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26 Citations 21 References 1 Figures

RCH infections in first trimester miscarriage in the Malabar region of Kerala

vailable) in African journal of microbiology research 2(3):56-59 · April 2008 with 3,837 Reads

blication

Denoj Sebastian
K. F. Zuhara K Sekaran
8.53 · University of Calicut

e the prevalence of TORCH (Toxoplasma gondii, Rubella, Cytomegalovirus and Herpes simplex) infections with incidence of abortion in
women in the Malabar area of Kerala, in order to establish basic knowledge for future pregnancy care. Patients attending the Institute of
nd Child Health, Calicut Medical College, Kerala were subjected for the study. Seventy one miscarriage cases and thirty normal
women were studied through their medical, clinical, and serological data. Results were analyzed using person's chi-square test. This
wed that general population of Malabar area has an infection susceptibility of 32.3% to Toxoplasma gondii, 9.6% to Rubella, 3.2% to CMV
lovirus) and 61.3% to HSV (Herpes simplex virus) infections. This was revealed through the estimation of TORCH specific IgG. IgM
TORCH agents was also studied in abortion cases and was observed as T. gondii-50.7% (p<0.03), Rubella-11.3% (p<0.597), CMV-
0.231) and HSV-59.2% (p<0.022). When 40.8% of the miscarriage cases were showing IgM specific to one or the other TORCH agents,
f the control cases possessed IgM to TORCH agents. Cross infections with more than one of the TORCH agents was observed and
e aborted mothers were infected with all the four pathogens. The significant role of T. gondii and HSV infection on spontaneous abortion,
to CMV and Rubella, is provided here. The increased susceptibility of the general population of Malabar to these two pathogens,
es this observation further. Various abortion categories are also influenced by these pathogens differently. We also observed cross
with two or more of the pathogens in the TORCH group, with a statistical significance of p<0.003.

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ce of TORCH infections in various abortion categories

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rican Journal of Microbiology Research Vol.(2) pp. 056-059, March, 2008

ailable online http://www.academicjournals.org/ajmr
SN 1996-0808 ©2008 Academic Journals

ull Length Research Paper

Influence of TORCH infections in first trimester

miscarriage in the Malabar region of Kerala
Denoj Sebastian1, K. F. Zuhara1* and K. Sekaran2
 See all › See all › 1 See all ›
2 Department of Life Sciences, University of Calicut, Kerala. Download citation Share Download full-text PDF
26 Citations Department of
21 References Gynaecology and Obstetrics, Calicut Medical College, Kerala.
1 Figures

Accepted 20 March, 2008

To correlate the prevalence of TORCH (Toxoplasma gondii, Rubella, Cytomegalovirus and Herpe
simplex) infections with incidence of abortion in pregnant women in the Malabar area of Kerala, in orde
to establish basic knowledge for future pregnancy care. Patients attending the Institute of Maternity an
Child Health, Calicut Medical College, Kerala were subjected for the study. Seventy one miscarriag
cases and thirty normal pregnant women were studied through their medical, clinical, and serologic
data. Results were analyzed using person’s chi-square test. This study showed that general populatio
of Malabar area has an infection susceptibility of 32.3% to Toxoplasma gondii, 9.6% to Rubella, 3.2% t
CMV (Cytomegalovirus) and 61.3% to HSV (Herpes simplex virus) infections. This was revealed throug
the estimation of TORCH specific IgG. IgM specific to TORCH agents was also studied in abortion case
and was observed as T. gondii- 50.7% (p<0.03), Rubella-11.3% (p<0.597), CMV-28.2% (p<0.231) and HSV
59.2% (p<0.022). When 40.8% of the miscarriage cases were showing IgM specific to one or the othe
TORCH agents, only 20% of the control cases possessed IgM to TORCH agents. Cross infections wit
more than one of the TORCH agents was observed and 5.6% of the aborted mothers were infected wit
all the four pathogens. The significant role of T. gondii and HSV infection on spontaneous abortio
compared to CMV and Rubella, is provided here. The increased susceptibility of the general populatio
of Malabar to these two pathogens, substantiates this observation further. Various abortion categorie
are also influenced by these pathogens differently. We also observed cross infections with two or mo
of the pathogens in the TORCH group, with a statistical significance of p<0.003.

Key words: Miscarriage, abortion, TORCH infection.

