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89]

Original Article

Prevalence of Torch Infections and Its Associated Poor

Outcome in High‑Risk Pregnant Women of Central India: Time
to Think for Prevention Strategies
H. V. Manjunathachar, Kavita N. Singh1, Vivek Chouksey, Ravindra Kumar2, Ravendra K. Sharma3, Pradip V. Barde4
Division of In vivo Research, ICMR‑National Institute of Research in Tribal Health, 1Department of Obstetrics and Gynaecology, NSCB Medical College,
2
Division of Genetic Disorder, ICMR‑National Institute of Research in Tribal Health, 3Division of Social Science and Ethnomedicine, ICMR‑National Institute of Research
in Tribal Health, 4Division of Virology and Zoonoses,  ICMR‑National Institute of Research in Tribal Health, Jabalpur, Madhya Pradesh, India

Abstract
Introduction: The TORCH infections during pregnancy are associated with adverse congenital abnormalities, poor foetal outcome and
subsequent reproductive failures. The absence of baseline data on status of TORCH infections and associated foetal outcomes prompted
us to conduct the current study in Central India. Materials and Methods: A total of 144 high‑risk pregnant women attending tertiary care
unit, suspected for TORCH infections were enrolled from August 2017 to December 2018. All the participants were tested for the presence
of IgM and IgG antibodies and followed up to record the foetal outcome. Results: The overall TORCH infection (IgM positivity) positivity
rate was 61.1% (88/144). Rubella was the most prevalent infection (46.5%) followed by herpes simplex virus (HSV) 1 and 2 (41%) and
cytomegalovirus (CMV) (34.7%). The highest IgG sero‑positivity was recorded against CMV (88.6%), followed by Rubella (86.8%), HSV 1 and
2 (28.4%), and toxoplasmosis (15.2%). Follow‑up of IgM TORCH positive pregnant women revealed that majority of the neonates/infants
are having congenital cardiac abnormalities  (39.2%), followed by microcephaly/hydrocephaly  (25%), low birth weight  (10.7%), and
deafness (3.6%). Thirty‑two percent of neonatal mortality was associated to multiple TORCH infections. Conclusion: A high prevalence of
IgM seropositivity of TORCH infection was noted in the present study with the increased rate of poor foetal outcome warrants the need of
proper prenatal counselling, universal immunisation and nutritional supplements during pregnancy.

Keywords: Bad obstetric history, Central India, congenital malformations, pregnancy, TORCH infections

Introduction of stillbirths and accounting for approximately half of them,

The maternal infections that are transmissible in‑utero at the
different stages of pregnancy caused by many pathogens, of
which TORCH complex acronym comprises of Toxoplasma
gondii, Rubella virus (RV), cytomegalovirus (CMV) and herpes
simplex virus  (HSV) type  1 and 2, contributes majorly in
neonatal and infant deaths globally.[1] Most of these pathogens
causes asymptomatic or mild maternal morbidity but have
serious adverse effects on foetal outcomes.[2] The primary
TORCH infection during the different stages of pregnancy has
life‑threatening serious consequences on fetus in comparison
to recurrent infections and may cause spontaneous abortions,
congenital malformations, intrauterine growth restriction, still
births, prematurity and chronic postnatal infections.[2,3] As
per the estimate, TORCH infections are the foremost cause
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reported especially in developing countries.[4] On an account,
almost 7.5 lakhs neonatal deaths recorded in India in 2013, and it
is highest for any country in the world.[5,6] In India, child‑bearing
women belonging to low socio‑economic group or residing in
rural/tribal areas, comes under high‑risk pregnancy group since,
they exposed to a range of infections due to poor environmental
Address for correspondence: Dr. Pradip V. Barde,
Division of Virology and Zoonoses, ICMR‑National Institute of Research in
Tribal Health, Jabalpur ‑ 482 003, Madhya Pradesh, India.
E‑mail: pradip_barde@hotmail.com
Received: 31‑03‑2020 Revised: 09‑07‑2020
Accepted: 17-08-2020 Published Online: 04-11-2020
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How to cite this article: Manjunathachar HV, Singh KN, Chouksey V,

DOI: Kumar R, Sharma RK, Barde PV. Prevalence of torch infections and its
10.4103/ijmm.IJMM_20_136 associated poor outcome in high-risk pregnant women of Central India: Time
to think for prevention strategies. Indian J Med Microbiol 2020;38:379-84..

