University of Michigan Health System Womens, Childrens and Behavioral Health Nursing Services Womens Hospital Birth Center

Triage

TORCH Infections
Guideline # WHBC-03-094 Date of Origin: March 2003 Date of Last Review: March 2007 Date of Next Review: March 2009 I. STATEMENT OF PURPOSE To provide Triage guidelines for the management and health education of pregnant women with TORCH exposures and infections. INTRODUCTION A. TORCH is an acronym for a group of five infectious diseases: Toxoplasmosis Other (Hepatitis B) Rubella (German measles) Cytomegalovirus (CMV) Herpes Simplex Virus (HSV) B. Each disease may be teratogenic 1. Each crosses the placenta 2. Each may adversely affect the developing fetus 3. The effect of each varies, depending on developmental stage at time of exposure.

II.

III.

DESCRIPTION, ASSESSMENT, INTERVENTIONS AND HEALTH EDUCATION A. Toxoplasmosis 1. Description Caused by the protozoa Toxoplasma gondii. More than 60 million people in the United States are infected, but very few have symptoms. Incidence of congenital Toxoplasmosis is 1 in 1000-8000 in U.S. 2. Transmission a. Ingestion of Toxoplasma eggs from soil b. Ingestion of raw or partially cooked meat, especially pork, lamb or venison c. Contact with infected cat feces. d. Transplacentally (if new infection occurs during pregnancy) e. Through organ transplant or transfusion- very rare f. Women with compromised immune systems are at risk for reactivation of a previous infection. 3. Physical Findings a. Flu-like symptoms b. Swollen lymph glands (posterior cervical) c. Muscle aches and pains lasting days to weeks. 4. Diagnostic findings serologic antibody testing, ELISA

5. Potential maternal and neonatal effects a. Maternal effects- 90% of women are asymptomatic. Increased risk for miscarriage or premature labor and delivery b. Neonatal effects High risk gestational age is 10-24 weeks. Sequelae can be neurological, opthalmological, and cognitive. IUGR, hydro- and microencephaly. Severity varies, with earlier exposure usually more severe. 6. Interventions a. Pregnant women with new infection and immuno-compromised women may be candidates for treatment with pyrimethamine and sulfadiazine. 7. Health Education a. Women planning a pregnancy may be tested before pregnancy. If the test is positive there is no need to worry about passing a new infection to the baby. Women who test negative can take precautions. b. Wear gloves and wash hands carefully after handling soil. c. Cook meat thoroughly (until no longer pink inside and juices run clear) d. Wash hands and any equipment or surfaces that raw meat contacts thoroughly with warm water and soap. e. Keep your cat inside and do not feed raw meat. Avoid handling stray cats or new kittens that may have eaten raw meat. Have someone else change the litter box. f. References and Exhibits AWHONN , 2ND edition Table 22-1, TORCH Disease CDC Fact Sheet- Toxoplasmosis B. Hepatitis B (HBV) 1. Description Hepatitis B (HBV) is a serious viral disease responsible for 4000 to 5000 deaths each year in the U.S. due to cirrhosis and liver cancer. Acute infection occurs in 1 to 2 pregnancies per 1000. Estimated that 300 million people worldwide are chronically infected with HBV. 2. Transmission a. Incubation usually 50-180 days b. Mode of transmission - Sexual contact - Perinatal - Transplacental - Contact with blood, stool and saliva - Shared razors, toothbrushes, towels, and other personal items. c. At risk populations a. Southeast Asians, Eskimos, Africans, Chinese, Flipinos and Indonesians b. Homosexuals c. IV drug users d. Hemophiliacs e. Transfusion or organ recipients f. Hemodialysis patients

3. 4. 5.

6.

7.

8.

g. Household contacts of infected persons h. Persons with multiple and/or infected sexual partners i. Persons diagnosed with a STD j. Healthcare or safety workers Physical Findings Low-grade fever, nausea, anorexia, jaundice, hepatomegaly, and malaise. Diagnostic findings + HbsAg , + HbeAg (7-14 days after exposure) See Interpretation of Hepatitis B Panel. Potential Maternal and Neonatal Effects a. Maternal Premature labor and delivery, cirrhosis and liver cancer b. Neonatal Stillbirth. Infants infected at birth have a 90% chance of becoming chronically infected. Interventions a. Maternal Pregnant women who are exposed to HBV should receive vaccine and HBIG. Pregnant women who are already infected should eat well, get sufficient rest, avoid stress and avoid alcohol. Alpha interferon and lamivudine are not recommended during pregnancy. b. Neonatal - Infants of infected women should receive HBV vaccine and HBIG. Health Education b. Hepatitis B vaccination is the best prevention. c. The proper and consistent use of latex condoms may prevent sexual transmission. d. Do not use IV drugs. Never share needles, syringes, water or works. e. Do not share personal items that may have blood on them razors, toothbrushes. f. Consider the risks before getting a tattoo or piercing. g. Health care workers should use BSP and safe handling of sharps. References and Exhibits AWHONN, 2nd edition, Table 22-1, TORCH Disease CDC Fact Sheet - Viral Hepatitis B Interpretation of the Hepatitis B Panel

