mg orally 5 times daily for 5 days, or
  • Acyclovir 400 mg orally 3 times daily for 5 days, or
  • Acyclovir 800 mg orally 2 times daily for 5 days 1
• For severe disease requiring hospitalization: acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days 1
• For frequent recurrences (≥6 per year): suppressive therapy with acyclovir 400 mg orally twice daily 1

Special Considerations

Amniocentesis for Diagnosis

• Offer amniocentesis to identify Toxoplasma gondii in amniotic fluid by PCR if:
  • Maternal primary infection is diagnosed
  • Serologic testing cannot confirm or exclude acute infection
  • Abnormal ultrasound findings are present 2
• Do not perform amniocentesis before 18 weeks' gestation or less than 4 weeks after suspected acute maternal infection 2

Immunocompromised Patients

• More intensive monitoring may be required, particularly for CMV and HSV reactivation 1
• Consider prophylaxis for HSV/VZV in patients with history of recurrent infections or additional risk factors 1

Preconception Care

• Screen for TORCH infections as part of preconception care 1
• Update immunizations before pregnancy when possible (hepatitis B, rubella, varicella) 1
• Women diagnosed with acute Toxoplasma gondii infection should wait 6 months before attempting pregnancy 2

Common Pitfalls to Avoid

• Relying solely on patient-reported risk factors for toxoplasmosis screening (may miss >50% of cases) 3
• Performing amniocentesis too early (before 18 weeks or less than 4 weeks after suspected infection) 2
• Failing to consult with specialists for confirmed or suspected acute Toxoplasma infection during pregnancy 2
• Overlooking the need for partner evaluation and treatment in cases of sexually transmitted infections like HSV 1
• Neglecting to provide preventive education to women planning pregnancy 2

By following these guidelines, healthcare providers can effectively manage TORCH infections during pregnancy, minimizing the risk of congenital infections and their potentially severe consequences.