Treatment Approach for TORCH Infections in Recurrent Abortions
For pregnant women with active toxoplasmosis, treatment depends on timing of infection, with spiramycin used before 18 weeks gestation and pyrimethamine/sulfadiazine/folinic acid used after 18 weeks or when fetal infection is confirmed. 1
Toxoplasmosis Management
Diagnosis
- Serologic testing for Toxoplasma IgG antibody should be performed in women with recurrent abortions to determine infection status 1
- Pregnant women who have evidence of primary toxoplasmic infection or active toxoplasmosis should be evaluated in consultation with appropriate specialists 1, 2
- Infants born to women with serologic evidence of toxoplasmosis should be evaluated for congenital toxoplasmosis 2, 1
Treatment
- Spiramycin (1g or 3 million IU orally three times daily) is the first-line treatment for suspected or confirmed infection before 18 weeks gestation 1
- Pyrimethamine plus sulfadiazine plus folinic acid is recommended for:
- Suspected or confirmed infection at or after 18 weeks gestation
- When amniotic fluid PCR is positive for T. gondii
- When abnormal fetal ultrasound findings suggestive of congenital toxoplasmosis are present 1
- For HIV-infected pregnant women, TMP-SMZ can be administered for prophylaxis against toxoplasmosis 2, 1
- Because of the low incidence of toxoplasmosis encephalitis during pregnancy and the possible risk associated with pyrimethamine treatment, chemoprophylaxis with pyrimethamine-containing regimens can reasonably be deferred until after pregnancy in some cases 2
Rubella Management
- Rubella infection during pregnancy can cause serious fetal consequences including congenital malformations 3, 4
- There is no specific antiviral treatment for rubella infection during pregnancy 5
- Prevention through vaccination before pregnancy is the most effective approach 5, 6
- Women with confirmed rubella infection during pregnancy should be monitored with serial ultrasounds to detect potential fetal abnormalities 6
Cytomegalovirus (CMV) Management
- CMV has the highest infection rate among TORCH pathogens in many populations 7
- Currently, no approved specific antiviral therapy exists for pregnant women with primary CMV infection 6
- Hyperimmune globulin has been studied but with inconsistent results 6
- Serial ultrasound monitoring is recommended to detect fetal abnormalities 3
Herpes Simplex Virus (HSV) Management
- Antiviral therapy during pregnancy is recommended for women with primary HSV infection or severe herpes infection 2
- Acyclovir appears to have no increased risk for major birth defects after prenatal exposure 2
- For women with history of genital herpes, antiviral prophylaxis in the third trimester can reduce the risk of recurrence at delivery 2
General Considerations
- TORCH infections are major contributors to prenatal, perinatal, and postnatal morbidity and mortality 6, 4
- The total infection rate of TORCH pathogens can be as high as 6.06% in pregnant women, with CMV having the highest prevalence in many populations 4
- Women with adverse pregnancy history have higher rates of TORCH infections 4
- Early recognition through prenatal screening is key to management 6
- Prevention strategies should be emphasized, including hand hygiene, avoiding undercooked meat, and vaccination when available 1, 5
Monitoring and Follow-up
- Regular ultrasound monitoring is essential for pregnant women with confirmed TORCH infections 1, 6
- Amniocentesis with PCR testing may be considered to determine fetal infection status, particularly for toxoplasmosis 1
- Neonatal evaluation is crucial for infants born to mothers with TORCH infections 2, 1