TORCH:

principles and practice TORCH: A Literature Review and Implications for Practice LOIS HAGGERTY, RN, MSN Major issues related to TORCH (toxoplasmosis, rubella, cytomegalo virus, and herpes virus) perinatal infection are of concern to maternity and neonatal nurses. General and congenital modes of transmission, associated congenital defects, incidence of infection, and relative fetal/neonatal effects of primary as compared to recurrent maternal infection are described. Associated nursing implications emphasizing prenatal prevention and early detection, intrapartal management, neonatal symptom detection, and nursery infection control as well as concerns about breastfeeding with maternal TORCH are discussed.

Although the Rubella epidemic resulting in serious neonatal illnesses occurred years ago, its legacy has heightened awareness of the hazards of perinatal infection. lnfections representing a potentially serious threat during the pregnancy period are the TORCH group: toxoplasmosis, rubella, cytomegalovirus (CMV), and herpes virus (HSV). With the exception of toxoplasmosis, caused by the protozoan parisite Toxoplasma gondii, each of these diseases is caused by viruses. Cytomegalovirus and herpes virus are members of the same viral family and the incidence of these diseases tends to increase during pregnancy. Active maternal infections occur in approximately 15%of all pregnancies.' However, depending upon the disease entity, a small number of these women will have infected neonates and a n even smaller number of afflicted infants will

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manifest serious medical problems (Table 1). Many factors influence the outcome of these pregnancies. Generally, primary maternal infection and early gestational age are associated with more severe newborn health problems. Other factors may include maternal immune responses and variations in viral strains.

bor and delivery, and the neonatal period, the nurse should be alert to mothers and infants at risk for developing TORCH infections or to signs and symptoms that such infections have manifested. Preventing the spread of infection is a major nursing responsibility. PRENATAL PREVENTION AND EARLY DETECTION

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NURSING MANAGEMENT

Rubella

Nursing management in perinatal infection involves several dimensions. The nurse must recognize mechanisms that may help prevent infection and counsel pregnant women in this regard. The nurse must also be prepared to discuss the risks of possible infection and management options with potentially infected women and respond to their concerns and questions. During pregnancy, la-

Rubella is the most easily preventable disease of the TORCH group since vaccine is available. According to the Centers for Disease Control, rubella vaccine should be given at 15 months of age. Pregnant women are screened for rubella with a simple blood test called the HI or HA1 test (hemagglutination-inhibition test). A titre greater than 1:lO demonstrates immunity to rubella. If the titre is

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Table 1. Infections Representing Potentially Serious Threats During Pregnancy

General Mode of Transmission

Organisms

Mode of Congenital Transmission

Associated Congenital Defects

Incidence of Infection

Occurrence of Fetal/Neonatal Infection With Primary Versus Recurrent Infection

Toxoplasmosis

Ingestion of oocysts in raw meats or ingestion of oocysts from hands contaminated by cat feces or soil

Maternal bloodstream via placenta

Microcephaly, hydrocephaly, cerebral calcifications, and ch~reoretinitis~

One study indicated that laboratory evidence of congenital infection was present in three of 4048 neonates; but only one of these newborns was sympt~matic.’~

Primary infection

Cytomegalovirus (CMV)

Intimate and/or oral genital contact

Maternal bloodstream via placenta

Microcephaly, cerebral calcifications, hepatosplenomegaly, jaundice and seizures7

Average incidence is one percent of all births but neonatal infection is most often clinically inapparent. Of this one percent, approximately five percent to 10% have the more virulent form of the disease and either develop serious late complications (hepatosplenomegaly, jaundice, and petechiae) or die. Another 10% of those born with subclinical congenital infection subsequently manifest perceptual, psychomotor, neurologic, or behavioral complications during the preschool period.6

Primary and recurrent infection (primary infection is thought to be more serious)

