Maternity - Pregnancy, part 8: Complications: TORCH Infections, Chlamydia, Gonorrhea, HIV/AIDS
by Meris Shuwarger BSN, RN, CEN, TCRN September 09, 2021 Updated: December 07, 2022 5 min read
This article covers some of the complications of pregnancy, specifically infections that could place the developing fetus at risk.
This series follows along with our Maternity Nursing Flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
TORCH is an acronym for the group of some of the most common infections associated with congenital anomalies, also called teratogenic infections.
What is teratogenic?
TORCH infections are teratogenic (i.e., they may cause birth defects). The mnemonic “T.O.R.C.H.” is used to remember these infections:
Toxoplasmosis is a parasitic infection that a pregnant patient may acquire by consuming raw or undercooked meat or by handling cat feces.
Patients should be taught to cook foods thoroughly and to not clean a cat litter box. Because toxoplasmosis can be found in garden soil (the soil may contain contaminants and/or animal feces), patients should also be told not to garden during pregnancy.
Other is a catch-all for infections that include varicella (chicken pox), syphilis (a bacterial infection usually spread by sexual contact), and parvovirus (parvovirus B19 can cause severe anemia), all of which are considered teratogenic.
Rubella, also known as German measles, is a contagious disease. It is the “R” in the MMR vaccine: measles, mumps, and rubella.
Patients are typically tested in early pregnancy to see if they are rubella immune. It is important to know if they have had the condition previously, or if they have been thoroughly vaccinated and have good levels of antibodies against rubella. If not, the patient should be advised to avoid anybody with a known rubella infection.
Patients should also be instructed to get vaccinated. They will receive their MMR vaccine in the postpartum period. Vaccination is done postpartum because live virus vaccinations are contraindicated during pregnancy, meaning the patient cannot get the MMR vaccine during pregnancy. They will have to do it once they have delivered.
Cytomegalovirus (CMV) is part of the herpes virus family, and is relatively common. However, because this is a teratogenic infection, a patient should be tested for CMV. Teach the patient to avoid any contact with someone with known or suspected CMV.
Herpes simplex virus
Herpes simplex virus is a sexually transmitted infection (STI) that can cause genital lesions.
If the patient has active lesions, herpes may be transmitted to the baby during childbirth, and this can lead to serious complications for the baby. During pregnancy, a patient with herpes is usually given antivirals, and a C-section is often recommended. If the patient has active lesions, they should have a C-section to avoid passing herpes on to the baby. Remember that the decision to have a C-section when there are no active lesions is between the patient and their provider.
It is also very important to understand how dangerous herpes can be for a newborn. This is the reason people should not kiss babies that aren’t theirs, and why they should avoid kissing babies on their faces or on their hands. This is because if someone has HSV, herpes simplex virus, the type that causes cold sores, they can pass HSV onto that baby, which can cause blindness or death.
Sexually transmitted infections (STIs)
A sexually transmitted infection (also called sexually transmitted disease, or STD) is an infection transmitted through sexual contact, caused by bacteria, viruses, or parasites. These can cause serious health problems, including infertility.
Gonorrhea and chlamydia
Gonorrhea and chlamydia are two sexually transmitted infections, whose symptoms overlap. It is common to have both at the same time, though chlamydia is generally more common than gonorrhea.
Gonorrhea and chlamydia signs and symptoms
The signs and symptoms of gonorrhea and chlamydia in a pregnant person include dysuria (painful urination) and vaginal discharge.
Note that these infections are commonly asymptomatic — the patient will not exhibit symptoms, despite having the condition. This is important, because not knowing whether a patient has either of these infections means they will not receive treatment for them. But if the patient has gonorrhea or chlamydia, this can cause complications for the newborn.
One such complication is ophthalmia neonatorum, an infection of the baby’s eyes. That is why erythromycin ointment is put in the eyes of all babies prophylactically to prevent this condition.
Gonorrhea and chlamydia treatment
Gonorrhea and chlamydia may be treated with the administration of antibiotics (e.g., azithromycin for chlamydia, cephalosporins for gonorrhea).
Syphilis is a bacterial infection that can cause preterm labor and infant infection.
Syphilis signs and symptoms
The signs and symptoms of syphilis include genital chancres (ulcers), a rash on the hands and/or feet, and flu-like symptoms.
Syphilis can be easily treated with antibiotics, for example, a dose of penicillin G.
Trichomoniasis is a type of protozoan infection (parasitic disease) that can cause PROM and preterm labor. PROM is an acronym for Premature Rupture Of Membranes — the rupture of the amniotic sac before labor begins.
