Indian Journal of Microbiology Research 2023;10(4):209–215
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Indian Journal of Microbiology Research
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Original Research Article
An examination of the seroprevalence of torch infections and their correlation with
adverse reproductive outcomes in females exhibiting a bad obstetric history
Mohammed Mohammed
, May Salem Al-Saadi
, Abdullah Salim Al-Karawi
*
1
Gilgamesh Ahliya University, College of Health and Medical Technologies, Baghdad, Iraq
2
Dept. of Microbiology, College of Science, Mustansiriyah University, Baghdad, Iraq
A R T I C L E I N F O
Article history:
Received 21-09-2023
Accepted 03-11-2023
Available online 27-12-2023
Keywords:
Bad obstetric history perinatal
outcome
Cytomegalovirus
High- risk pregnancy
Herpes simplex virus
Rubella virus
Seronegative
Seropositivity
Toxoplasma
A B S T R A C T
Background
: The term TORCH infections refer to a group of diseases including Toxoplasma, Other
(syphilis, varicella-zoster, parvovirus B19), Rubella, Cytomegalovirus (CMV), and Herpes infections.
These are a set of pathogens capable of traversing the placental barrier, subsequently causing congenital
infections. Often these infections are asymptomatic initially and pose significant diagnostic challenges
during gestation, potentially leading to undesirable obstetric outcomes. This research intends to explore the
correlation between TORCH infections and perinatal outcomes within pregnancies deemed high-risk.
Methodology
: We examined 143 high-risk pregnant patients aged 18-46 from the Obstetrics and
Gynecology Department at the Baghdad Gynecology and Obstetrics Hospital. Hundreds of normal
pregnancy group were also included. The high-risk group encompassed women with recurring pregnancy
loss, fetal congenital anomalies, intrauterine fetal death, and low birth weight intrauterine neonatal death.
The presence of IgG and IgM antibodies against TORCH agents in patients’ serum control serum
were assessed using ELISA kits. We compared perinatal outcomes between TORCH seropositive and
seronegative high-risk pregnant women.
Findings
: Among the 143 high-risk pregnancies, a significant proportion of young, low-parity women
from diverse residences were co-seropositive for Toxoplasma gondii, rubella virus, Cytomegalovirus, and
Herpes Simplex infections. Of these, 55 cases (48.4%) were seropositive for all the four TORCH agents
compared to 88 cases (38%) were seropositive for antibodies to one to three of the TORCH agents. IgG
seropositivity was 74.5%, while IgM seropositivity was 31.8% for Toxoplasma gondii, 3.6% for CMV
and 0% for RV infections, respectively. Significantly, high-risk pregnancies with TORCH seropositivities
exhibited a clearly strong correlation with Habitual abortions outcomes.
Conclusion
:
High-risk
manifestations
demonstrated
for
Toxoplasma
gondii,
Rubella
virus,
Cytomegalovirus and Herpes Simplex infections strongly associated with habitual abortions compare to
high but less significant association in those seropositive to one, two or three of the TORCH agents
This is an Open Access (OA) journal, and articles are distributed under the terms of the
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1. Introduction
The expression ‘Bad Obstetric History’ (BOH) denotes
prior unfavorable fetal results, encompassing two or more
sequential spontaneous miscarriages, intrauterine fetal
* Corresponding author
.
E-mail address
:
abdullah.s.shaker@uomustansiriyah.edu.iq
(A. S.
Al-Karawi).
demise, retardation of growth, stillbirth, early neonatal
death,
and
congenital
anomalies.
Several
possible
etiologies of BOH may encompass genetic determinants,
hormonal
fluctuations,
abnormal
maternal
immune
reactions, and maternal infections.
The term ‘high-risk
pregnancy’ is associated with a pregnancy that augments
the mother’s, fetus’s, or neonate’s risk of morbidity or
mortality during gestation or delivery. Such pregnancies
https://doi.org/10.18231/j.ijmr.2023.037
2394-546X/© 2023 Author(s), Published by Innovative Publication.