© 2020 Indian Journal of Medical Microbiology | Published by Wolters Kluwer - Medknow 379
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Manjunathachar, et al.: TORCH infections in Central India
condition and lack of good hygienic practices. The high‑risk
pregnancy, where mother or developing fetus or both are
prone for high‑ risk complications during or after pregnancy
and birth.[1,3] Toxoplasmosis, a protozoan infection caused by
T. gondii, causes life‑threatening events in pregnant women
when infection acquired during the first or second trimester of
pregnancy as a primary infection and pose major threat to the
fetus.[2,7,8] The infection is transmitted through handling infected
cat feces, consumption of contaminated vegetables, fruits and
milk.[9,10] RV is transmitted by droplets between person to
person and vertical transmission occurs between mother to
child. Rubella infection in the first trimester of pregnancy is
responsible for congenital malformations in infants referred
as congenital rubella syndrome (CRS).[1,11] CMV is considered
as one of the leading cause for congenital deafness, loss of
vision and cognitive impairment in infants.[12,13] Herpes viral
infections are the most common infections spreads through oral
or genital contact in humans. Genital herpes caused by HSV
type‑2 spreads mainly through sexual contact and the infection
during the last trimester of pregnancy leads to neonatal herpes
with reported 80% case fatality rate.[2,13,14]
Among all states in India, Madhya Pradesh reported highest
neonatal mortality rate.[6,15,16]  TORCH infection in pregnancy
may be a major cause of high neonatal mortality. In the absence
of national level screening programme for TORCH, serological
detection of infections during the pregnancy is the only means
of revealing such infections and may help obstetrician to
counsel the couple to avoid poor pregnancy outcome. However,
meager studies have been conducted from the different parts of
the country and reported huge variation in the infection status
from the region to region owing to changes in the life style
pattern, socio‑economic status and availability of diagnostic
facilities.[1,2,11,17,18] Even though, Madhya Pradesh recorded high
neonatal mortality, to the best of our knowledge, no studies
have been conducted to evaluate the TORCH infections in
pregnant women and their teratogenic effects on the foetal
development from the Central part of India. Therefore, the aim
of the present study is evaluate the status of TORCH infections
in high‑risk pregnant women attending a tertiary care antenatal
unit at Jabalpur and their deleterious effect on foetal outcome.
Materials and Methods
Study area and design
This follow‑up study was conducted between August 2017 and
December 2018 at the ICMR‑National Institute of Research in
Tribal Health. Pregnant women aged between 18 and 40 years
from different districts of Madhya Pradesh attending Obstetrics
and Gynaecology department of NSCB Medical College and
Hospital, Jabalpur were recruited at different gestational phases
of pregnancy.
The pregnant women suspected of TORCH infection,
namely  (1) Pregnant women with signs and symptoms
suggestive of infection,[19] (2) Pregnant women suspected to
be complicated with congenital malformations in fetal growth,
380 Indian Journal of Medical Microbiology  ¦  Volume 38  ¦  Issue 3 & 4  ¦  July-December 2020
(3) pregnant women with previous bad obstetric history (BOH)
were included in the study. Women with other known issues
which affect the current pregnancy such as Rh incompatibility,
eclampsia, preeclampsia, gestational diabetes or reproductive
organ defects were excluded from the study. After briefing
about the study aim to participants properly, informed written
consent was obtained. The study was carried out under
establishment of virology research and diagnostic laboratory
(VRDL) network had Institutional Ethical Committee (IEC)
approval (No. NIRTH/IEC/1157/2017 dated 7th July 2017).
Sample size
The sample size was calculated using standard statistical tool.
Epi Info™, Division of Health Informatics & Surveillance
(DHIS), Center for Surveillance, Epidemiology & Laboratory
Services (CSELS), USA and the five year TORCH
sero‑positivity rate (toxoplasmosis ‑ 24.2%, Rubella ‑ 9.2%,
CMV ‑53.8% and HSV 1 and 2%–11.7%) reported by Nirmal
et al.[20] Keeping the 9.2% sero‑positivity rate of Rubella with
accepting the 5% Type I error rate and study power of 80%,
the minimum required sample size of 130 was calculated.
Clinical data collection and laboratory investigations
Clinical history such as previous obstetric history and general
conditions such as anaemia and gestational age were recorded
using a predesigned questionnaire from each recruited
individual.
Two millilitres of venous blood was collected aseptically and
sera was separated by centrifugation at 3500 rpm and stored
at  −20°C until testing. All the samples were tested for the
detection of IgM and IgG antibodies against the T. gondii,
Rubella, CMV, HSV 1 and 2 by enzyme‑linked immunosorbent
assay using commercially available kits (ChemuxBioScience,
Inc., USA) following manufacturer’s protocol. Assay validity
was evaluated as per the manufacturer’s recommended method.
The reports of TORCH infection status were distributed
to patients and based on the positive result of the reports,
obstetrician counseled patients/couple about possible outcomes,
prevention and available treatment measures. Further,
information about fetal outcomes and child health status was
recorded telephonically by follow‑up of IgM‑positive cases.
Statistical analysis
Collected data were entered in Microsoft Excel‑2007 for the
primary analysis. The statistical analyses were carried out
using the SPSS software version 20 (SPSS Inc., IBM Corp.,
Armonk, USA). Possible associations with each variable were
studied using the Fisher’s exact test. Odd ratios (ORs) were
computed with 95% confidence interval for each of the TORCH
components in the all the participants. A two‑tailed P < 0.05
was considered as statistically significant.
Results
A total of 144 pregnant women aged between 18 and 40 years
belong to Jabalpur and 10 adjacent districts of Madhya Pradesh
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Manjunathachar, et al.: TORCH infections in Central India