Trichomoniasis signs and symptoms
The signs and symptoms of trichomoniasis include a yellow/green, malodorous vaginal discharge; itching; and dysuria.
Treatment of trichomoniasis requires administering antibiotics, (e.g., metronidazole). In the event of a PROM infection, antibiotics should be administered to avoid possible infection in the newborn.
HIV/AIDS is a retrovirus that destroys T lymphocytes leading to immunosuppression. It can be passed through body fluids, such as blood, semen, and vaginal secretions. During pregnancy HIV/AIDS may also be passed to the baby via the placenta and, after birth, when breastfeeding (via the breast milk).
HIV/AIDS nursing care
Nurses should use standard precautions when tending to a patient with HIV/AIDS.
During pregnancy and labor, the mother should continue to take prescribed antiretrovirals.
Antiretrovirals should be administered to the infant at delivery. And the newborn should be bathed immediately after birth (before remaining with the mother) to clean it of any body fluids from an HIV-infected mother.
HIV/AIDS patient teaching
A patient who has HIV or AIDS and is about to have a baby must be prepared. In addition to taking their prescribed medications, they should eat healthy and perform good hand hygiene. And they should be told in advance what to expect during delivery and in the postpartum period.
A C-section should be planned for around 38 weeks of gestation if the maternal viral load of HIV is greater than 1,000 copies per milliliter, because the higher the viral load, the higher the chances of passing the virus to the newborn. Performing a C-section minimizes the amount of body fluids that mix, potentially lessening the chance that the patient passes HIV to their baby.
Learn more about the most important lab value ranges for HIV/AIDS and more with Level Up RN's Lab Values Flashcards, designed to help nursing students pass their exams as well as being a helpful reference for practicing RNs, PNs, and other medical professionals.
The mother should NOT breastfeed. This is one of the very few times where there is a very strong contraindication to breastfeeding. Instead, a patient with HIV can use donor breast milk or they can choose to formula feed. But they should not breastfeed.
In addition to the contraindication to breastfeeding, there are other contraindications for pregnant patients with HIV/AIDS. The HIV-positive patient should avoid amniocentesis and chorionic villus sampling or CVS (a test made in early pregnancy to detect congenital abnormalities in the fetus). Internal fetal monitors should not be used, as this involves placing a small electrode into the superficial surface of the baby’s scalp, which is a risk for infection, including passing HIV on to the baby.
During delivery, an episiotomy should not be performed (a procedure in which a laceration is made on the perineum to help the passage of the baby), nor should forceps or vacuum extraction be used.
Hi, I'm Meris. And in this video, I'm going to be talking to you about complications of pregnancy. We're going to be talking about a bunch of different types of infections that could place the developing fetus at risk. I'm going to be following along using our maternity flashcards. If you don't have your own and you want a set, please check out our website leveluprn.com to get some for yourself. And if you already have a set, I would absolutely invite you to follow along with me. Let's get started.
Okay, so first up, we're going to be talking about TORCH infections. And TORCH is actually not a type of infection. It's a mnemonic to help you remember which infections are considered teratogenic. Teratogenic means harmful to a pregnancy.
So TORCH is actually the mnemonic used to remember this. T is for toxoplasmosis. O is for other. We'll get to that in a second. R is for rubella. C is for cytomegalovirus. And H is for herpes simplex virus. So let's talk a little bit about each of these.
Toxoplasmosis is first. And this is a parasitic infection. And this is the reason why pregnant patients are taught not to clean a cat box or to use gloves when they clean a cat box and wash their hands right after. But this is because toxoplasmosis can be found in cat feces. It can also be found in the dirt, so patients should also be told not to garden during pregnancy as well. It can also be found in some foods. So educate patients to cook all their foods thoroughly.
Now, O stands for other, which is not very helpful. But the ones that we included on this list would be varicella, syphilis, and parvovirus. So those are all considered teratogenic.
Now, rubella is a contagious disease. And this is also sometimes called German measles. You may have heard of it. But rubella is the R in the MMR vaccine. Measles, mumps, and rubella. So in early pregnancy, we typically test a patient to see if they are rubella immune. Have you had the condition before, or are you thoroughly vaccinated and you have good levels of antibodies against it? If not, we're going to tell the patient to avoid anybody with known rubella. And we're also going to tell them that they should get vaccinated. They should have the MMR vaccine in that postpartum period, because live virus vaccinations are contraindicated during pregnancy. So they cannot get the MMR vaccine during pregnancy. They will have to do it once they deliver.