209
210
Mohammed, Al-Saadi and Al-Karawi / Indian Journal of Microbiology Research 2023;10(4):209–215
are complicated by factors that adversely affect pregnancy
outcomes (either maternal, fetal, or both). Interestingly,
while only 10-30% of pregnant women are categorized
as high-risk during their antenatal period, they contribute
to 70-80% of perinatal mortality and morbidity.
The
TORCH test is categorized under the Infectious-Disease
Antidiv Titer blood examinations. It quantifies the
presence and concentration of antibodies against a specific
cluster of infectious diseases in the bloodstream. The
TORCH acronym encapsulates a group of acute and
chronic infections that women can potentially acquire
during gestation, resulting in profound implications for
the newborn. These infections can induce a spectrum of
symptomatic congenital disabilities in neonates, collectively
called the TORCH syndrome.
A positive IgG antidiv test
generally signifies past exposure to a TORCH agent and
does not necessarily imply a currently active infection. In
contrast, the detection of IgM antibodies is more intricate
and can yield false negative and positive outcomes.
Toxoplasmosis is engendered by Toxoplasma gondii, a
parasite ubiquitously found in humans. Maternal infection
can induce severe eye or central nervous system infections
in infants, the later the maternal infection occurs during
gestation, the higher the probability of fetal infection.
Conversely, toxoplasmosis acquired early in pregnancy can
result in a miscarriage or severe birth defects.
Rubella
impacts 0.1-2% of neonates. Birth defects are most likely
to transpire when infants are infected during the initial
eight weeks of gestation.
Cytomegalovirus (CMV), a
member of the herpesvirus group of infections, can induce
severe complications in infants, such as hearing loss, mental
retardation, pneumonia, hepatitis, or blood disorders.
Herpes simplex virus infection can pose a risk if transmitted
to an infant during delivery but generally does not affect
gestation or fetal health.
There is a lack of adequate data
on the prevalence and contributing factors among pregnant
women co-infected with TORCH in Iraq. This research
aims to fill this knowledge void by evaluating the status
and factors associated with high-risk pregnancies among
women attending antenatal health care about TORCH
infections. A thorough look on the possibility of any
differences between the 4 major TORCH agents and some
of the TORCH agents in respect to BOH manifestations
was also put in consideration.
2. Materials and Methods
This
prospective
study
involved
patients
attending
laboratories in Baghdad. The participant group comprised
243 women, including 143 with high delivery risk factors
and 100 clinically normal women with prior normal
pregnancies and full-term deliveries. The inclusion criteria
were based on a previous history of 2-3 pregnancy losses,
specifically habitual abortion (HA), intrauterine fetal deaths
(IUFD), neonatal death (NND), congenital malformation
(GM), stillbirth (SB), and low birth weight (LBW).
From each participant, 3 ml of venous blood was
collected under strict aseptic precautions. The serum
was used for serological evaluation of IgM and IgG
antibodies
for
Toxoplasma
gondii,
Rubella
virus,
Cytomegalovirus infections, and Herpes simplex virus
as per the manufacturer’s instructions using ELISA
techniques. The following kits were utilized:
1. Rubella IgG ELISA from BIOTEC Laboratories Ltd.
(UK).
2. Rubella IgM ELISA from BIOKIT, S.A. SPAIN.
3. CMV IgG ELISA from BIOKIT, S.A. SPAIN.
4. CMV IgM ELISA.
5. Toxoplasma gondii IgG Elisa kit from Biotech
Laboratories Ltd. (UK).
6. Toxoplasma gondii IgM from BIOTECH Laboratories
Ltd. (UK).
7. HSV-IgG and IgM Elisa kits from Serion Diagnostics
(Germany).
