Overview Maternal infections can be teratogenic, can cause adverse effects to the fertilized ovum, embryo or fetus.

The occurrence of these infections can involve either sexually transmitted or through systemic infection. TORCH infections are diseases identified as causing serious harm to the embryo or fetus. Organisms with these infections can cross the placenta and may be a virus, bacteria or a protozoon. The infected woman will just manifest mild flu-like symptoms. However, a more serious or worst fatal effect on a fetus or newborn is at risk. It is difficult to prevent and predict fetal injury from these infections because the mother may manifest no symptoms and yet internally the infection is injuring the fetus. Definition The umbrella term TORCH is an abbreviation for diseases that are collectively known and tested to cross the placenta and cause fetal harm which includes: Toxoplasmosis, Rubella, Cytomegalovirus and Herpes Simplex Virus. Some sources identify O as other infections which could include syphilis, hepatitis B virus and human immunodeficiency virus (HIV). Generally, TORCH infections are diseases identified to cause serious harm to the embryo or fetus. Toxoplasmosis Toxoplasmosis is caused by the protozoan Toxoplama Gondii. It is spread most commonly through contact or eating poorly cooked or uncooked meat. Handling infected cat stool in soil or cat litter may also contribute to the spread of this disease. The pregnant woman experiences no symptoms (asymptomatic) of the disease. However, few days after body malaise and cervical lymphadenopathy may be observed and experienced. Clinical Manifestations of Toxoplasmosis The clinical manifestations experienced by a pregnant woman with toxoplasmosis are the following:

Myalgia Body malaise Rash Splenomegaly Cervical lymphadenopathy

If the infection crosses the placenta, the infant may be born with the following problems:

Central nervous system damage Hydrocephalus Microcephaly Intracerebral calcification Retinal deformities

Nursing Diagnosis for Toxoplasmosis

Serum analysis during pregnancy such as the Sabin-Feldman dye test

Nursing Management for Toxoplasmosis

Therapy with Sulfonamides Sulfadiazine, if the diagnosis is established by serum analysis during pregnancy. However, the prevention of fetal deformities is uncertain. Taking this medication also leads to increased bilirubin in newborns. Pyrimethamine, an antiprotozoal agent can also be used. Pregnant women taking this drug must be monitored early in pregnancy as this drug is an antifolic drug that reduces folic acid levels.

Important Information

If toxoplasmosis is diagnosed before 20 weeks age of gestation damage to the fetus is more severe than if the disease is acquired later. The incidence of abortion, stillbirths, neonatal deaths and severe congenital anomalies is high.

Rubella Rubella virus only cause mild rash and systemic effects to the mother but a devastating teratogenic effect on the fetus is noted. The period of greatest risk for teratogenic effects of rubella on the fetus is during the first trimester. If the infection occurred during or between the third and seventh week of pregnancy, the damage usually results to fetal death. Permanent hearing impairment is most often the result if the infection occurred in the early second trimester. Fetal damage from maternal infection with rubella or most commonly known as German measles are the following:

Deafness Mental and motor challenge Cataracts Cardiac defects most commonly patent ductus arteriosus and pulmonary stenosis Restricted uterine growth or small for gestational age Thrombocytopenic purpura Dental and facial clefts such as cleft lip and palate

Nursing Diagnosis for Rubella On the first prenatal check-up, typically, a rubella titer is obtained. If the titer result is greater than 1:8 immunity to rubella is suggested. A titer result of less than 1:8 suggests that a woman is susceptible to viral invasion. A recent infection has occurred if the result of the titer is greatly increased over a previous reading or is initially extremely high.

Immunization Immunization to rubella during pregnancy is not allowed because the vaccine causes a live virus that would result to unpleasant effects to the fetus similar to those with a subclinical case. If a woman is immunized with a rubella vaccine she is not advised not to get pregnant for 3 months. By this time, the rubella virus is not longer active and may not cause teratogenic effects to the fetus if pregnancy would occur. Nursing Management for Rubella

Prevention. The best management for rubella is to prevent its occurrence. All pregnant women should avoid contact with children with rashes. Infants who are born to mothers who had rubella during pregnancy should be isolated fro other newborns as the neonate may be capable of transmitting the disease after birth. Live attenuated vaccine should be given to all children. Women of childbearing age should be tested for immunity and vaccinated if susceptible if established that they are not pregnant. Nurses who care for pregnant women or newborns should receive immunization against rubella to ensure that they neither spread nor contract the disease.

Cytomegalovirus The cytomegalovirus (CMV) is a member of the herpes virus family. It is another teratogen that can cause extensive fetal damage while the woman only manifests few symptoms. This virus can cause both congenital and acquired infections referred to as cytomegalic inclusion disease. It is transmitted from person to person by droplet infection. If the woman acquires the infection during pregnancy, the virus has the ability to cross the placenta to the fetus or through the cervical route during delivery. The virus can be found in urine, saliva, cervical mucus, semen and breast milk. Infants with mothers infected to cytomegalovirus during pregnancy may be born with the following conditions:

Severely neurologically challenged hydrocephalus, microcephaly, spasticity Eye damage optic atrophy, chorioretinitis Deafness Chronic Liver disease Skin covered with large petechiae blueberry-muffin lesions

Nursing Diagnosis for Cytomegalovirus Women infected with CMV may not be aware of the disease as they manifest no clinical signs and symptoms. However diagnosis can be established by the isolation of CMV antibodies in the blood serum. Nursing Management for Cytomegalovirus

No treatment for the infection exists even if it presents in the mother with enough symptoms to allow detection. Prevention is the key of not contracting the infection. Exposure to CMV can be prevented by thorough hand washing before eating and avoiding crowds of young children at daycare or nursery settings.

