TORCH screening in pregnancy. Where are we now? An audit of use in a tertiary level centre

The Utility of Serologic TORCH Testing During Pregnancy for Maternal-related Versus Fetal-related Indications: A Retrospective Study

BACKGROUND

Clear guidelines have not been established about the utility of TORCH serology testing in women for whom TORCH infection is suspected according to clinical and laboratory manifestations during pregnancy. We aimed to compare rates of TORCH infections [specifically cytomegalovirus (CMV), Toxoplasma and rubella] in women who underwent TORCH serology testing due to maternal- versus fetal-related indications.

METHODS

This 10-year single-center retrospective study included all the women beyond 24 weeks of gestation who underwent TORCH serology testing due to maternal- or fetal-related indications. Maternal-related indications included fever, gastroenteritis, elevated liver enzymes and thrombocytopenia. Fetal-related indications included intrauterine growth restriction, polyhydramnios and oligohydramnios.

RESULTS

During the study period, 304 women underwent TORCH serology testing due to maternal-related indications and 771 due to fetal-related indications. For the maternal-related compared with the fetal-related indication group, maternal and congenital TORCH infections were more prevalent ( P = 0.015), specifically CMV ( P = 0.036). Eight (2.6%) of the women with maternal-related indications had a primary TORCH infection; 4 of them (50%) had concomitant congenital infections. Six (0.8%) of the women with fetal-related indications had a primary infection; none had a related congenital infection. Among the women with maternal-related indications, higher rates of maternal TORCH infection were found among those with thrombocytopenia (7.1%) and elevated liver enzymes (3.0%). During the study period, maternal-indicated TORCH testing detected 10.8% of neonates born with a confirmed TORCH infection.

CONCLUSIONS

The clinical yield of TORCH serology for nonspecific sonographic fetal features was low. Nonetheless, maternal-related indications should prompt testing for CMV and Toxoplasma infection.

Clinical utility of maternal TORCH screening in fetal growth restriction: A retrospective two-centre study

OBJECTIVE

The aim of this study was to evaluate the indications for maternal TORCH (Toxoplasma gondii, rubella, cytomegalovirus (CMV), and herpes simplex virus (HSV)) serology, with a focus on the yield in isolated fetal growth restriction (FGR).

MATERIALS AND METHODS

A retrospective review of antenatal TORCH testing between January 2014 and December 2018 was carried out at two hospitals in Melbourne, Australia. TORCH testing ordered for pregnancy losses and stillbirth was excluded.

RESULTS

Medical records of 718 pregnancies were reviewed, representing 760 fetuses. Isolated FGR was the indication for TORCH screening in 71.2% of pregnancies. Screens ordered for isolated FGR were positive in 7.4% (95% CI 5.5-10.0%). There were 49 positive maternal immunoglobulin M (CMV = 34, Toxoplasma = 15). Two acute maternal infections during pregnancy were diagnosed (CMV = 1, Toxoplasma = 1), with both screens ordered to assess symptomatic maternal illness. There was one neonatal CMV infection, born to a woman with symptomatic primary CMV. No maternal or neonatal rubella or HSV infections were identified. We found a diagnostic yield of TORCH screening for isolated FGR of 0.0% (95% CI 0.00-0.8%). An estimated AUD$64 269.75 was expended on maternal TORCH screens in this study.

CONCLUSION

Maternal TORCH testing for isolated FGR is of no diagnostic yield and should be abandoned.

The Utility of Maternal TORCH Screening Due to Obstetrical Indications in Detecting Congenital Infections: A Retrospective Observational Study

BACKGROUND

The diagnostic yield of TORCH screening for obstetrical indications is unclear. We evaluated TORCH testing results among women with intrauterine growth restriction (IUGR), polyhydramnios and oligohydramnios; and associations with congenital infections in neonates.

METHOD

This retrospective single-center study included all the women diagnosed with IUGR, polyhydramnios or oligohydramnios who underwent serological TORCH testing during 2010-2019. TORCH screening included Toxoplasma, cytomegalovirus (CMV), rubella IgM and IgG. The data, which were cross-referenced with data of neonates with congenital TORCH infections during the same period, included indications for neonatal testing, sonographic findings and neonatal ophthalmologic and hearing findings.

RESULT

Six women of 771 (0.8%) were diagnosed with primary TORCH infection: 4 (0.5%) with toxoplasmosis, and 2 (0.3%) with CMV. None had a confirmed congenital infection. The rates of positive maternal TORCH screening in IUGR and polyhydramnios were 2.1% and 0.6%, respectively. Maternal TORCH infection was not identified in any woman with oligohydramnios or severe polyhydramnios. None of the neonates with congenital infection were screened for TORCH during pregnancy due to polyhydramnios, oligohydramnios or IUGR. Among the neonates with congenital CMV, the most common indication for performing neonatal CMV polymerase chain reaction was suspected primary maternal infection during pregnancy due to symptomatic CMV. No incidences of congenital rubella were noted in the last decade in our medical center.

CONCLUSION

Our results suggest that routine TORCH screening in pregnancies complicated with IUGR, polyhydramnios or oligohydramnios should be avoided. Suggestive maternal symptoms and specific fetal sonographic features should prompt testing for CMV and Toxoplasma infection.

A systematic review of maternal TORCH serology as a screen for suspected fetal infection

BACKGROUND

The acronym 'TORCH' refers to well-recognised causes of perinatal infections: toxoplasmosis, rubella, cytomegalovirus (CMV) and herpes simplex virus (HSV). A TORCH serology panel is often used to test for maternal primary infection following detection of ultrasound abnormalities in pregnancy.

AIM

This review aims to estimate the diagnostic yield of maternal TORCH serology in pregnancy following fetal ultrasound abnormalities.

MATERIALS AND METHODS

Primary studies published since 2000 that assessed maternal TORCH serology for suspected fetal infection and included information on indications for testing, definition of positive TORCH serology results, and perinatal outcomes were included.

RESULTS

Eight studies with a total of 2538 pregnancies were included. The main indications for testing were polyhydramnios, fetal growth restriction and hyperechogenic bowel. There were 26 confirmed cases of congenital CMV, of which 15 had multiple ultrasound abnormalities. There were no cases of congenital toxoplasmosis, rubella or HSV confirmed in any of the eight studies.

CONCLUSIONS

The clinical utility of TORCH serology for non-specific ultrasound abnormalities such as isolated fetal growth restriction or isolated polyhydramnios is low. It is time to retire the TORCH acronym and the reflex ordering of 'TORCH' panels, as their continued use obscures, rather than illuminates, appropriate investigation for fetal ultrasound abnormalities.