3. Results
Table 1 presents the demographic characteristics of the
enrolled patients. Occupation, history of contact with cats,
and blood transfusion yielded significant data (P = 0.01).
Residency, however, did not show any significant variations
as demonstrated.
Table 2 displays the age ranges of the recruited patients
along with their symptoms of Bad Obstetric History (BOH).
The majority of BOH cases were observed in the age
groups of 18-27 years for all three selected groups (45.5%,
47.7%, and 37% respectively). Conversely, the lowest
seroprevalence rates were found in the age ranges of 38-
46 years (23.6%, 17%, and 24% respectively) as shown in
Table 2.
Among the 143 cases with BOH manifestations, 55
(38.5%) exhibited TORCH seroprevalence (Table 3).
Habitual abortion was observed in 40 cases (72.7%) within
the TORCH group, while cases of intrauterine fetal death
(IUD) accounted for 3 cases (5.5%), neonatal death (NND)
for 6 cases (10.9%), and congenital malformation (CM),
stillbirth (SB), and low birth weight (LBW) were present
at lower rates (3.6%) respectively. In the group with
seroprevalence of 1 to 3 TORCH agents, habitual abortion
was significantly lower compared to the TORCH group (25
cases [28.4%] versus 40 cases [72.7%]) with a p-value of
0.05. The rates of other BOH manifestations were higher
but not significant compared to those in the TORCH group,
except for LBW which was observed in 22 cases (25%)
with a p-value of 0.05. Notably, habitual abortion within
the TORCH group was significantly higher compared to the
normal pregnancy group as shown in Table 3. Furthermore,
in Table 3, we present the obstetric outcomes for the
TORCH group, where all 55 patients experienced habitual
Mohammed, Al-Saadi and Al-Karawi / Indian Journal of Microbiology Research 2023;10(4):209–215
211
Table 1:
Demographic profile of patients and normal pregnant ladies
Category
Group
Torch Infected Patient
Normal Pregnant
Women
Odds Ratio
P-value
Residency
Urban
72.73% (40/55)
80% (80/100)
0.64
0.28
Rural
27.27% (15/55)
20% (20/100)
1.56
0.28
Occupation
Employee
72.73% (40/55)
37% (37/100)
4.86
<0.001
Housewife
27.27% (15/55)
63% (63/100)
0.21
<0.001
History of contact with
cats during antenatal life
Yes
65.45% (36/55)
45% (45/100)
2.29
0.01
No
34.55% (19/55)
55% (55/100)
0.44
0.01
History of blood
transfusion
Yes
9.09% (5/55)
0% (0/100)
N/A
<0.001
No
90.91% (50/55)
100% (100/100)
N/A
<0.001
Table 2:
Age range in relation to TORCH seropositivity among patients and controls
Group
Age Range
TORCH Seropositivity Rate
TORCH Group
18-27 years
45.5% (n=25/55)
28-37 years
30.9% (n=17/55)
38-45 years
23.6% (n=13/55)
Single, Double, or Triple Group
18-27 years
47.7% (n=42/88)
28-37 years
35.2% (n=31/88)
38-46 years
17.0% (n=15/88)
Normal Pregnancy Group
18-27 years
37.0% (n=5/100)
28-37 years
39.0% (n=39/100)
38-46 years
24.0% (n=24/100)
Table 3:
Seroprevalences to TORCH agents and to 1, 2 or 3 of TORCH agents and bad obstetric history BOH) patterns
Group
Total Out
of 143
positive
Women
HA
IUD
NND
CM
SB
LBW
TORCH Group
38.5%
(55/143)
72.7%
(40/55)
5.5% (3/55)
16.4% (9/55)
18.2%
(10/55)
5.5% (3/55)
21.8%
(12/55)
P-value (vs
Normal
Pregnancy)
-
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
Single, Double,
or Triple
Manifestation
61.5%
(88/143)
28.4%
(25/88)
11.4%
(10/88)
12.5%
(11/88)
9.1% (8/88)
13.6%
(12/88)
25% (22/88)
P-value (vs
Normal
Pregnancy)
-
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
abortion during the first trimester.
