What is the treatment approach for TORCH (Toxoplasmosis, Rubella, Cytomegalovirus, Herpes simplex virus) positive patients during pregnancy?

Treatment for TORCH Positive Patients in Pregnancy

For pregnant women with confirmed TORCH infections, treatment is pathogen-specific: spiramycin for toxoplasmosis before 18 weeks gestation (switching to pyrimethamine/sulfadiazine/folinic acid after 18 weeks or if fetal infection confirmed), acyclovir for herpes simplex virus, and supportive care for rubella and CMV as no effective antiviral treatments exist for these during pregnancy. 1, 2

Toxoplasmosis Management

Timing-Based Treatment Algorithm

• Before 18 weeks gestation: Initiate spiramycin 1g (or 3 million IU) orally three times daily immediately upon suspected or confirmed maternal infection 3, 1, 2

• At or after 18 weeks gestation: Switch to combination therapy with pyrimethamine plus sulfadiazine plus folinic acid 3, 1, 2

• When fetal infection is confirmed (positive amniotic fluid PCR for T. gondii): Use pyrimethamine/sulfadiazine/folinic acid regardless of gestational age 3, 1

• When abnormal fetal ultrasound findings suggest congenital toxoplasmosis (intracranial calcifications, microcephaly, hydrocephalus): Initiate pyrimethamine/sulfadiazine/folinic acid 3, 1, 4

Critical Diagnostic Considerations

• All suspected acute toxoplasmosis cases must be confirmed at a toxoplasmosis reference laboratory (PAMF-TSL or NCCCT) before intervention, as false-positive IgM results at commercial laboratories are common 3, 4

• If acute infection is suspected, start spiramycin immediately without waiting for confirmatory testing, then adjust based on results 4

• Amniocentesis for T. gondii PCR should be performed at ≥18 weeks gestation and ≥4 weeks after suspected maternal infection to minimize false-negative results 3, 4

Special Populations

• HIV-infected pregnant women: TMP-SMZ can be administered for toxoplasmosis prophylaxis, though pyrimethamine-containing regimens may be deferred until after pregnancy due to teratogenicity concerns balanced against low disease incidence 3, 1, 2

• Immunocompetent women with chronic toxoplasmosis: No treatment is necessary unless severely immunocompromised 3, 4

Herpes Simplex Virus Management

• Primary HSV infection or severe disease: Administer acyclovir during pregnancy, which has no increased risk for major birth defects based on decades of safety data 1, 5

• Women with history of genital herpes: Offer antiviral prophylaxis in the third trimester to reduce recurrence risk at delivery 1

• The risk of neonatal HSV infection is 30-50% for genital HSV acquired in the third trimester versus approximately 1% for early pregnancy acquisition 5

Cytomegalovirus Management

• No effective antiviral treatment is currently recommended during pregnancy for CMV 6

• Focus on serial ultrasound monitoring to detect fetal abnormalities (intracranial calcifications, microcephaly, hepatosplenomegaly) 4

• Amniocentesis with PCR may be considered if ultrasound findings suggest congenital infection 4

Rubella Management

• No specific antiviral treatment exists for rubella during pregnancy 6

• Management is supportive with close fetal monitoring via ultrasound 6

• Prevention through pre-pregnancy vaccination is the primary strategy 1

Hepatitis B Management (Often Included in Expanded TORCH)

• Pregnant women with HBV DNA >200,000 IU/ml or HBeAg-positive: Start tenofovir disoproxil fumarate at 24-28 weeks gestation and continue until 12 weeks postpartum 3

• Women with chronic HBV and advanced fibrosis/cirrhosis: Continue tenofovir throughout pregnancy 3

• Breastfeeding while on tenofovir is safe and should not be discouraged 3

• Hepatitis B immunoglobulin administration during pregnancy is not recommended as it does not reduce mother-to-child transmission 3

Critical Monitoring Requirements

• Monthly fetal ultrasounds are essential for all confirmed TORCH infections to detect developing abnormalities 3, 1

• Neonatal evaluation is mandatory for all infants born to TORCH-positive mothers, including serologic testing at reference laboratories, ophthalmologic examination, neurologic assessment, and hearing evaluation 3, 1

• For toxoplasmosis specifically, infant testing must include Toxoplasma IgG dye test, IgM ISAGA, and IgA ELISA at reference laboratories, as commercial laboratory IgM ELISA has insufficient sensitivity 3

Common Pitfalls to Avoid

• Never rely on commercial laboratory IgM results alone for toxoplasmosis diagnosis—false positives are frequent and lead to unnecessary interventions 3

• Do not perform amniocentesis before 18 weeks gestation or within 4 weeks of suspected maternal toxoplasmosis infection due to high false-negative rates 3, 4

• Avoid delaying spiramycin initiation while awaiting confirmatory testing if acute toxoplasmosis is clinically suspected—early treatment reduces transmission risk 3, 4

• Do not assume chronic toxoplasmosis requires treatment in immunocompetent women—reactivation risk during pregnancy is extremely low 3, 4