were investigated. The mean age of the pregnant women depicts the geographic variation of infection rate and risk
was 24  ±  3.9  years. The overall TORCH, IgM positivity factors. Further, Tiwari et al.[3] reported 45.56% IgM positivity
rate in high‑risk pregnant women was 61.1%  (88/144). in pregnant women of New  Delhi. Subsequently, Nirmal
Based on the IgM positivity, Rubella is the most prevalent et al.[20] reported the increasing trend of TORCH infections, i.e.,
infection  (46.5%) followed by HSV 1 and 2  (41%), 98.8% of TORCH positivity from same region, highlighting the
CMV  (34.7%), and toxoplasmosis  (6.3%) in high‑risk need of the antenatal TORCH screening in pregnant women
pregnant women having rash or any clinical signs. On the and immunization strategy to evade the adverse foetal outcome.
whole, highest IgG seropositivity was recorded against
In India, the reported seroprevalence rate of toxoplasmosis is
CMV  (88.6%), followed by Rubella  (86.8%), HSV 1 and
up to 80%.[8,10] In the present study, 15.2% and 6.3% pregnant
2 (28.4%), and toxoplasmosis (15.2%). The combined infection
women showed anti‑toxoplasma IgG and IgM antibodies,
status is presented in Table 1. The IgM seropositivity TORCH
respectively whereas Shrivastava et  al.[10] reported 9.37%
participants showed statistically significant differences with
and 29.68% toxoplasma IgG and IgM antibodies respectively
age. Whereas, there was no substantial shifts in IgM and
in pregnant women from Indore, Madhya Pradesh. The
IgG seropositivity of participants in relation to trimester
seroprevalence of toxoplasmosis in different countries ranges
and BOH  [Table  2]. The rate of IgM positivity was more
between 7.7% and 76.7%.[4,5,8] The varying prevalence status
in 1st and 2nd trimesters as compared to the last trimester
between the geographical regions may be due to climate
of pregnancy; however, the differences were statistically
variability, hygiene and sanitization practices, and life
insignificant (P > 0.05). Relationship of TORCH infections
standards of the people[4,5,8,10] Toxoplasmosis is a completely
in pregnant women along with the foetal outcome was
treatable infection in pregnancy with antibiotic therapy; hence,
recorded [Table  3]. Follow‑up of TORCH IgM‑positive
early antenatal detection and prompt treatment of infection
pregnant women revealed that, majority of mothers had
may prevent the foetal complications. Further, several studies
more than one TORCH infection and the neonates/infants are
reported that encysted forms of T. gondii activate in subsequent
having congenital cardiac abnormalities (39.2%), followed by
microcephaly/hydrocephaly (25%), low‑birth weight (10.7%) pregnancy and may lead to infection in the first trimester of
and deafness  (3.6%). Besides, 32% of neonates were died pregnancy and often leads to spontaneous abortions.[18,21‑23]