Rubella

Droplet infection via respiratory tract

Maternal bloodstream via placenta

Heart, blood vessel defects-deafness, cataracts, and glaucoma7

Approximately 10% to 15% of women in the childbearing years are estimated to be susceptible.’ Percentage of infected fetuses per infected mothers varies according to gestational age. It is estimated to be as high as 54% during the first eight weeks and as low as 10% between 13 and 24 weeks.14

Primary infection

(Continued)

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Table 1. (Continued)

Organisms Herpes virus (HW

General Mode of Transmission

Mode of Congenital Transmission

Associated Congenital Defects

Direct contact with lesions or discharge and sexually transmissible

Rarely via placenta-nearly always via direct contact with vaginal secretions during delivery or ascending infection after prolonged membrane rupture

Incidence of congenital malformation is rare as HSV infection is usually a neonatal, not a congenital problem

Incidence of Infection Nahamias et a/., indicate that 1/10001/I 500 private obstetric patients have genital herpes. Incidence is thought to be much higher in lower socioeconomic groups. Risk of neonatal infection is about 60% with exposure at delivery to active maternal infections. Amstey estimates this risk at 25% to

Occurrence of Fetal/Neonatal Infection With Primary Versus Recurrent Infection Primary and recurrent infection (primary infection is thought to be more serious)

30°/o.5.’5

equal to or less than 1:10, monitoring of titres on a monthly basis during the first trimester may be recommended. A rise in titres may indicate the need for further consultation or diagnostic evaluation. A woman exposed to rubella whose titre is 1:lO should have a repeat titre in a week to 10 days. An exposed woman whose titre is less than 1:lO should have a repeat titre in 21 to 28 days. A fourfold or greater rise in titres of the paired sera is definitive for rubella infection, while a smaller rise demands further diagnostic studies.’ Susceptible women with rubelliform rashes should have titres drawn at the time of the appearance of the rash and repeat titres within seven to 10 days.’ Titres of these paired sera are compared to determine whether a rise has occurred. Elevations in titres are evaluated in the same manner as for exposed susceptible individuals who do not manifest the rash. Nonimmune pregnant women should be immunized after delivery and counseled to avoid pregnancy for three months after immunization to prevent the trans-

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mission of vaccine virus to a fetus.3 Susceptible pregnant women should be counseled to avoid other susceptible individuals. Members of pregnant women’s households should receive the vaccine if necessary. Symptoms of rubella include a maculopapular rash, fever, and arthritic-like symptoms. However, while rubella infection may not be clinically obvious, it can still be hazardous to the fetus.2 Prior to the fetus’s age of viability, an infected woman may decide to proceed with therapeutic abortion. The nurse’s empathy in presenting factual information on fetal risks is essential in supporting parents through such difficult decisions. Herpes Herpes may be of the genital variety (HSV2) or the nongenital variety (HSVl). HSV2 is more often implicated in newborn disease than HSV1.4 HSVl (cold sores) can infect genitals if oral sex occurs when one partner has an oral lesion. The nurse should inform

the pregnant woman that antibody to HSVl does not protect against HSV2 nor does previous infection with either type protect against recurrences with the same type. No cure exists for herpes. lncreased incidence of spontaneous abortion and prematurity have been associated with genital herpes infection during pregn a n ~ y . ~The , ’ nurse should counsel pregnant women to avoid sexual relations with partners who have penile lesions and that partners with a history of genital herpes should use condoms. Pregnant women should also avoid oral sex with a partner who has a suspicious oral lesion. The prenatal health history and exam should determine whether the client has a history of herpetic lesions below the waist, active genital lesions, or a partner with a history of herpes virus. This woman is at risk for developing genital herpes virus infections and cervical cultures may be recommended every two weeks during the last two months of pregnancy to detect active virus. If HSV2 occurs during pregnancy, abortion

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is generally not considered an option since newborn infection nearly always results from direct contact with the active virus during delivery and only rarely results from intrauterine exposure.

