CBL 1 – Infections and TORCH Flashcards
Who should be screened for TORCH?
Everyone when taking antenatal history
Defn TORCH?
a group of infections that can cause serious birth defects or other conditions in a fetus if the mother contracts the infection during pregnancy
What are the TORCH infections? (6)
Toxoplasmosis
Other agents (HIV, syph, parvo B19, varicella, zika)
Rubella
Cytomegalovirus (CMV)
Herpes Simplex Virus (HSV)
Risk factors for toxoplasmosis ? (4)
- Food (raw/undercooked)
- Outdoor cats
- Gardening (the soil)
- Vertical transmission
Is there routine screening for toxoplasmosis?
No, except for immunocompromised people
Rate of vertical transmission of toxoplasmosis?
20-50%
Symptoms of toxoplasmosis?
Flu like illness
How is toxoplasmosis confirmed?
Serology
What do you do if a client has toxoplasmosis?
CONSULT
How to screen for HSV?
Always ask about genital herpes for client AND partner
If someone has a Hx of HSV what should you order?
Type specific serologies
When is the greatest risk of HSV for vertical transmission/transmission through vaginal birth?
Primary infection in T3
What is the chance of HSV vertical transmission for primary T3 infection?
30-50%
What are the recommendations for T3 for people with Hx of HSV in pregnancy?
Vacyclovir or Acyclovir starting at 36 weeks
What are the recommendations for HSV outbreak in labour/ROM ?
CS <4 hours + CONSULT obvi
Risk factors for Parvovirus? ) (4)
Teachers
Household contact
Early Childhood Educators
Caregivers
Is routine screening recommended for 5ths disease/Parvo?
No
How many people are immune to parvo?
Most, 50-75% people
Symptoms of parvo?
Flu like symptoms
Confirming parvo infection?
Serology
What to do with confirmed parvo infection?
Consult
How many people are immune to varicella?
> 90 %
Are you at risk for vertical transmission of varicella if immune?
No
If non immune with varicella infection what should you do? (3)
Consult OB for VZVIG within 96 hours of exposure
Consider immunization in newborn if exposed near time of birth
If client becomes symptomatic consult ASAP
Can RMs Rx and admin Varicella vaccine pp?
Yes
How often should you screen for syphilis?
Twice in pregnancy (once at initial appointment and once in T3 (planning HB) or in labour)
What is the most common intrauterine infection?
CMV
Symptoms for CMV?
Flu like, but largely asymptomatic
Most common nb sequelae for CMV transmission?
Hearing Loss
Who should be screened for Rubella?
Everyone
When should rubella vaccine be offered if not immune?
PP
When would you not re-immunize with low levels for rubella?
Equivocal/Low dose after 2 MMR vaccines
What should you do if rubella infection in pregnancy?
Consult
What are the risks of COVID for pregnant people?
> risks of hospitalization in pregnancy
Risks for fetus pregnant person with COVID 19?
- Higher rates of PTB
- Higher rates of NICU admission
Management of COVID hospitalization in pregnancy?
3rd trimester growth ultrasound
EMF in labour
Send placenta to pathology
What is Toxoplasmosis?
Part of TORCH, parasite
What should you order for suspected toxoplasmosis infection?
IgG and IgM, repeat 2 weeks later
What should you order for confirmed Toxoplasmosis infection?
Amnio after 18 weeks GA and within 4 wks of exposure
U/S if amnio unclear (IUGR, microcephaly, etc)
What is the Tx to reduce chance of toxoplasmosis vertical transmission?
Spiramycin
What should you do if confirmed case of vertically transmitted Toxoplasmosis infection?
Refer to MFM
What are the types of HSV?
Type 1 – usually lip
Type 2 – usually genitals
Both can be found in genitals, and both cause viral shedding
Why are we concerned with HSV in pregnancy? (3)
- Part of TORCH – vertical transmission (rare)
- Intrapartum (through contact with vaginal secretions in birth)
- Postpartum (through direct skin contact)
What is the most risky HSV situation in pregnancy?
Primary exposure in 3rd trimester (30-50% chance of transmission to babe)
What are the possible clinical scenarios with HSV in pregnancy ? (3)
Primary (HSV 1 or HSV 2 IgM with no IgG and breakout)
Non-primary – first recognized episode but has antibodies (IgG)
Recurrent – clinical episode with someone with antibodies (IgG)
Management of HSV? (4)
- Offer type specific HSV testing to client in early pregnancy and repeat at 32-34 wks
- Offer acyclovir/valacyclovir to partner or client at 36 wks
- C/S if active lesions (consult not transfer)
AND C/S if primary outbreak in T3 (transfer?) - Reduce FSE, ARM, instrumental delivery
What is fifth’s disease AKA parvovirus?
Part of TORCH, spread by resp secretions
Risks of parvo?
Most have no adverse outcomes >20 wks
Risks of miscarriage <20 wks 13 %
Symptoms of parvo?
Flu, rash, joint pain, most asymptomatic
Is routine screening for parvo rec?
No, most people are immune
Who is more likely to get parvo?
Parents, people working with kids
What to do if parvo infection diagnosed?