TRODUCTION

e first trimester of pregnancy is an important period
en fraught with complications like bleeding and pain,
ading to severe apprehension in the mother (Florence
.
al., 1999) Pregnancy loss has been attributed to
veral factors involved in human reproduction. Genetic
d uterine abnormalities, endocrine and immunological
sfunctions, infectious agents, environmental pollutants,
ychogenetic factors and endometriosis are most
portant causes (Rock and Zacur, 1983; Dicker et al.,
92) of spontaneous abortion.
Spontaneous abortion is a new issue in terms of its
cial and economic impact. Today majority of women
cide to conceive in their thirties or forties, since they
After the age of 30-35 years, potential fertility de
and the rate of spontaneous abortion increases (
et al., 1989; Brock et al., 1990). But on the other
teenage pregnancy is a fairly common occurren
countries like India. Bhalerao et al. (1990) had p
out that pregnant teenagers are at greater ris
require additional care. Stress, pollutants, smokin
also increase the risk of miscarriage.
Some maternal infections, especially during the
gestation, can result in fetal loss or malformation
cause the ability of the fetus to resist infectious o
sms is limited and the fetal immune system is una
prevent the dissemination of infectious organisms

i dd i h f i f di i i (Ml di l 2002) Th f
e career-oriented
See all › during
See all › the age See
of maximum
all › fecundity. rious tissues (Mladina et al., 2002). The fetus
neonate are infected predominantly
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citation a
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26 Citations 21 References 1 Figures bacterial and protozoal pathogens. Infections with v
pathogens cause miscarriage or may lead to cong
orresponding author. E-mail: denojs@gmail.com. anomalies in the fetus while others are associat

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ebastian et al. 057

Table 1. Prevalence of TORCH infections in various abortion categories

Category Toxoplasma (%) Rubella (%) CMV (%) HSV (%)

Control 20 6.7 13.3 26.7
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Missed Abortion 48.7 7.7 33.3 48.7
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Threat Abortion 54.5 9.1 36.4 45.5

onatal infectious morbidity. There are also reports say-

Control
g that most of the infections of the mother will not result
70
fetal infection (Langford, 2002). Test 59
IgM Positives (%)

60
This study was conducted among the pregnancy cases 50.7
50
the Malabar area of Kerala, a place noted for its culture
40
early/childhood marriages, as per previous studies, 28.2 26.7
30
th a view of assessing the role of TORCH (T. gondii, 20
20 11.3 13
ubella, Cytomegalovirus and H. simplex) infections in 6.7
10
egnancy related complications, especially miscarriage.
0
ecognizing the prevalence infections with intrauterine
d other pathogens in both mother and fetus is an Toxo Rub CMV HSV
(p<0.03) (p<0.597) (p<0.231) (p<0.02
portant part of prenatal care.
Infection
ATERIALS AND METHODS