Cytomegalovirus Cytomegalovirus is the most common congenital viral infection6 and the most difficult to prevent because cytomegalovirus is generally asymptomatic. Women in middle to upper income groups are less apt to have antibodies to cytomegalovirus than those in lower income groups and are, therefore, more susceptible to primary infection during pregnancy.6 Symptoms that may be significant are mononucleosis-like flu symptoms in the absence of a positive heterophile. Parents have the option of aborting a pregnancy if cytomegalovirus infection is diagnosed before legal viability of the fetus. Toxoplasmosis Toxoplasmosis may be prevented by effective prenatal counseling. The nurse should advise the patient at the initial prenatal visit to avoid ingestion of undercooked meat, contact with cat feces or kitty litter, and to use good handwashing techniques and/or gloves during gardening, since these may be reservoirs for growth of the toxoplasma parasite. Toxoplasmosis is generally clinically silent but occasionally presents with mononucleosis-like flu symptoms. Various drugs available for maternal treatment may be of risk to the fetus. A woman diagnosed before fetal viability can decide between continuing the pregnancy or therapeutic abortion. Toxoplasmosis is not considered contagious as it is tissue bound and not e ~ c r e t e d . ~ Careful handwashing to prevent self- and cross-contamination in perinatal infection should be em-

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phasized. Prenatal visits of potentially communicable patients should be scheduled for a time and place where they are least likely to infect other patients. INTRAPARTAL MANAGEMENT Because herpes virus is the TORCH infection of greatest risk to the fetus during delivery and because herpes virus is generally diagnosable by history and viral culture, it is the TORCH infection most amenable to nursing and medical interventions during the antepartal and intrapartal period. Cesarean section before membrane rupture is generally recommended if active genital infection is present in the reproductive tract within the last two weeks of gestation.’ Vaginal delivery with active recurrent infection (although not recommended) appears less hazardous to neonates than vaginal delivery with active primary infection.8 Prolonged rupture of the membranes (over four hours) may expose the infant to ascending infection. In the absence of active virus or lesions, delivery through the birth canal is acceptable. The nurse should prepare the patient for cesarean delivery when indicated. If the virus is active, the patient may be anxious concerning both the effects of surgery on herself and the chances of having an infected infant. The nurse can provide much needed support and education. If abdominal delivery is performed before or shortly after membrane rupture, the nurse can assure the patient that the chance of delivering an infected infant is very small.4 In admitting patients to labor and delivery, the nurse should review the prenatal chart and elicit a history to determine whether the patient is at risk for herpes virus. Patients who have not had prenatal care or whose records are unavailable require special at-

tention. Identification of risk focuses on determining whether the patient has a history of herpetic lesions below the waist or a sexual partner with herpes virus. Nurses should also observe for the presence of lesions. Medical and other nursing personnel should be alerted to patients at risk for herpes virus or those with suspect lesions. To protect themselves and other patients, nurses should exercise infection control measures with patients who have active herpes virus. Gown, glove, and linen precautions are necessary. Perineal pads should be handled like linens and double bagged. When the virus is inactive, no special precautions are necessary. Pregnant personnel should not be assigned to patients with herpes virus. Furthermore, any nurse with herpetic lesions on exposed body surfaces should not work with newborns. POSTPARTUM MANAGEMENT In the postpartum period, nursing activities focus on neonatal symptom detection and infection control measures. Neonatal Symptom Detection The incubation period for neonatal herpes in an infant infected at birth averages six to twelve days.7 Therefore, symptoms may not occur until the infant has been discharged from the hospital. Nurses should know which infants are at risk for the development of herpes virus arid should observe for lesions, jaundice, purpura, or other symptoms. At the time of discharge, mothers should be encouraged to report any unusual signs/symptoms immediately. Not all infected infants develop herpetic lesions; a few remain asymptomatic after the incubation period. Cytomegalovirus, toxoplasmosis, and rubella may be asymptomatic in the newborn nursery