Refer to MFM or OB for regular US/Dopplers to rule out anemia and hydrops
What to do if someone is exposed to varicella and not immune in preg?
Serum testing
Immunoglobulin administered in 96 hrs of exposure
Cannot be Rx by midwives for some reason
What to do if someone is symptomatic of varicella and not immune? (3)
Oral acyclovir
Detailed US
Hospital admission
What should you consider if varicella outbreak close to birth?
Newborn immunization
Recommendation for CMV exposure with no previous immunity?
Amnio at least 7 weeks after onset after 21 wks GA
Serial US (IUGR, microcephaly, liver calcifications)
Incidence of fetal transmission with primary infection of CMV?
Primary infection 30-40 % vertical transmission, 25 % sequelae to fetus if infected
CMV fetal sequalae? (3)
- Hearing loss
- visual impairment
- delay of motor development
Fetal risks of Rubella?
Severe <16 wks
Miscarriage, congenital rubella syndrome
Tx of rubella in pregnancy?
- Post exposure prophylaxis immunoglobulin
- Risk of VT – offer termination >16 wks
What level of IgG non immune rubella?
<10 iu/ml
Reading serologies?
IGG - good (there forever) – immune?
IGM - Mal (iMmediate) – active infection
Who is recommended to have CS with HSV?
Primary outbreak in T3
Legions at time of delivery (controversial)
Vaccines to be avoided in pregnancy?
MMR and Varicella
What are the T1 lab reqs?
● Blood group and antibody screen
● CBC
● HIV serology
● STS serology (Syph, chlamyd, Hep B)
● HBsAg
● anti-HCV (for clients with risk factors)
● Rubella antibody titre
● CT/GC
● Urine C&S (1)
How is toxo diagnosed?
Can be identified with serologic testing or amniocentesis, or by the presence of abnormal ultrasound findings. Amnio is more diagnostic.
What could fetal effects of syphilis be?
○ skeletal deformities
○ severe anemia
○ Hepatomegaly
○ Spleenomegaly
○ Jaundice
○ CNS issues including blindness and loss of hearing
○ skin rashes
○ Meningitis
○ Prematurity
○ Low birth weight
○ Miscarriage, stillbirth, neonatal death - fetal / neonatal demise occurs in 40% of affected pregnancies
What is the OTHER in TORCH (5)?
syphilis,
varicella,
parvovirus,
HIV,
hep B
Which parts of TORCH do we routinely test for?
Syphillis
Rubella
Varicella (if not immune)
HIV
Hep B
What is the transmission rate from parvo B19 infection to fetus?
17-33%
What could childhood effects of syphilis be?
○ <2 years from birth
■ asymptomatic
■ Preterm birth
■ Low birthweight
■ Stillbirth
■ Disseminated infection
■ Skin or mucous membrane lesions
■ Bone deformities
■ Anemia
■ Hepatosplenomegaly
■ Neurologic complications as above, deafness
○ >2 years from birth
■ Scarring of cornea
■ Lymphadenopathy
■ Dental abnormalities
What does parvo look like in children?
Red cheeks, flu
Does Varicella testing need to happen routinely?
No, screening first if they have had it (prior to 2004) or had routine vaccines
What can happen if parvo crosses placenta?
Miscarriage
Hydrops
Fetal anemia
Hypoxia
Impaired hepatic function
What is the chance of nb transmission with active recurrent HSV lesions at time of birth for vag birth?
2-5 %
What are the potential abn findings on US for toxo? (6)
○ Hydrocephalus
○ Intracranial calcifications
○ Microcephaly
○ Fetal growth restriction
○ Ascites
○ Hepatosplenomegaly
Risks of toxo for the fetus?
Vertical transmission can lead to blindness, cerebral/cardiac anomalies
Serology for toxo?
IgG/IgM both negative = absence of infection or extremely recent acute infection
Positive IgG + negative IgM = old infection (infection greater than 1 year ago)
Both IgG/IgM both positive = recent infection OR false-positive test result
Serology for 5ths disease/parvo
+ IgG, - IgM = immune
- IgG, + IgM = recent infection/false positive
+ IgG, + IgM = recent infection, repeat bloodwork should show increasing parvovirus B19 IgG titre. If IgG titre does not increase, then it indicates an older infection
- IgG, - IgM = non-immune susceptible to infection
What is OTHER in Torch ? (5)
syphilis
varicella
parvovirus
HIV
hep B
Tx for syph?
Benzathine Pen G (different than Pen G we give in labour)
2.4 million units IM weely 1-2 x
Tx for chalmydia?
Amox 500 mg PO TID 7 days
Potential U/S findings that can relate to TORCH congenital infections ? (9)
-Big heart
-Big spleen/lover
-Big plaenta
-Big brain
-Hydrops
IUGR
-Oligo/Poly
-Brain calcifications
-Abdominal calcifications
- Cerebral ventriculomegaly
-Intracranial calcifications
-Cardiomegaly - Hepatosplenomegaly
-Intra-abdominal calcifications
-Hyrdops Fetalis
-Placentomegaly
-Hydroamnio/Oligo
-IUGR