Fi 1 TORCH i f i i i i
 Seeone
all › miscarriage
See all ›
venty cases and 30See all › pregnant women
normal
ended the Institute of
26 Citations 21Maternity
Referencesand Child Health, Calicut Medical
1 Figures
llege, Kerala, were subjected for this study. The approval of the
titute’s ethical committee was obtained prior to the sample
lection. Informed written consent was obtained from all the
tients considered under this study. Miscarriage categories like
mplete, incomplete, missed and threatened abortions were
ected using medical, clinical and other diagnostic parameters.
e patients’ history was collected as per the performa, which
nsidered age, gravida, parity, previous miscarriages, pregnancy
uced hypertension (PIH), diabetes and infections with HIV,
patitis virus etc.
Serum samples were collected at about 8 - 12 gestational weeks
d stored in small screw caped vials at –20oC until serological
alysis. Samples were screened for the presence of IgM and IgG
tibodies against T. gondii, Rubella virus, Cytomegalovirus and H.
mplex virus using ELISA kits from Equipar Diagnostics (Italy). The
ts were done as per the directions given in the manual supplied
ng with the kits. The results were read at 450 nm in the ELISA
ader (Sunrise Model, TECAN, Austria). Syphilis was diagnosed
ng VDRL test. Tests for presence of HIV and HBsAg were done
the Microbiology laboratory of Calicut Medical College and the
sults were recorded in the proforma.
The IgM levels were interpreted as negative, low positive or high
sitive. A positive IgM is an indication of recent infection. Statis-
al analysis is done using the SPSS software for microcomputers.
e Chi Square test is used to assess statistical significance.
ESULTS
e incidence of miscarriages in various age groups was
14.81% in 15 - 19 years group (teenagers); 49.38% in
- 24 years group; 24.69% in 25 - 29 years and 11.1%
the 30 - 34 years group. Here 39.4% were primigravida
1) while 33.3% were G2, 16.7%-G3, 7.6%-G4 and 3%
8 Afr. J. Microbiol. Res.
Figure 1. TORCH infections in miscarriage cases.
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-G5. Abortion had previously occurred in 32.3%
parity of the group was as Nullipara -13.8%, Prim
(P1)-69%, P2 -10.3% and P3 -6.9%. None of the pa
in the group had diabetes or infection with HIV
Hepatitis. One among the test group and none
control group had PIH. Renal disease was obser
two patients.
The IgG prevalence against TORCH in normal
lation was found as Toxoplasma- 67.7%, Rubella- 9
CMV- 96.8% and HSV -38.7%. The IgM levels obs
against these pathogens are represented in Figure
cases having infected with more than one of these a
are detailed in Figure 2. The miscarriage cases
studied under various categories like complete, in
plete, missed and threatened abortions, for the pre
of infections with these pathogens. The result
presented in Table 1.
DISCUSSION
The incidence of first trimester miscarriage amon
teenagers under this study was 14.3%. This is hig
the 5.5% miscarriage rate observed among the teen
in other parts of India (Bhalerao et al., 1990). Th
nage pregnancy rates reported from various parts
world ranged from 8 - 14%. The mean age of the m
riage cases here was 23.8 years, and is found a
close to that of normal pregnant women, which is
years.
 See all › See all › See all ›
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26 Citations 21 References 1 Figures
No Infection As Rubella, role of CMV also is not very signific
1 Infection the miscarriage cases. Here 28.2% of the misca
2 Infection cases and 13% of normal pregnant women were
70 60 3 Infection positive to CMV. Only 3.2% of the general popula
60 4 Infection
susceptible to this intrauterine pathogen as per the
Frequency %