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ensure that the patient understands and uses the correct techniques. An infected mother should not visit the nursery area unless the infant is not permitted in the mother’s room. If the mother must go into the nursery to visit the infant, she should observe gown and glove (or thorough handwashing) precautions. The mother may view her infant from the nursery window if she washes her hands thoroughly and wears a clean gown. Mothers with active, nongenital herpes lesions should be in a private room. Dressings covering their lesions should be handled like infected discharges and double bagged. After the lesions have begun to crust, the mother may receive her infant or view him/ her at the nursery window wearing a mask or dressing to cover the infected area and using proper gowning and gloving (or thorough handwashing). The nurse should be sensitive to the problems associated with maternal-infant Herpes separation in the early puerperium Herpes infection of the neonate and provide support. lnfants of is a severe and potentially fatal women with active nongenital disease associated with hepatitis, herpes become suspect for infecpneumonia, encephalitis, and diftion once they have gone out to fuse intravascular c ~ a g u l a t i o n . ~ the mother and, at this point, are Therefore, infection control in the subject to the same isolation pronursery warrants serious attencedures already discussed. tion. Women with a history of nongenital or genital herpes that Nursery Infection Control is inactive at term need not be isolated. Women with active geniNurses should take extreme tal or nongenital herpes should care to prevent cross-infection be isolated in a private room. from suspected herpetic infants to Gown, glove, and linen precauother infants and to protect themtions should be enforced with paselves from possible contaminatients with active genital herpes. tion. Since herpes virus is spread Perineal pads should be treated by direct contact, gown, glove, like infected discharges. The and linen precautions are impormother should be educated to the tant. Diapers and other contamineed for, and methods of, precaunated articles should be treated tions. The mother should thorlike infected discharges. Infants of oughly wash her hands, put on a mothers with genital lesions or clean gown, and be out of bed positive cervicovaginal cultures or before receiving her infant. Nurscytology at term should be isoing supervision is important to lated regardless of delivery mode.g and go undetected. The nurse should recognize that absence of symptoms of cytomegalovirus, toxoplasmosis, and rubella in the nursery is not synonymous with absence of disease. These infections may become symptomatic after discharge if the infection was acquired late in pregnancy. Clinical signs that should alert the nurse to the possibility of overt infections include enlargement of the liver and spleen. Petechial or purpuric rash may indicate cytomegalovirus or rubella. Some of these infections are associated with increased incidence of intrauterine growth retardation and prematurity. A known maternal history of infection alerts the team to the need for careful observation and follow-up to detect symptoms of disease, such as hearing loss or developmental delays that may manifest in later infancy or early childhood, despite the appearance of normalcy at birth.

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Some nurseries separate suspect infants within the nursery via spatial arrangements or incubators. Infants with active herpes should be isolated outside the nursery in an isolation area. Again, nurses with herpetic lesions on exposed body parts should not be assigned to newborns. Mothers with herpes lesions should be observed with their infants to ensure that they will know how to use precautions at home once discharged. When the lesions become inactive, the need for precautions no longer exists. Since cytomegalovirus is thought to be spread by direct contact, infected infants should be isolated in isolettes or incubators and gown and linen precaution should be used. Good handwashing techniques are critical. Because virus is shed in the urine, used diapers or linens should be treated like infected discharges and double bagged. Infected infants may continue to shed virus for several months, representing a potential source of infection. Shifting of hospital personnel from the nursery to other areas because of cytomegalovirus susceptibility is often not practical, and exposure on pediatrics may be as significant as in the nursery. There is little data to indicate that cytomegalovirus is readily disseminated to other patients and personnel in a hospital setting.” Many women of childbearing age are thought to be seropositive for cytomegalovirus and are, therefore, not susceptible to primary infection? Furthermore, the intimate contact associated with disease transmission may discourage dissemination. Women and newborns infected with toxoplasmosis are not contagious and need not be i ~ o l a t e d . ~ Infants with congenital rubella are contagious and may shed virus for several months after birth. Members of their households should be immunized if necessary. Many

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hospitals require testing for rubella antibodies of personnel in ob-gyn and pediatrics. Individuals without immunity should receive rubella vaccine. Gown and handwashing precautions as well as placement of t h e infant in a n incubator or isolette will help prevent the spread of infection t o other infants.