C. Rubella (German measles) 1. Description Rubella is a mild childhood illness that can pose a serious threat to the fetus, if a mother contracts the illness during pregnancy. Most women of childbearing age are immune to rubella, either through vaccination or previous illness, but 2 in 10 are thought to be susceptible. 2. Transmission g. Incubation 2 to 3 weeks h. Highly contagious i. Spread through nasopharyngeal secretions j. Transplacental transmission likely. 3. Physical Findings Rash (lasting about 3 days), swollen glands, low-grade fever, joint pain, headache, loss of appetite, sore throat and hepatomegaly. Often asymptomatic.

4. Diagnostic findings- ELISA, Isolation of virus from urine or endocervical secretions. Fluorescent antibody (FA) or complement fixation (CF) test. 5. Potential Maternal and Neonatal Effects a. Maternal Infection can cause miscarriage and stillbirth. The risk of congenital rubella syndrome is highest (up to 90%) when exposure is between 11 and 20 weeks gestation. b. Neonatal - About 25 percent of neonates whose mothers contracted rubella during the first trimester are born with one or more birth defects blindness, cataracts, hearing loss, heart defects, mental retardation, movement disorders, and development of diabetes during childhood or later. Some infected babies have short-term health problems diarrhea, LBW, feeding problems, pneumonia, meningitis, anemia, red-purple spots on faces and bodies and enlarged spleen and liver. Neonates with congenital rubella infection are contagious and should be isolated. 6. Interventions a. Maternal Mild analgesics, rest and support. b. Neonatal - No specific treatment for congenital rubella treatment. Eye or cardiac defects may be corrected or improved with surgery. Careful screening for problems and special education are indicated. 7. Health Education a. Vaccination of non-immune women before pregnancy is the best prevention. b. The rubella and MMR (measles, mumps, rubella) vaccines are not recommended during pregnancy. A woman should wait 28 days after vaccination to attempt conception (although the risk to an inadvertent pregnancy during this time is very small). Breastfeeding women may be vaccinated. c. Pregnant women who are non-immune for rubella should avoid anyone with rubella or the symptoms of rubella. 8. References and Exhibits AWHONN, 2nd edition, Table 22-1 TORCH March of Dimes Facts Sheets - Rubella D. Cytomegalovirus (CMV) 1. Description Cytomegalovirus is the most common congenital infection at birth in the U.S. Each year about 40,000 babies (1%) are infected. Fortunately, most babies are not harmed, but about 8,000 babies per year develop lasting disabilities from CMV. 2. Transmission a. Incubation unknown. CMV is in the herpes family and like herpes can reactivate. b. CMV is very common in young children (perhaps 70% of children between 1 and 3 years of age in childcare will be excreting CMV).

3. 4.

5.

6.

7.

8.

c. Transmission can occur through contact with saliva, urine, feces, blood, and mucous. It can also be transmitted sexually and through transfusion and organ donation. d. Transplacental transmission tends to be most serious. e. Infants who are infected during birth or from breastfeeding rarely have serious problems from the infection. Physical Findings Sore throat, fever, body aches, fatigue and hepatomegaly. Most infections are asymptomatic. Diagnostic findings a. Maternal - ELISA, fluorescent antibody (FA), complement fixation (CF), seroconversion to +IgM, and isolation of the virus by culture. b. Prenatal - Affected infants may demonstrate the following ultrasound findings: microcephaly, hydrocephalus, necrotic cystic or calcified lesions in the brain, liver or placenta, IUGR, oligohydramnios, ascites, pleural or pericardial effusion, hypoechogenic bowel and hydrops. -Amniocentisis with culture or DNA identification. -Cordocentesis can be used to document presence and severity of disease. c. Newborn virus isolation is the optimal method of documenting CMV infection. Specimens can be taken from urine, nasopharnyx, conjunctiva and spinal fluid. Potential Maternal and Neonatal Effects a. Maternal Most infections are asymptomatic b. Neonatal Infection is most likely to occur with primary maternal infection. Approximate congenital infection rate of 1%. Of these, 10 % will be symptomatic, of which 25 % will have fatal disease and 90% of the survivors will have serious sequelae- IUGR, microcephaly, CNS abnormalities, hydrocephaly, periventricular calcification, deafness, blindness, and mental retardation. A small percentage of newborns asymptomatic at birth will also develop late sequelae. Interventions a. Maternal treat symptoms b. Neonatal - no satisfactory treatment available. Infant is contagious and should be isolated. Health Education a. Women can reduce their risk of CMV by practicing universal precautions and careful hand washing, especially after any contact with saliva, urine, feces, blood and mucous. b. Avoid sharing glasses or eating utensils. c. Medical or day care workers may consider being tested prior to pregnancy to determine if they have had CMV, as they would then have little cause for concern. References and Exhibits AWHONN, 2nd edition, Table 22-1 TORCH March of Dimes Fact Sheets Cytomegalovirus in Pregnancy

