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Why is TORCH test done during pregnancy?

Monday, 01 September 2003
Answered by: Puneet Bedi
Consultant in Obstetrics and Gynaecology
Apollo Hospital
New Delhi
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Q. I am in my early stages of pregnancy. Recently I noticed an itchy red rash on my entire body. I was advised by my doctor to take a dose of Avil as it could be some allergic reaction. However, the rash did not subside. Subsequently, my gynaecologist asked me to undergo a TORCH test as it could be some viral infection. I have not had the MMR vaccine. The test showed CMV IgM-0.15 and IgG-4.10 while Rubella IgM was 0.14 and IgG 28.8. My doctor was quite alarmed- but asked me not to worry- because if the infection reaches the foetus, it would either stop growing (in which case it would abort by itself) or it would lag in growth by the 9th week- when she advised an ultrasound examination. The repeat TORCH test showed that the CMV levels are more or less the same but the Rubella IgM has gone down to 0.02 and IgG to 9.3. In the 9th week I did go for ultrasonography and the doctor told me that the growth of the foetus was coming along fine- it measured 24 mm & had a heartbeat rate of 169 per min. The doctor also suggested that things seemed to be coming along fine- but that I should go in for another USG at 13 weeks. In case growth at this stage was also normal, we could safely presume that all was well and go ahead with the pregnancy. Of course, he would also do another ultrasound at 18-20 weeks in the normal course to ascertain all was well. I have a few questions with regard to my case: - Rubella is known to cause congenital disorders in children if contracted by the mother in the 1st trimester. Can the level of infection I have had have such an effect? - The IgM test is supposedly a better indicator of current infection- is it normal to have some antibodies in the reference range or should it be zero? - In case the growth of the foetus is normal at 13 weeks, can I safely assume that the foetus has not been affected by the virus? - Is there any other way of testing if an unborn child has some disorder(s), not just physical (which can be seen by ultrasound I presume), but also mental/neurological disorders? - Is it safe to go ahead with the pregnancy if all is well at the 13th week as I would rather terminate the pregnancy than take any chances of having a crippled child.

A.  You have written the details of the tests and the dates but have not mentioned the reference range used by the lab from where you got the tests done. Each test is to be evaluated against the reference range of the lab written in brackets in the reports given to you. And from the reference points that I use, all these tests for rubella and CMV seem to be within the normal range so I do not quite understand why you and your doctor are so worried? But you will have to cross check these tests with the reference range given by the lab that you got the tests done from. If the IgM is less than the reference range you do not have to worry at all since the second test was even lower and either way both are below the abnormal range. Rubella is devastating if it infects a mother in the first three months and there is no question of getting the pregnancy through irrespective of the ultrasound reports since the chances of having an abnormal child is very high. Fortunately there is no evidence to suggest that you had Rubella clinically as the rash of Rubella lasts only a few hours (maximum up to a day or so) while you had a persistent rash (as apparent from what you wrote) and it seems some kind of a skin condition. The IgG and the IgM reports do not suggest an active infection. And there are some discrepancies in the reports. If the IgG was positive, it will remain positive probably for the rest of your life and it only means that you had the infection, like most of us, sometime in the past in which case you do not have to worry at all. Rubella is a once in a life time infection and once you have had it, it will give you life-long immunity. Unless you take steroids or have a serious immune deficiency you cannot have Rubella again. High IgM levels suggests a recent infection but yours seem to be within the normal range. You have written that the IgG for Rubella decreased within one week. IgG levels dropped from about 32 to less than ten. This does not make any sense to me and one of the two reports have to be incorrect since IgG does not drop for decades leave alone a week or two. Please get these reports interpreted properly by the lab which performed these tests and preferably by a clinical microbiologist or an infectious diseases specialist if possible. There is also no proof that you had CMV infection (also a viral infection). To answer your questions point wise: -IgM is a better indicator(in fact the only immediate reliable indicator) of current infection and in your case fortunately it seems to be normal. IgM is never Zero as it cross-reacts with many other IgMs and other idea proteins. We have to follow the reference range provided by the lab. -There is no direct relation between an active infection and ultrasound growth and, it can therefore, not be relied upon as the diagnostic criteria either to confirm or refute the diagnosis of Rubella. In fact it gives us no information at all. You cannot take a decision based on the ultrasound report. - The unborn child cannot be tested for infection by ultrasound. If there is a reasonable suspicion of a fetal infection the only way to check would be to take the blood from the fetus at twenty weeks and analyze it for IgM against Rubella and do a PCR diagnosis of Rubella. -I do understand your anxiety and in your position I would feel exactly the same that it is better to abort a possibly abnormal child at this stage. Fortunately there is no evidence that you had an active infection of Rubella or CMV so you do not have to worry at all. If you are still apprehensive please get your reports interpreted by a microbiologist or a infectious diseases specialist. In case the review of reports with the lab leads to any doubt, please consult a microbiologist and if you are sure that you did not carry a Rubella infection you do not need to worry any further. Alternately, if there is a reasonable suspicion that you had an active infection (which according to me there is no proof of) you can ensure that he considers an abortion. -Ultrasound has no role in diagnosing or refuting a diagnosis of Rubella -Please get your case assessed and, in my opinion since there is no proof that you had Rubella or CMV, you should carry your pregnancy without any further doubt. -The ultrasound at twenty weeks and the triple test at sixteen weeks should be done as in all pregnancies to exclude abnormality in the baby, and your case is no different. I wish you all the best for the rest of the pregnancy.