Table 4 highlights the significance of seropositivity
for Toxoplasma gondii IgM in combination with Rubella-
IgG, CMV-IgG, and HSV-IgG in the etiology of habitual
abortion. In this group, habitual abortion was reported in
10 out of 12 cases (93.3%), which was significantly higher
than the rates observed in TORCH-IgG (19 out of 14 cases
[46.3%]). Seropositivity for one or two or even three of the
TORCH agents’ IgG resulted in 30 out of 88 cases (34%),
which was significantly lower than the other mentioned
groups. Additionally, Table 4 shows that out of the 100
normal pregnancy cases, 12 cases (12%) were seropositive
for onlyone, two or three of the TORCH infections.
In Table 5, we conducted an analysis to study the effects
of TORCH seroprevalence and seroprevalence of one, two,
or three TORCH agents on the type of BOH manifestations.
The rate of habitual abortion in the TORCH group was
significantly higher (72.7%) compared to the group with
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Mohammed, Al-Saadi and Al-Karawi / Indian Journal of Microbiology Research 2023;10(4):209–215
Table 4:
TORCH IgG and IGM seroprevalences rates with special emphasis on Habitual abortion (HA) rates
Category
Total
HA
IUFD
NND
CM
SB
LBW
Toxo. IgM+
RubellaIgG+
CMV-IgG+
HSV-IgG
12/55
(21.82%)
10/12
(93.3%)
0
0
0
0
2/12 (16.6%)
CMV IgM
Toxo-IgG
CMV-IgG
HSV-IgG
2/55
(3.64%)
0
0
0
0
0
0
Rubella IgG
Toxo-IgG
Rubella-IgG
CMV-IgG
HSV-IgG
41/55
(74.5%)
19/41
(46.3%)
2/41
(4.8%)
3/41 (7.3%)
3/41 (7.3%)
10/41 (24.3%)
4/41 (9.7%)
TORCH -IgG
positivity in
Single or Double
or Triple
TORCH Agents
88/88
(100%)
30/88
(34.09%)
7/88
(7.95%)
12/88
(13.64%)
15/88
(17%)
15/88 (17%)
9/88 (10.2%)
Table 5:
Comparison between the “TORCH Group” and the “single, double, or triple manifestation” group and their odds ratios
Outcome Variable
TORCH Group
Single, Double, or Triple
Manifestation
Odds Ratio
P-value
HA
72.7%
28.4%
4.6
<0.001
IUD
5.5%
11.4%
0.45
0.10
NND
16.4%
12.5%
1.38
0.45
CM
18.2%
9.1%
2.26
0.02
SB
5.5%
13.6%
0.37
0.07
LBW
21.8%
25%
0.84
0.61
seroprevalence of one, two, or three TORCH agents (28.4%)
with a p-value of 0.001. The calculated non- adjusted odds
ratio was found considerably high at 4.6.”
4. Discussion
The widespread utilization of TORCH screening among
clinicians investigating congenital and perinatal infections is
noteworthy. However, questions have been raised regarding
the suitability and specificity of the current screening
methodologies.
In patients with bad obstetric history
(BOH), maternal infections are a significant factor in
miscarriage. T. gondii encysted forms can cause fetal
infection in the first trimester and frequently result in
recurrent miscarriages due to their presence in the uterus
with persistent infections and subsequent rupture during
placentation.
In accordance with preceding studies, our
current research data identified TORCH infections as
etiological agents in recurrent pregnancy loss, in 55 out
of 143 pregnant women exhibiting BOH symptoms.
Assessing IgM antibodies in maternal sera can signal the
acute phase of maternal infection and the probability of
congenital transmission of T. gondii.