within two weeks after birth. Majority of the neonatal deaths Hence, the pregnant women showing seroconversion should
were observed in pregnant women affected with mixed be monitored during their subsequent pregnancies and advised
TORCH infections. to avoid handling infected cat litter material, consumption of
raw vegetables, fruits, meat and milk products. Further, in the
absence of vaccination against toxoplasmosis, the prevention
Discussion of infection in pregnant mother can be achieved through
In present study, IgM positivity of TORCH infections in hygiene, sanitisation and proper education by health‑care
pregnant women was found to be 61.1%, which is in contrast authorities.
with the seropositivity rate of 13.8% reported by Padmavathy
The World Health Organization (WHO) reported that 103,000
et al.[21] from Bangalore. The variation in seropositivity rate
infants were born with CRS globally and 50% of CRS cases
are reported from South‑East Asia region, illustrates the burden
of CRS.[24] To overcome this situation, the WHO South‑East
Table 1: Serological status of IgG and IgM antibodies
Asia region committed to control Rubella and CRS by 2020. In
against oxoplasmosis, Rubella, Cytomegalovirus, and
India, several studies reported 5%–50% CRS cases following
Herpes Simplex Virus type 1 and 2 infections in pregnant
maternal infection of Rubella and the severity is much more,
women
if infection acquired at first trimester of pregnancy.[18,25,26] In
Type of pathogens Antibody Seropositivity 95% CI the current study, it was observed that 86.8% and 46.5%
(n=144), n (%) pregnant women were showing anti‑rubella IgG and IgM
Toxoplasma gondii IgM 9 (6.3) 3.32-11.45 antibodies respectively. However, the antibodies titre level
IgG 22 (15.2) 10.31-22.05 was less, depicts the absence of vaccination programme and
IgM and IgG 6 (4.1) 1.92-8.79 silent transmission of infection to susceptible population in
Rubella IgM 67 (46.5) 38.58-54.66
Madhya Pradesh. Earlier, Kori et al.[18] demonstrated 61.8%
IgG 125 (86.8) 80.31-91.31
immuno‑protection to Rubella in pregnant women. In line with
IgM and IgG 62 (43.1) 35.25-51.22
our results, several studies from different parts of India reported
CMV IgM 50 (34.7) 27.43-42.80
Rubella seropositivity ranging from 68.4% to 90.8%, thus
IgG 128 (88.8) 82.71-93.04
leaving another one third population susceptible to infection.
IgM and IgG 49 (34) 26.79-42.09
HSV 1 and 2 IgM 59 (41.0) 33.28-49.14
[2,10,20,27]
Based on the study, it clears that the participants
IgG 41 (28.4) 21.79-36.33
were not protected against Rubella. This may be due low
IgM and IgG 20 (13.8) 9.17-20.48 socio‑economic status, poor education in the community, lack
CMV: Cytomegalovirus, HSV: Herpes simplex virus, CI: Confidence of universal vaccination and health‑care facilities in this rural/
interval tribal dominated region.