Complications The principal tissues and organs affected with CMV are the blood, brain and the liver. The following are the possible complications of this infectious disease:

Hemolysis leads to anemia and hyperbilirubinemia Thrombocytopenia with subsequent petechiae and ecchymosis Hepatosplenomegaly Encephalitis lethargy or hyperactivity and convulsions Cerebral palsy

Herpes Simplex Virus (Genital Herpes Infection) A substantial risk to the fetus is noted in pregnant women who have a primary first-episode herpes infection. When a woman contracts the genital herpes infection, systemic involvement occurs. After which the virus then spreads to the bloodstream, termed viremia, and crosses the placenta to a fetus. Clinical Manifestations of Herpes Simplex Virus With herpesvirus type 2 the following clinical manifestations will be experienced by the woman:

Genital irritation and itching Vaginal and urethral discharge Copious and foul-smelling vaginal discharges Enlarged tender lymph nodes Dysuria Reddened papules at the start then becomes itchy pustular that break and form painful wet ulcers, which then dry and develop crusts.

The effect of the herpes simplex virus infection varies, depending on the time the infection occurred:

If the infection takes place in the first trimester of pregnancy, severe congenital anomalies or spontaneous miscarriage may occur. There is a 20% to 50% rate of spontaneous abortion if the infection occurred during this time. If the infection occurs during the second or third trimester of pregnancy, there is a high incidence of premature birth, intrauterine growth restriction and continuing infection of the newborn at birth. Infection after the 20th week age of gestation leads to the incidence

of premature birth but not to teratogenic defects. The neonate can acquire the infection. Survivors have permanent visual damage and impaired psychomotor and intellectual development. If the woman has genital lesions present at birth the fetus may contract the infection from direct exposure at birth.

Nursing Management for Herpes Simplex Virus

Women who have history of genital herpes and existing genital lesions is often advised to undergo cesarean section if fetal involvement is not present to reduce the risk of direct neonate exposure to infection at birth. Intravenous or oral Acyclovir (zovirax) can be administered to women during pregnancy. Treatment is towards relieving the womans vulvar pain. Creams containing sulfonamide may be used to treat bacterial infections. During the peak of infection, the client may be advised to stay in bed as it may be most comfortable for him or her. In cases where an infection is suspected to the pregnant woman, an amniocentesis can be performed to determine fetal involvement. If fetal involvement is present, a cesarean section delivery should never be performed.

Other Viral Infections Syphilis Syphilis is a sexually transmitted disease and places a fetus at risk for intrauterine or congenital syphilis. This maternal infection is caused by a spirochete Treponema Pallidum. Suspicion or presence of this infection requires great concern for the maternal-fetal population despite the availability of accurate screening tests and proven medical treatment. Clinical Manifestations of Syphilis Newborns born with congenital syphilis may have the following:

Congenital anomalies Extreme rhinitis (sniffles) Characteristic syphilitic rash Oddly shaped primary teeth

Nursing Diagnosis for Syphilis

Serologic testing either VDRL or rapid plasma regain should be done at the first prenatal visit. The diagnostic test may be repeated again close to term, about the 8th month age of gestation if the concern is exposure. Increasing titer means that reinfection has occurred in the woman.

Lyme Disease

This is a multisystem disease caused by the spirochete Borrelia Burgdorferi. Lyme disease is contracted through the bite of a deer rick and the highest incident of infection is during summer and fall. Clinical manifestations of Lyme Disease The symptoms of Lyme disease is chronic not dramatic. Thus, women may not report them at prenatal visit unless proper education about the importance of reporting a migratory rash and joint pain is known to be related to this infectious illness. The nurse should ask the pregnant woman during prenatal visits for the presence of the following clinical manifestations:

Erythema chronicum migrans large macular lesions with a clear center. This typical rash develops after the tick bite. Pain in large joints (such as the knee) may be present Spontaneous miscarriage can result from the infection during pregnancy Severe congenital anomalies

Prevention

To prevent contracting the disease women who are anticipating to be pregnant must avoid wooded or tally grassy areas where they are apt to be bitten by ticks. In case where women are taking nature trips, it is not advisable to take tick repellent lotions as these products contain diethyltoluamide because the ingredient is teratogenic. To prevent exposure to tick the woman should be advised to wear long and light-colored slacks tucked to the socks to help prevent the legs from possible exposure. Instruct the woman to inspect her body carefully and immediately remove any ticks found.

Nursing Management for Lyme Disease Treatment of Lyme disused for pregnant and non-pregnant women differs.

For nonpregnant adults tetracycline and doxycycline may be used. These drugs cannot be used in pregnant women since it causes tooth discoloration and possibly, long-bone formation in fetus. For pregnant women, a course of penicillin will be prescribed to reduce the symptoms.