In our research, IgM
antibodies were detected in 10 out of 12 (93.3%) patients
with HA manifestation, which concurs with other studies
reporting approximately 66.3% of T. gondii-infected women
demonstrating an IgM response.
It is recommended that
pregnant women undergo testing for TORCH antibodies,
those who experience unfavorable outcomes should take
precautions to avoid infection, such as staying away
from cat litter, ensuring the meat is thoroughly cooked,
and washing their hands after handling raw meat.
The
pathophysiology of TORCH infections is different and can
lead to severe clinical symptoms and drastic consequences.
Although it is still a common cause of blindness, congenital
toxoplasmosis can be prevented by taking precautions,
including avoiding contact with cats and raw meat (15).
Cytomegalovirus (CMV) is the most frequent cause of
congenital infection in the United States and numerous other
regions.
Rubella is preventable by vaccination and linked with
significant morbidity and adverse pregnancy outcomes,
mainly when contracted during the first trimester, leading
to severe fetal consequences.
In our research, all serum
samples underwent testing for Rubella-specific IgG and
Mohammed, Al-Saadi and Al-Karawi / Indian Journal of Microbiology Research 2023;10(4):209–215
213
IgM antibodies, demonstrating a seropositivity rate of
28.5% among cases with a bad obstetric history. Elevated
seropositivity (93.3%) was noted in women experiencing
recurrent abortions, followed by low-birth-weight cases
(21.8%).
Implementing routine screening for rubella in all
antenatal cases can enable early detection and appropriate
management to enhance fetal outcomes.
Selective employment of cesarean delivery and antiviral
treatment can assist in reducing the incidence and enhancing
outcomes in neonatal herpes cases.
CMV and HSV
possess intrauterine transmission routes and can instigate
significant mortality and morbidity.
Our research reported
a seropositivity rate of 3.6% for CMV-specific IgM
among women with BOH. Other investigations conducted
in Iraq have reported seropositivity rates ranging from
6.8% to 8.3% among Iraqi women.
A primary CMV
infection during gestation increases the risk of manifesting
symptomatic congenital infection, leading to the loss of
the fetus.
Numerous researchers have recommended
the serological evaluation of CMV-specific IgM during
pregnancy.
Patients with a confirmed HIV diagnosis
should undergo a check for their toxoplasma antidiv
titers. If results are positive with a CD4 count below
100, it is advisable to administer prophylactic antibiotics
along with antiretroviral therapy until the CD4 cell count
elevates.
In neonates, a significant portion, about half, of
the morbidity and mortality from HSV II originates from
a primary infection that women acquire during gestation
or from the reactivation of a previous infection.
In
our research, the seropositivity rate for HSV IgM among
BOH patients was null, while a prior study reported
a 2% seropositivity rate in asymptomatic women with
recurrent infections during pregnancy.
The seropositivity
rate for HSV IgG among BOH patients in our research
was 11%, analogous to findings reported in another study.
Mixed TORCH infections were observed in 55 out of 143
patients (28.5%), typically associated with Toxoplasma IgM
antibodies. Similar reports of mixed infection have been
previously noted.
Rubella typically presents as a mild
viral disease in children but occasionally infects adults.
A primary viral infection during pregnancy may lead to
harm to the fetus. In our study, the rubella seropositivity
rate was 28.5%, whereas other investigations have reported
seropositivity rates varying from 4% to 17.7%, with a surge
in incidence noted every 3-4 years.
Considering that 10-
20% of women within the childbearing age bracket are
vulnerable to rubella, a rise in the incidence of rubella is
likely to increase the number of pregnant women infected
with rubella.
Pregnant women who test positive for
rubella IgG may indicate a past infection with one of these
infectious agents. Testing a second blood sample drawn
two weeks later can compare the antidiv level. Increased
IgG antidiv levels would suggest a recent infection.
It
is crucial to highlight that IgM antibodies are not always
specific and may cross-react with other IgMs and proteins.