Breastfeeding w i t h Maternal TORCH

Often, questions arise as to whether o r not mothers infected with one of t h e TORCH organisms should be advised against breastfeeding because of t h e potential of infecting t h e newborn. More data may be needed before a conclusive response can be given. Evidence is lacking that herpes virus can be transmitted by breast milk but breast milk of mothers with cytomegalovirus does contain t h e virus in 25% of women with positive s e r ~ l o g y .Postpartal ~ women vaccinated with rubella virus can breastfeed without posing a risk to their n e ~ n a t e . ~ . Since " toxoplasmosis is not excreted, it is not transmitted oia breast milk. Ultimately, t h e mother's decision about breastfeeding may be based on inconclusive data. Medical advice may vary according t o how conservative a position t h e pediatrician selects. T h e nurse can help the mother t o understand that data is inconclusive regarding t h e advisability of breastfeeding with some TORCH infections. The nurse should support t h e woman to make an informed decision.

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SUMMARY

Twenty million Americans are afflicted with herpes." Every year in t h e United States at least 1,750 infants are born who appear normal a t birth but, subsequently, develop serious problems due to congenital cytomegalovirus infect i ~ n Finally, .~ approximately 10% t o 15% of women in the fertile years remain susceptible to rubella despite t h e prevalent use of ~accine.~ Health education by nurses can be instrumental in preventing some of these infections while early maternal and neonatal symptom detection can ensure prompt diagnosis and treatment. Infection control can limit t h e incidence of these problems.

ACKNOWLEDGMENT The author wishes to thank Dr. Marguerite Herschel of St. Margaret's Hospital, Dorchester, MA, for her help in preparing this article.

REFERENCES 1. Knox GE. Influence of infection on fetal growth and development. J Reprod Med 1978;21(6):352. 2. McCubbin JH, Smith JS. How to diagnose rubella during pregnancy. Am Fam Physician 1981; 23(2):205-8. 3. Connaughton J. Teratogenicity of rubella virus and potential civil liability of the physician. J Indiana State Med Assoc 1978;1:22. 4. Schoenbaum SC, Cloherty JP. Manual of neonatal care. Cloherty JP, Stark AR, eds. Boston: Little Brown Co., 1980:28, 29. 5. Nahamias AJ, Josey WE, Naib ZM,

et al. Perinatal risk associated with maternal genital herpes simplex virus infection. Am J Obstet Gynecol 1971;110:825. 6. Stagno S, Pass RF, Dworsky ME, et al. Congenital cytomegalovirus infection. N Engl J Med 1982;306: 945. 7. Sever J , Larsen JW, Grossman JH. Handbook of perinatal infections. Boston: Little Brown Co., 1979:3, 6, 10, 14, 25, 159. 8. Bolognese RJ, Corson SL, Fucillo DA. Herpesvirus hominis type I1 infections in asymptomatic pregnant women. Obstet Gynecol 1976;48:507. 9. Kibrick S. Herpes simplex infection at term: what to do with mother, newborn and nursery personnel. JAMA 1980;243:159. 10. Hanshaw JB, Dudgeon JA. Viral diseases of the fetus and newborn. Philadelphia: W.B. Saunders, 1978: 108. 11. Grossman JH. Viral infections in obstetrics and gynecology. Obstet Gynecol Annu 1980;9:59. 12. Leo J. The new scarlet letter. Time 198262. 13. Kimball AC, Kean BH, Fuchs F. Congenital toxoplasmosis: a prospective study of 4,048 obstetric patients. Am J Obstet Gynecol 1971;111:2 11. 14. Alford CA. Infectious diseases of the fetus and newborn infant. Remington T, Klein J, eds. Philadelphia: W.B. Saunders, 1976232. 15. Amstey M. Maternal viral infection with adverse results: cytomegalovirus and herpes virus. Semin Perinat 1977;1:8.

Address for correspondence: Lois Haggerty, RN, MSN, School of Nursing, Boston College, Chestnut Hill, MA 02167. Lois Haggerty is an assistant professor at Boston College School of Nursing in Newton, Massachusetts.

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