Now, C for cytomegalovirus. This is part of the herpes virus family, and it's pretty common, too. But this is going to be teratogenic, so we would need to test the patient for CMV. We would need to follow them closely and make sure that they're doing okay. And of course, teach the patient to avoid any contact with someone with known or suspected CMV.
Now, the H in herpes simplex virus. Herpes can be transmitted to the baby during childbirth if the patient has active lesions. And this can lead to really, really bad complications for the baby. So typically, the patient is given antivirals during their pregnancy. And in many cases, they'll just do a C-section regardless. But no matter what, if the patient has active lesions, they should be having a C-section to avoid passing that on to the baby. Whether or not they have a C-section with no active lesions, that's going to be between the patient and their provider. But very, very important to understand that herpes is very dangerous for a newborn. And this is also the reason, by the way, small aside, little soapbox, don't kiss babies that aren't yours. Don't kiss babies on their face or on their hands or anything like that. Because if you have HSV, herpes simplex virus, the type that causes cold sores, you can still pass HSV onto that baby and cause things like blindness or death. This is very, very serious. And there was actually a case a couple of years ago, maybe five or six years ago, of a baby who died because someone with HSV kissed them. So don't kiss babies that aren't yours, please.
Okay, moving on to sexually transmitted infections such as gonorrhea, chlamydia, syphilis, and trachoma analysis. So the big ones here that I want to call your attention to are gonorrhea and chlamydia, because these are very commonly asymptomatic, meaning that your patients will not have symptoms, even though they have the condition. Why does this matter? We might not know that they have it. Therefore, we can't treat it, and they can cause something in the newborn if they have one of these conditions. And they can cause ophthalmia neonatorum, which is an infection of the baby's eyes. So this is why we give which medication? Pause the video. Think about it. Let me know. Okay, I hope you paused it. This is why we put erythromycin ointment in the eyes of all babies, because we might not catch that the patient has an STI because they're asymptomatic. So we're just going to prophylactically-- to prevent this condition, we're just going to give all newborns erythromycin ointment in their eyes. And this will help to prevent this very serious condition.
Now, syphilis. Syphilis can be treated very easily with a shot of penicillin G. And then trichomoniasis, it's a type of protozoan infection. It's actually really cool to look at under the microscope. It's not so cool to have. It's going to cause kind of a yellow-green discharge. And this can also cause a lot of intense itching and painful urination. Now, with this, it can be treated with antibiotics, but it does need to be investigated and treated. All right.
Lastly, I want to call your attention to this card. This is our card on HIV and AIDS. This is very important patient teaching because there's a lot to know when caring for a patient who's having a baby and has HIV or AIDS. Remember that HIV AIDS can be passed through body fluids such as blood, semen, vaginal secretions, but also through breast milk. So what are we concerned about, right? We're concerned that our patients could pass HIV to their babies if they chose to breastfeed. So this is one of the very few times that you will see a very strong contraindication to breastfeeding. A patient with HIV can use donor breast milk, or they can choose to formula feed. But they should not breastfeed.
The other thing is we would want to plan for a C-section around 38 weeks of gestation if the maternal viral load of HIV is greater than 1,000 copies per milliliter. Basically, the higher the viral load is, the more chance of passing that virus to the newborn. So we would plan to do a C-section to minimize the amount of body fluids that mix. We would also want to avoid anything that could cause that mixing of body fluids, right, such as chorionic villa sampling, an episiotomy, where there's a laceration made on the perineum to help the passage of the baby, forceps or vacuum extraction, and internal fetal monitors. Internal fetal monitors are great devices. They allow us to help monitor these babies a lot more closely. But it does involve a small electrode being placed into the superficial surface of the scalp, which is a risk for infection and in this case is a risk for passing HIV on to that baby. So incredibly important that you teach your patient who has HIV or AIDS this really, really important stuff to know about having a baby so that they are prepared. They should still keep taking their prescribed medications, their antiretrovirals. That's all good and well. Obviously, we want to talk to the provider about that. We want them to eat really healthy, perform good hand hygiene, but we also just want to tell them what's going to happen with pregnancy delivery in the postpartum period because it's important that they have this information ahead of time and not when they're going in to deliver.
All right. I hope that review was helpful. If it was, please like this video so that I know you enjoyed it. If you have a great way to remember something or an anecdote that might help somebody else, please leave us a comment below so that we can see it. Because I know I want to see it, and so does everybody else watching this video. Be sure you subscribe so that you can be the first to know when the next video in this series drops. Thanks so much and happy studying.
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