Reference ranges provided by private laboratories should be
adhered to.
Active infection does not directly correlate
with ultrasound growth changes; therefore, ultrasound alone
cannot serve as a diagnostic criterion for confirming or
refuting the diagnosis of rubella.
It is worth noting that TORCH screening can yield both
false-positive and false-negative results.
IgM antibodies
against TORCH organisms typically persist for about three
months, while IgG antibodies remain detectable for a
lifetime, providing immunity and preventing or reducing
the severity of reinfection. Thus, the presence of IgM
antibodies indicates current or recent infection, while the
absence of IgM antibodies but presence of IgG antibodies
without an increase on serial testing suggests previous
infection or vaccination-induced immunity. Individuals
lacking evidence of either IgM or IgG antibodies specific
to the organism are at risk of infection due to the absence of
demonstrable immunity.
Regarding mixed seropositivity among enrolled women,
we noted that out of the 55 cases positive for TORCH
agents in our study, a significant number exhibited
habitual abortion (HA) manifestations (93.3%). Other
manifestations did not significantly differ between cases
with mixed seropositivity’s. These findings are consistent
with previous reports.
Our study clearly demonstrates
the significant role-played by TORCH agents in habitual
abortion, as all 55 women with BOH symptoms experienced
HA during the first trimester (Table 3). These results
align with data presented by previous studies.
In our
study, we observed that vaginal bleeding in early pregnancy
emerged as a prevalent complication and the primary reason
for hospitalization during the first and second trimesters.
The underlying mechanisms of habitual abortion (HA)
and its detrimental impact on pregnancy outcomes are not
comprehensively elucidated. Aberrant TORCH infections
may contribute to complications in the first trimester,
which, if left unresolved, can escalate to spontaneous
abortion. Molecular investigations have demonstrated a
notable elevation in placental indicators of oxidative stress
in pregnancies among women with a history of bad obstetric
outcomes (BOH).
5. Conclusions
Currently, accurately predicting the outcome of pregnancies
affected by TORCH infections and identifying those that
will result in miscarriage remains challenging. The lack
of accurate prediction for pregnancies with threatened
miscarriage, leading to either survival or spontaneous
miscarriage, may result in unnecessary and potentially
harmful interventions or wasteful procedures. Therefore,
we propose that women diagnosed with TORCH pathology
should be provided with the option of hospital bed rest
or, if declined, should receive counseling on modified bed
214
Mohammed, Al-Saadi and Al-Karawi / Indian Journal of Microbiology Research 2023;10(4):209–215
rest at home. Additionally, psychological counseling and
fetal surveillance should be offered to improve outcomes.
It is crucial to engage patients in discussions regarding the
increased likelihood of operative delivery.
6. Author Contributions
Each author that worked on this project significantly
influenced the research’s design, conduct, and analysis, as
well as the interpretation and analysis of the data. They
all contributed to the original manuscript’s creation or its
thorough intellectual content review. They agreed to be
accountable for every part of the work and accepted its
submission to the current journal.
7. Source of Funding
None.
8. Conflict of Interest
None.
Acknowledgments
We
thank
Gilgamesh
Ahliya
University
University
in
Baghdad/Iraq
(http:/gau.edu.iq),
also
we
thank
Mustansiriyah University in Baghdad/Iraq (http://uom
ustansiriyah.edu.iq) for its support to the achievement of
this work.
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Author biography
Mohammed Mohammed,
Ph.D Scholar
May Salem Al-Saadi,
Ph.D Scholar
https://orcid.org/0009-0006-8176-
Abdullah Salim Al-Karawi,
Lecturer
Cite this article:
Mohammed M, Al-Saadi MS, Al-Karawi AS. An
examination of the seroprevalence of torch infections and their
correlation with adverse reproductive outcomes in females exhibiting a
bad obstetric history.
Indian J Microbiol Res
2023;10(4):209-215.
