TORCH screening in polyhydramnios: an observational study

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.

Amniotic Fluid Disorders: From Prenatal Management to Neonatal Outcomes

Amniotic fluid volume assessment has become standard in the surveillance of fetal well-being, especially in high-risk pregnancies. Amniotic fluid disorders are a frequent and important topic in fetal and perinatal medicine. However, although important advances have been achieved, many important and challenging questions remain unanswered to date. An abnormally low amniotic fluid volume, referred to as oligohydramnios, has been traditionally considered a possible indicator of placental insufficiency or fetal compromise and is associated with an increased rate of obstetric interventions. An excess of amniotic fluid, referred to as polyhydramnios, may be secondary to fetal or maternal conditions and has been associated with a variety of adverse pregnancy outcomes, especially when it is severe. The ultrasonographic detection of an amniotic fluid disorder should prompt a proper workup to identify the underlying etiology. Data on the association of isolated oligohydramnios or idiopathic polyhydramnios with adverse obstetric and perinatal outcomes are conflicting. While the management of secondary oligohydramnios is usually guided by the underlying condition, the management of isolated oligohydramnios is poorly defined. Similarly, the management of idiopathic and secondary polyhydramnios is not yet standardized. There is an urgent need for randomized clinical trials to provide stronger recommendations on the management of these two common conditions.

Term Idiopathic Polyhydramnios, and Labor Complications

Background and Aim: Polyhydramnios is associated with an increased risk of various adverse pregnancy outcomes, yet complications during labor have not been sufficiently studied. We assessed the labor and perinatal outcomes of idiopathic polyhydramnios during term labor. Methods: Retrospective cohort study at a tertiary medical center between 2010 and 2014. Women with idiopathic polyhydramnios defined as an amniotic fluid index (AFI) greater than 24 cm or a deep vertical pocket (DVP) > 8 cm (cases) were compared with women with a normal AFI (5-24 cm) (controls). Statistics: Descriptive, means ± SDs, medians + IQR. Comparisons: chi-square, Fisher's exact test, Mann-Whitney Test, multivariate logistic models. Results: During the study period 11,065 women had ultrasound evaluation completed by a sonographer within two weeks of delivery. After excluding pregnancies complicated by diabetes (pre-gestational or gestational), fetal anomalies, IUFD, multifetal pregnancies, elective cesarean deliveries (CD) or missing data, we included 750 cases and 7000 controls. The degree of polyhydramnios was mild in 559 (75.0%) cases (AFI 24-30 cm or DVP 8-12 cm), moderate in 137 (18.0%) cases (30-35 cm or DVP 12-15 cm) and severe in 54 (7.0%) cases (AFI >35 cm or DVP > 15 cm). Idiopathic polyhydramnios was associated with a higher rate of CD 9.3% vs. 6.2%, p = 0.004; a higher rate of macrosomia 22.8% vs. 7.0%, p < 0.0001; and a higher rate of neonatal respiratory complications 2.0% vs. 0.8%, p = 0.0001. A multivariate regression analysis demonstrated an independent relation between polyhydramnios and higher rates of CD, aOR 1.62 (CI 1.20-2.19 p = 0.002) and composite adverse neonatal outcome aOR 1.28 (CI 1.01-1.63 p = 0.043). Severity of polyhydramnios was significantly associated with higher rates of macrosomia and CD (p for trend <0.01 in both). Conclusions: The term idiopathic polyhydramnios is independently associated with macrosomia, CD and neonatal complications. The severity of polyhydramnios is also associated with macrosomia and CD.

Bronchopulmonary dysplasia is associated with polyhydramnios in a scan for novel perinatal risk factors

BACKGROUND

The pathogenesis of bronchopulmonary dysplasia (BPD) is multifactorial, and there are limited data about prenatal exposures and risk of BPD.

STUDY DESIGN

Our study performed parallel analyses using a logistic regression model in a cohort of 4527 infants with data from a curated registry and using a phenome wide association study (PheWAS) based on ICD9/10-based phecodes. We examined 20 prenatal exposures from a neonatal intensive care unit (NICU) curated registry database related to pregnancy and maternal health as well as 94 maternal diagnosis phecodes with a PheWAS analysis.

RESULT

In both the curated registry and PheWAS analyses, polyhydramnios was associated with an increased risk of BPD (OR 5.70, 95% CI 2.78-11.44, p = 1.37 × 10^-6).

CONCLUSION

Our data suggest that polyhydramnios may be a clinical indicator of premature infants at increased risk for bronchopulmonary dysplasia. Combining curated registry data with PheWAS analysis creates a valuable tool to generate hypotheses.

IMPACT

Polyhydramnios was significantly associated with bronchopulmonary dysplasia in both a curated registry and by ICD coding analysis with a phenome wide association study (PheWAS). Preterm polyhydramnios may be a clinical indicator of infants at increased risk for developing bronchopulmonary dysplasia after preterm birth. Combining curated registry with PheWAS analysis creates a valuable tool to generate hypotheses about perinatal risk factors and morbidities associated with preterm birth.

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.

Performance of diagnostic ultrasound to identify causes of hydramnios

INTRODUCTION

We aimed to assess the diagnostic yield of ultrasonography in the identification of the etiology of hydramnios, and the added value of MRI or amniocentesis.

METHODS

We conducted a single-center retrospective study including pregnancies with confirmed hydramnios (defined as deepest pocket ≥8 cm) between January 2013 and May 2017. Twin pregnancies, secondary hydramnios discovered after the diagnosis of a causal pathology, and pregnancies of unknown outcome were excluded. All pregnancies underwent a targeted scan, and selected cases underwent MRI or amniocentesis.