Gibbs RS and Sweet RL. Evaluating and Treating Obstetric & Gynecologic Infections. Gardiner-Caldwell SynerMed, 1995. E. Herpes Simplex Virus (HSV) 1. Description Herpes is caused by the herpes simplex viruses, which are similar to the viruses that cause chickenpox and shingles. After the initial infection, the herpes simplex viruses can hide within nerve cells and later launch new attacks. There are 2 main kinds of herpes simplex virus (HSV): type I, which is usually associated with cold sores around the mouth; and type 2, which is usually associated with genital sores. However, either type can infect either the mouth or genitals and both can be passed on to the newborn. Approximately 45 million Americans have genital herpes with about 1,000 newborn infections occurring each year. 2. Transmission a. Incubation 2 to 10 days b. Intimate mucocutaneous exposure- intercourse, mouth to genital contact or kissing in the presence of a cold sore. c. Passage through an infected birth canal d. Ascending infection in the presence of ROM e. Transplacental infection happens rarely with an initial maternal infection during pregnancy f. Contact with virus-containing saliva. 3. Physical Findings Painful, genital lesion. Often form in clusters of blisters that break leaving a painful ulcer. Frequently will experience a prodrome burning, itching, numbness, tingling before the blisters appear (thought to be contagious during this stage, too). Usually the lesions will recur in the same area. Recurrence generally becomes less frequent with time. Primary infections may include fever, malaise, myalgia and lymphadenopathy. 4. Diagnostic findings a. Tissue culture-swab specimen from vesicles b. Pap smear of lesion c. Visualization of a blister or ulcer-like, painful lesion by experienced clinician. 5. Potential Maternal and Neonatal Effects a. Maternal Women with a primary infection during the pregnancy may be at increased risk for PTD and LBW infant. c. Neonatal - Infants of women with the primary infection occurring during the pregnancy are at greatest risk. Potential sequelae include: skin, mouth or eye lesions with potential permanent damage to the nerves or eyes. HSV in the newborn often can spread to the brain and other internal organs (approximate 50% mortality). About 50% of the survivors develop mental retardation, cerebral palsy, seizures, blindness or deafness. 6. Interventions a. Women with prodromal symptoms or an active lesion (still in blister or ulcer stages) will be counseled to have cesarean delivery. The greatest

protection to the fetus is if this is accomplished before ROM greater than 4 hours. d. Anti-viral drugs can shorten the duration of a herpes attack, alleviate symptoms and reduce the number of attacks. Oral acyclovir is sometimes used in late pregnancy to decrease the need for cesarean birth. e. Acyclovir and vidarabine are used to treat neonatal HSV more successful with localized infection than one that has spread to brain and other internal organs. 7.Health Education a. Encourage women with a history of genital herpes to avoid triggers (heat, friction, intercourse, peanuts, chocolate, fever or stress), especially during the later part of pregnancy. b. Recommend condoms or abstinence in pregnant women without HSV who have partners with HSV. c. Encourage careful hand washing to prevent spread of HSV to others or to other parts of the body d. People with active cold sore lesions should avoid kissing others, especially newborns. e. Educate women of the importance of reporting prodromal symptoms or lesions to their care providers with suspected labor or ruptured membranes. 9. References and Exhibits March of Dimes Fact Sheet: Genital Herpes AWHONN 2nd edition, Table 22-1 TORCH

IV.

AUTHOR Karen Adkins-Bley, RN, JD SIGNATURES

V.

__________________________________ Mary Louise Braney, MS, RN Director, Patient Care Services

________________________________ Robert H. Hayashi, MD Director, MFM Division

__________________________________ Terri L. Murtland, RN, MSN, CNM Triage Coordinator