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.

II. 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.

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 , 2
ND
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
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
3. Physical Findings Low-grade fever, nausea, anorexia, jaundice,
hepatomegaly, and malaise.
4. Diagnostic findings +HbsAg , +HbeAg (7-14 days after exposure)
See Interpretation of Hepatitis B Panel.
5. 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.
6. 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.
7. 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.
8. References and Exhibits
AWHONN, 2
nd
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, 2
nd
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).
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.
3. Physical Findings Sore throat, fever, body aches, fatigue and hepatomegaly.
Most infections are asymptomatic.
4. 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.
5. 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.
6. Interventions
a. Maternal treat symptoms
b. Neonatal - no satisfactory treatment available. Infant is contagious and
should be isolated.
7. 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.
8. References and Exhibits
AWHONN, 2
nd
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 2
nd
edition, Table 22-1 TORCH


IV. AUTHOR
Karen Adkins-Bley, RN, J D


V. SIGNATURES



__________________________________ ________________________________
Mary Louise Braney, MS, RN Robert H. Hayashi, MD
Director, Patient Care Services Director, MFM Division



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