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Manjunathachar, et al.: TORCH infections in Central India

Table 2: Status of IgM and IgG sero-positivity in pregnant women based on different variables such as age, bad
obstetric history, and trimester
Parameter n=144 Toxoplasma gondii Rubella CMV HSV 1 and 2
IgM IgG IgM IgG IgM IgG IgM IgG
Age
≤24 78 9 (11.5) 16 (20.5) 47 (60.3) 67 (85.9) 36 (46.2) 70 (89.7) 45 (57.7) 22 (28.2)
>24 66 0 (0.00) 6 (9.1) 20 (30.3) 58 (87.9) 14 (21.2) 58 (87.9) 14 (21.2) 19 (28.8)
P, OR (95% 0.012, NC 0.066, 2.58 0.001, 3.487 0.8, 0.84 0.003, 3.183 0.79, 1.2 <0.0001, 5.064 1, 0.97
CI) (0.9-7.03) (1.7-6.9) (0.3-2.2) (1.5-6.6) (0.4-3.4) (2.4-10.6) (0.4-2.07)
BOH^
Present 66 0 (0.0) 8 (12.1) 30 (45.5) 54 (81.8) 25 (37.9) 57 (86.4) 26 (39.4) 20 (30.3)
Absent 51 7 (13.7) 11 (21.6) 28 (54.9) 48 (94.1) 19 (37.3) 48 (94.1) 27 (52.9) 14 (27.8)
P, OR (95% 0.007, NC 0.2, 0.5 0.408, 0.684 0.28, 0.28 1.000, 1.027 0.2, 0.39 0.203, 0.578 0.83, 1.14
CI) (0.18-1.35) (0.328-1.426) (0.07-1.05) (0.482-2.184) (0.1-1.54) (0.276-1.209) (0.51-2.57)
Trimester
1st trimester 65 5 (7.8) 4 (6.2) 34 (52.3) 54 (94.5) 21 (32.3) 57 (87.7) 23 (35.4) 20 (30.8)
2nd trimester 55 4 (7.3) 15 (27.3) 26 (47.3) 52 (94.5) 25 (45.5) 52 (94.5) 30 (54.5) 15 (27.3)
3rd trimester 24 0 (0.0) 3 (12.5) 7 (29.2) 19 (79.2) 4 (16.7) 19 (79.2) 6 (25) 6 (25)
P, OR 0.31, NC 0.38, 0.45 0.059, 2.66 0.75, 1.29 0.18, 2.38 0.32, 1.87 0.44, 1.64 0.79, 1.33
(95% CI)* (0.095-2.22) (0.97-7.28) (0.39-4.2) (0.72-7.86) (0.54-6.42) (0.57-4.71) (0.46-3.86)
P, OR 1.000, 1.384 0.002, 0.17 0.71, 1.22 0.08, 0.28 0.18, 0.57 0.22, 0.41 0.04, 0.45 0.69, 1.18
(95% CI)$ (0.136-14.009) (0.05-0.56) (0.59-2.51) (0.07-1.07) (0.27-1.21) (0.1-1.63) (0.21-0.95) (0.53-2.62)
^
117 subjects are included, remaining 26 participants are primiparous. BOH: Bad obstetric history, *P value, OR was calculated by comparing positivity in
1st trimester and 3rd trimester, $ P value, OR was calculated by comparing positivity in 2nd trimester and 3rd trimester CI: Confidence interval, OR: Odds ratio,
CMV: Cytomegalovirus, HSV: Herpes simplex virus, NC: Not computed

Table 3: Association of fetal outcome Toxoplasmosis, Rubella, Cytomegalovirus, and Herpes Simplex Virus 1 and 2
infection in pregnant women
Parameters in infant IgM-positive mother* TORCH pathogens involved in congenital abnormalities in infants
LBW 3 (10.7) R+C+H-1, T+R+H-1, T+R+C+H-1
Deafness 1 (3.6) R+C+H-1
Cardiac abnormality 11 (39.2) R-1, R+H-4, R+C+H-1, C-1, R+C-3, T+R+C+H-1
Microcephaly/hydrocephalous 7 (25.0) R+C+H-2, R+C-2, R+H-1, C-1, T+R+C+H-1
Mortality 9 (32.1) R+C+H-3, R+C-2, T+R-1, R+H-1, T-1, R-1
*Data were depicted for 28-positive mothers and respective fetal outcome. T: Toxoplasmosis, R: Rubella, C: Cytomegalovirus, H: Herpes Simples virus
1 and 2, LBW: Low-birth weight