A.  You have written the details of the tests and the dates but have not mentioned the reference range used by the lab from where you got the tests done. Each test is to be evaluated against the reference range of the lab written in brackets in the reports given to you. And from the reference points that I use, all these tests for rubella and CMV seem to be within the normal range so I do not quite understand why you and your doctor are so worried? But you will have to cross check these tests with the reference range given by the lab that you got the tests done from. If the IgM is less than the reference range you do not have to worry at all since the second test was even lower and either way both are below the abnormal range. Rubella is devastating if it infects a mother in the first three months and there is no question of getting the pregnancy through irrespective of the ultrasound reports since the chances of having an abnormal child is very high. Fortunately there is no evidence to suggest that you had Rubella clinically as the rash of Rubella lasts only a few hours (maximum up to a day or so) while you had a persistent rash (as apparent from what you wrote) and it seems some kind of a skin condition. The IgG and the IgM reports do not suggest an active infection. And there are some discrepancies in the reports. If the IgG was positive, it will remain positive probably for the rest of your life and it only means that you had the infection, like most of us, sometime in the past in which case you do not have to worry at all. Rubella is a once in a life time infection and once you have had it, it will give you life-long immunity. Unless you take steroids or have a serious immune deficiency you cannot have Rubella again. High IgM levels suggests a recent infection but yours seem to be within the normal range. You have written that the IgG for Rubella decreased within one week. IgG levels dropped from about 32 to less than ten. This does not make any sense to me and one of the two reports have to be incorrect since IgG does not drop for decades leave alone a week or two. Please get these reports interpreted properly by the lab which performed these tests and preferably by a clinical microbiologist or an infectious diseases specialist if possible. There is also no proof that you had CMV infection (also a viral infection). To answer your questions point wise: -IgM is a better indicator(in fact the only immediate reliable indicator) of current infection and in your case fortunately it seems to be normal. IgM is never Zero as it cross-reacts with many other IgMs and other idea proteins. We have to follow the reference range provided by the lab. -There is no direct relation between an active infection and ultrasound growth and, it can therefore, not be relied upon as the diagnostic criteria either to confirm or refute the diagnosis of Rubella. In fact it gives us no information at all. You cannot take a decision based on the ultrasound report. - The unborn child cannot be tested for infection by ultrasound. If there is a reasonable suspicion of a fetal infection the only way to check would be to take the blood from the fetus at twenty weeks and analyze it for IgM against Rubella and do a PCR diagnosis of Rubella. -I do understand your anxiety and in your position I would feel exactly the same that it is better to abort a possibly abnormal child at this stage. Fortunately there is no evidence that you had an active infection of Rubella or CMV so you do not have to worry at all. If you are still apprehensive please get your reports interpreted by a microbiologist or a infectious diseases specialist. In case the review of reports with the lab leads to any doubt, please consult a microbiologist and if you are sure that you did not carry a Rubella infection you do not need to worry any further. Alternately, if there is a reasonable suspicion that you had an active infection (which according to me there is no proof of) you can ensure that he considers an abortion. -Ultrasound has no role in diagnosing or refuting a diagnosis of Rubella -Please get your case assessed and, in my opinion since there is no proof that you had Rubella or CMV, you should carry your pregnancy without any further doubt. -The ultrasound at twenty weeks and the triple test at sixteen weeks should be done as in all pregnancies to exclude abnormality in the baby, and your case is no different. I wish you all the best for the rest of the pregnancy.

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