TORCH Infections: Screening and Management in Pregnancy
Overview
TORCH infections encompass Toxoplasmosis, Other infections (syphilis, varicella-zoster, parvovirus B19, HIV), Rubella, Cytomegalovirus, and Herpes simplex virus—all capable of causing severe fetal morbidity including microcephaly, hearing loss, ocular damage, and CNS abnormalities. 1, 2, 3
Mandatory Universal Screening (All Pregnant Women)
Syphilis
- Perform serologic testing at the first prenatal visit for all pregnant women. 4
- Repeat in third trimester and at delivery for high-risk patients. 4
- No infant should be discharged without maternal syphilis status documented at least once during pregnancy and preferably at delivery. 4
- Test any woman delivering a stillborn infant after 20 weeks gestation. 4
Hepatitis B
- Test all pregnant women for HBsAg at the first prenatal visit. 4
- Repeat late in pregnancy for HBsAg-negative women at high risk (injection drug users, concurrent STDs). 4
- For HBV DNA >200,000 IU/ml or HBeAg-positive women, start tenofovir disoproxil fumarate at 24-28 weeks and continue until 12 weeks postpartum. 5
- Continue tenofovir throughout pregnancy for women with advanced fibrosis/cirrhosis. 5
HIV
- Offer HIV testing to all pregnant women at the first prenatal visit. 4
- Some authorities recommend universal testing, particularly in high HIV seroprevalence areas. 4
Risk-Based and Targeted Screening
Gonorrhea
- Test at first prenatal visit for women at risk or living in high-prevalence areas. 4
- Repeat during third trimester for those at continued risk. 4
- All pregnant women under 25 years should be screened for gonorrhea, as reinfection risk is high. 6
Chlamydia
- Screen in third trimester for women aged <25 years or those with new/multiple partners to prevent neonatal transmission. 4, 6
- First trimester screening may prevent adverse pregnancy effects, though evidence is minimal. 4
Toxoplasmosis
- No universal screening is currently recommended in the United States, but selective screening only in high-risk or symptomatic women will miss up to 50% of infected pregnant women. 4
- Any positive IgM result from commercial laboratories must be confirmed at a reference laboratory before treatment decisions—false positives are extremely common. 4, 5, 7
- For suspected acute infection based on symptoms or ultrasound abnormalities, send samples directly to a reference laboratory to avoid delays. 4
Herpes Simplex Virus
- Routine serial cultures are not indicated for women with recurrent genital herpes history in the absence of third trimester lesions. 4
- Cultures at delivery may guide neonatal management. 4
- Prophylactic cesarean section is not indicated without active genital lesions at delivery. 4
Treatment Algorithms by Pathogen
Toxoplasmosis (Confirmed or Suspected Acute Infection)
Before 18 weeks gestation:
- Start spiramycin 1g (3 million IU) orally three times daily immediately, even before confirmatory testing returns. 5, 7
- Early treatment reduces transmission risk by 52%. 7
At or after 18 weeks gestation OR if fetal infection confirmed:
- Switch to pyrimethamine + sulfadiazine + folinic acid. 5, 7
- Continue monthly fetal ultrasounds until delivery monitoring for ventriculomegaly, hydrocephalus, intracranial calcifications, hepatosplenomegaly, or growth restriction. 5, 7
Critical timing: First trimester infection causes most severe disease including miscarriage, while third trimester transmission risk reaches 71% but with milder disease. 7
Herpes Simplex Virus
- For primary HSV or severe disease during pregnancy, use acyclovir—decades of safety data show no increased birth defect risk. 5
- Offer antiviral prophylaxis in third trimester to women with genital herpes history to reduce recurrence at delivery. 5
Gonorrhea and Chlamydia
- Treat empirically with ceftriaxone 500mg IM plus azithromycin 1g orally as single dose for pregnant women with cervical motion tenderness and mucopurulent discharge, regardless of test results. 6
- Treat all sexual partners from previous 60 days, even if asymptomatic. 6
- Delaying treatment in pregnant patients with clinical PID findings can cause preterm labor and premature rupture of membranes. 6
Primary Prevention Education
Toxoplasmosis Prevention for Seronegative Women
- Cook meat to 63°C (145°F) for whole cuts, 71°C (160°F) for ground meat, 74°C (165°F) for poultry—use food thermometer. 4
- Freeze meat at -20°C (-4°F) for at least 48 hours. 4
- Wear gloves when handling raw meat; avoid contact with mucous membranes. 4
- Avoid unpasteurized goat milk, raw oysters/clams/mussels, and untreated water. 4
- Thoroughly wash kitchen surfaces and utensils after raw meat contact. 4
Critical Neonatal Evaluation
For all infants born to TORCH-positive mothers:
- Serologic testing at reference laboratories (not commercial labs). 5
- Ophthalmologic examination. 5
- Neurologic assessment. 5
- Hearing evaluation. 5
For congenital toxoplasmosis specifically:
- Children treated before 2.5 months of age for 12 months duration need audiometric follow-up at 24-30 months. 4
- Untreated, partially treated, or delayed treatment cases require annual audiologic monitoring until self-reporting capability. 4
Common Pitfalls to Avoid
- Never rely on commercial laboratory IgM results alone for toxoplasmosis—false positives lead to unnecessary interventions and treatment delays. 4, 5, 7
- Never delay spiramycin initiation while awaiting confirmatory testing if acute toxoplasmosis is clinically suspected—early treatment is critical for reducing transmission. 5, 7
- Screening only symptomatic or high-risk pregnant women for toxoplasmosis misses 50% of infected women at risk of transmission. 4
- Untreated partners cause reinfection in up to 20% of cases—ensure partner treatment verification. 6
- Postnatally-treated children (whose mothers received no antepartum treatment) have significant adverse outcomes: 85% vision impairment, 36% eye disease recurrences, 27% abnormal cognition, 16% IQ decrease >15 points. 4