Recently, the Government of India also launched nationwide
measles‑rubella vaccination campaign in 2017 targeting
children aged 9 months to 14  years in five states or union
territories with the objective to reduce the burden of CRS.[11,28]
Globally, the reported prevalence of CMV infection is ranging
from 45% in developed countries to 100% in developing
countries, whereas in India, recorded 80%–90% CMV IgG
antibodies in women of child‑bearing age.[1,28-30]Our results
are also in similar line, where anti‑CMV IgG antibodies
were observed in 88.8% pregnant women. Our results of
IgG antibodies against CMV infection are in parallel with
the reported 85.93% and 96.4% seropositivity from Indore,
Madhya Pradesh, and Turkey, respectively. [10,21] High
seropositivity in the current study may be due to primary
infection or reinfection of variant strain in this population.
Hence, conducting prenatal CMV detection may help
obstetrician regarding the status of infection and possible
outcome of pregnancy. Thus, proper counselling and treatment
of infected children may be considered timely to overcome the
complications. Centers for Disease Control and Prevention
also recommended prenatal counselling for pregnant women
about hand washing, reducing exposure to body fluids of young
children’s in preventive aspect.[31]
Disseminated herpes infection is quite severe, and it is
associated with a high rate of neonatal morbidity and
mortality. About 80% of this infection is acquired during
birth process and associated mortality was >75% in untreated
cases.[32] In the present study, the prevalence of HSV 1 and
2 infection in pregnant women of <24 years age group was
57.7%. Interestingly, 71.6% pregnant women in the study
area are susceptible to infection due to the lack of immunity
against the same. A study by Prasoona et al.[1] from South India
reported highest seropositivity (61%) of HSV‑II associated
with bad obstetric outcome. In contrast, we have noticed
there was no statistically significant association between
BOH with the HSV infection. Other studies conducted in
North India reported seropositivity rate of 16.8% and 53.12%
from different regions, and our results are in line with the

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Manjunathachar, et al.: TORCH infections in Central India
mentioned studies.[10,33] To avoid the horizontal transmission
between mother to new‑born, the Federation of Obstetric
and Gynaecological Societies of India, Good Clinical
Practice Recommendations suggests, offering a caesarean
section to avoid the risk of transmission.[34] It was noticed
that, infection rate in ≤24 years’ age group pregnant women
was statistically higher, and the results were in analogous
with earlier reports from Delhi, Hyderabad, Bengaluru
and Varanasi.[1,13,17,21] TORCH pathogens usually cause a
primary maternal viremia which pass through the placenta
and have teratogenic effects on fetus, except HSV‑1 or 2
where, ascending type of infection through the genital tract to
foetal membranes and then to the foetus is more common.[35]
Owing to type of infection in different stages of pregnancy,
significant morbidity and mortality may be noticed in the
developmental stages of neonate/infant. Several studies
reported that, the incidence of congenital malformation and
preterm deliveries probability will be more in toxoplasma
positive pregnant women, on the other hand, the incidence of
spontaneous abortion, cardiac, hearing and ocular problems
are more associated with Rubella, CMV, and HSV‑positive
cases.[6,7,12,15] Follow‑up of IgM positive pregnant women
cases recorded, high neonatal mortality, other congenital
abnormalities in neonates/infants. RV is known for its
teratogenicity and may cause intrauterine growth retardation,
cardiac, ocular, and hearing defects. Since, mixed TORCH
infections in pregnant women having worst adverse outcome
on foetal development so, obstetrician should keep in mind
while counselling and treating the patient.
Conducting the study in constricted socioeconomic group, i.e.,
tribes/rural regions where lack of basic amenities, including
connectivity, low education level in community hinders the
documentation of the foetal outcome are few limitations
recorded in the study. Hence, in the absence of previous reports
from this constricted socioeconomic region, the present data
will be helpful for planning and designing the preventive
strategies in this geographic location.
Conclusion
The prevalence of TORCH infections was very high in this
geographic region, and these infections probably associated
with high neonatal mortality rate recorded in Madhya Pradesh.
Further, the present study illustrates the importance of
prenatal diagnosis of TORCH infections in high‑risk
pregnant women for proper counselling in states where
higher neonatal mortalities recorded. Since pregnant women
in tribal/rural regions are more vulnerable to these infections,
health authorities should think and implement strategies to
provide vigorous pre‑pregnancy Information, Education and
Communication regarding do or don’t during pregnancy period
through local health‑care workers in local language, regular
health check‑up, nutritional supplements, implementation of
universal immunisation schemes and monitoring, strengthening
diagnostic facilities for antenatal screening of pregnant women
to prevent adverse fetal outcomes.
Indian Journal of Medical Microbiology  ¦  Volume 38  ¦  Issue 3 & 4  ¦  July-December 2020
Financial support and sponsorship
This study was financially supported by the Indian Council of
Medical Research, New Delhi, for financial support.
Conflicts of interest
There are no conflicts of interest.
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384 Indian Journal of Medical Microbiology  ¦  Volume 38  ¦  Issue 3 & 4  ¦  July-December 2020