RESULTS

A total of 158 patients with confirmed hydramnios were included. Hydramnios was associated with a fetal pathology in 37 cases (23.4%), with diabetes in 39 (24.6%), isolated macrosomia in 16 (10.1%), and considered idiopathic in 66 (41.7%). Ultrasonography established a diagnosis of the underlying pathology in 73% of cases. Amniocentesis was done in 31 cases (20%) and it allowed diagnosis of chromosome anomalies, esophageal atresia, myotonic dystrophy congenital type, Prader-Willi syndrome, and Bartter syndrome. MRI was done in 15 cases (10%) and it allowed one additional diagnosis of esophageal atresia. The diagnostic yields of MRI and amniocentesis were 91.7% and 95.2%, respectively. There were five false positive diagnoses at ultrasonography, and one false positive diagnosis at MRI.

CONCLUSION

Hydramnios can be associated with a wide variety of underlying pathologies. Diagnostic ultrasound can attain a diagnosis in the majority of cases. Amniocentesis offers a valuable complementary assessment.

[Postnatal outcome from polyhydramnios without sonographic abnormalities]

OBJECTIVES

To assess adverse outcome of polyhydramnios without morphological abnormalities and to determine the factors associated with an adverse outcome.

METHODS

This is a retrospective observational cohort study conducted in a French tertiary care unit between 2008 and 2018 including all women with singleton pregnancy complicated by polyhydramnios. Presence of morphological abnormality was an exclusion criteria. The primary outcome was the rate of adverse outcome, defined by a composite criterion including death or postnatal discovery of malformation or chronic pathology. Maternal, obstetrical, paediatric and polyhydramnios characteristics were collected.

RESULTS

Ninety-one women with polyhydramnios were included. The rate of adverse outcome was 24.2% (22/91). This rate was 20,3% in case of idiopathic polyhydramnios and 33,3% in case of maternal diabetes associated. The postnatal mortality rate was 5.5%. The rate of malformations not diagnosed in antenatal was 11%. Obesity (50% vs. 18,8%; P=0,004), early diagnosis (72,7% before 32 WG vs. 44,9%; P=0,02), and severity of polyhydramnios (22,7% vs. 4,3% in severe polyhydramnios; P=0,01) were associated significantly with an adverse outcome. In these cases, the incidence of preterm delivery was higher.

CONCLUSION

Polyhydramnios must have second-line ultrasound, including isolated maternal diabetes. A systematic genetic assessment can be discussed.

The association between polyhydramnios and CMV infection - retrospective cohort study

Objective: Polyhydramnios was suggested to be associated with CMV infection, resulting in polyhydramnios being common indication for CMV testing. However, the literature does not provide a robust evidence to support this management. We aimed to examine the association between congenital CMV infection and polyhydramnios.Methods: A retrospective cohort study was conducted. The rate of polyhydramnios was analyzed in 63 neonates/fetuses with CMV between 2013 and 2017 and compared to 351 neonates without CMV using PCR targeted to the viral DNA. The rate of oligohydramnios and small for gestational age was also evaluated.Results: All cases of polyhydramnios were of isolated polyhydramnios without malformations. The rate of polyhydramnios was six (9.5%) and 23 (6.6%) pregnancies with and without congenital CMV, respectively (p = .42). Persistent polyhydramnios (more than one documented event) was evident in one (1.6%) and 13 (3.7%) pregnancies in the positive and negative CMV groups, respectively (p = .36). The rate of congenital CMV was similar with and without oligohydramnios (6, 9.5% versus 17, 4.8%, respectively; p = .14) and with or without small for gestational age neonate (7, 11% versus 63, 18%, respectively; p = .18).Conclusion: The results of this study do not support an association between CMV infection and polyhydramnios. The need for CMV testing in isolated polyhydramnios should be reevaluated.

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

This audit was performed in the obstetrics and gynaecology department of a tertiary referral hospital, to investigate the use and results of TORCH screening. St Michael's Hospital delivers approximately 6,000 women from South Bristol a year and receives tertiary referrals from the South West of England and South Wales. It was found that 739 patients over a 6-year period from April 2006 to January 2012 underwent testing. The majority's indication (21%) was polyhydramnios. Three patients had evidence of primary CMV infection in pregnancy on serology, two for fetal indications (polyhydramnios and echogenic bowel) and one following a miscarriage. There were no confirmed cases of gestational toxoplasma or rubella. Routine testing for toxoplasma and rubella infection as part of the TORCH screening in cases of fetal or obstetric abnormality should thus be discontinued in our population.

Polyhydramnios: Causes, Diagnosis and Therapy

Polyhydramnios is defined as a pathological increase of amniotic fluid volume in pregnancy and is associated with increased perinatal morbidity and mortality. Common causes of polyhydramnios include gestational diabetes, fetal anomalies with disturbed fetal swallowing of amniotic fluid, fetal infections and other, rarer causes. The diagnosis is obtained by ultrasound. The prognosis of polyhydramnios depends on its cause and severity. Typical symptoms of polyhydramnios include maternal dyspnea, preterm labor, premature rupture of membranes (PPROM), abnormal fetal presentation, cord prolapse and postpartum hemorrhage. Due to its common etiology with gestational diabetes, polyhydramnios is often associated with fetal macrosomia. To prevent the above complications, there are two methods of prenatal treatment: amnioreduction and pharmacological treatment with non-steroidal anti-inflammatory drugs (NSAIDs). However, prenatal administration of NSAIDs to reduce amniotic fluid volumes has not been approved in Germany. In addition to conventional management, experimental therapies which would alter fetal diuresis are being considered.