50 40.8 estimation, since 96.8% were immune to it, as obs

40
30 20
20 13.3 14.1
6.7
10 0 1986) and 97.2% (Rodier et al., 1995) among thei
0 ple. As per this study, CMV and Rubella infections
Control
(p<0.003)
Group
Figure 2. TORCH cross infections in miscarriage cases.
Though the parameters like age, gravida, parity and
evalence of infections like AIDS, hepatitis virus etc. of
ese patients were studied, no significant correlation
as observed for these factors with the incidence of
scarriages. Though, as per previous studies (Regan et
, 1989; Alberman, 1988) maternal age and previous
scarriages had been reported as two independent risk
ctors for a further miscarriage, no evidence has been
tained from our study in this regard.
Toxoplasma IgM was observed in 50.7% of the miscar-
ge cases and this is significant, compared to it’s occur-
nce in 20% of the normal. This rate is higher when
mpared to the 11.6% Toxoplasma infection observed
Kaur et al. (1999) in Delhi. As per our study, 67.7% of
e general population of Malabar region has Toxo-
asma IgG, that is, immunity against T. gondii, leaving
.2% susceptible to the infection. The immunity status
und among this population is high compared to the
.6% (Ghazi et al., 2002), 47.5% (Ustacelebi et al.,
86) and 53.6% (Rodier et al., 1995) observed in other
pulations.
The high rate of resistance against Toxoplasma may
31 through their IgG estimation. Other workers hav
observed more or less the same resistance rat
92.1% (Ghazi et al., 2002), 87.8% (Ustacelebi
8.5 5.6
Abortion no significant role in causing miscarriage.
As T. gondii, Herpes Simplex Virus infections also
a statistically significant correlation with the incide
miscarriages. A positive IgM observed in 59.2%
cases is found as significant (P<0.22) compared
incidence in 26.7% of controls. This infection rate a
well with our observation of 61.3% infection suscep
to HSV in our general population. The HSV IgG le
38.7% observed is much lower than the correspo
observations of 90.9% (Ghazi et al., 2002) and
(Ustacelebi et al., 1986) by previous workers.
On considering the effect of the pathogens on di
categories of abortions, Toxoplasma and HSV
found to have high influence on the ‘complete ab
category. These have almost the same rate of eff
missed and threatened abortion also. HSV infectio
noted in all cases of incomplete abortion, while R
and CMV were not found as very prevalent. CMV
tion was totally absent in incomplete abortion cat
Mihaela et al. (Ghazi et al., 2004) have recently re
that CMV infections have no role in miscarriage, w
partially true as per this study.
Another important finding was the cross infection
condition where cases being infected by m
pathogens, revealed through the IgM positivity to
than one of the TORCH pathogens (Figure 2).
40.8% of the abortion cases and 20% of the norma
positive against any one of these, multiple po
observed against two, three and four were as 31%
 pendSeeupon
all › the environment
See all › andSee
lifeallstyle
› of the people
re. 26ACitations
previous 21observation
References (Decavalas
1 Figures et al., 1990)
at, ‘Toxoplasma antibodies are found to be higher in
orters from the rural areas, where contact with soil is
mmon regardless of whether cats are kept pets or not’,
n be true here also.
Through the IgG estimation, this study has also re-
aled that 90.4% of our population have been pre-
posed and acquired resistance to Rubella virus, which
in agreement with the corresponding rates of 93.3%
hazi et al., 2002), 89.9% (Ustacelebi et al., 1986) and
.5% (Rodier et al., 1995) observed in other popula-
ns. The Rubella IgM found in 11.3% of the miscarriage
ses of this study is in accordance with the 9.6% sus-
ptibility observed in our general population.. But, com-
red to the incidence in 6.7% of the normal, this is
significant (P <0.597).
ex virus infection on miscarriage is well proved here.
ubella and Cytomegalovirus were not found to have
luenced miscarriage, as per this study. The increased
sceptibility of our general population to T. gondii and
SV, compared to Rubella and CMV, further supports
ese observations. Various abortion categories are also
luenced by these pathogens differently. It is also
served that cross infections with two or more of the
ORCH agents have a statistically significant (p<0.003)
evalence in first trimester miscarriage cases.
CKNOWLEDGMENT
and 5.6% among the miscarriage, and as 13.3, 6.
0% among the control group, respectively.
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is Download full-text PDF
noticed that when 5.6% of the aborted mothers
infected with all the four pathogens, none of the c
was infected to this extent. Gong et al. (1999)
reported cross infections with all the TORCH path
in only 2.6% of their study. A much higher rate (93.4
multiple sero conversion to the TORCH pathogen
also reported by some workers among pregnant w
(Kaur et al. 1999). (Aubard et al). had reported d
maternal seroconversion against T. gondii and Cy
galovirus.
In conclusion, this study has established the g
role of TORCH pathogens on miscarriage in first trim
pregnancy. When only 14.1% of the miscarriage
were totally free of TORCH infections, 60% of the c
group was free out of it. The role of T. gondii and
Sebastian et al.
congenital toxoplasmosis. Retrospective study of 110 cases
Microbiol. 9: 2893-2898.
Ghazi HO, Telmesani AM, Mahomed MF. (2002). TORCH ag
pregnant Saudi women. Med. Princ. Pract. 11(4):180-182.
Gong Z, Luo L, Xiao H (1999). Preliminary study on TORCH e
laws in Wuhan region. Zhonghua Shi Yan He Lin Chuang B
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abortion and the effects of age, parity and other variables. In
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TORCH infections in pregnant women: a report from Delhi. So
Asian J. Trop. Med. Public Health. 30(2): 284-286.
Langford KS (2002) Infectious diseases and pregnancy.
Obstetrics and Gynecology. 12: 125-130.
 See all › See all › See all › Mihaela M, Koraljka H, Nina M, Srecko C, Magdalena G
e are highly indebted
26 Citations to IndianFigures
21 References Council of Medical Possible role of bacterial and viralDownload
Steril. 81(3): 662-669.
infectionscitation
in misscarriage
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esearch, New Delhi for extending1 financial assistance to
rry out this work. The authors also acknowledge the Mladina N, Mehikic G, Pasic (2002). TORCH infections in mothe
cause of neonatal morbidity. A. Med Arh. 54(5-6): 273-276
lp and co-operation rendered by Dr. N. S. Sreedevi, Dr. Regan L, Braude PR, Trembath PL (1989). Influence of past
lu Mathews and Dr. C. K Sasidharan and the P.G reproductive performance on risk of spontaneous abortion. BM
udents of IMCH, Calicut Medical College, Calicut during 299: 541-545
Rock JA, Zacur HA (1983). The clinical management of repeat
s work.
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Rodier MH, Berthonneau J, Bourgoin A, Giraudeau G, A
Burucoa C, Hekpazo A, Jacquemin JL (1995). Seropreval
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26 Citations 21 References 1 Figures

26) References (21)

cians concentrate on women with previous cases of BOH such as miscarriage and other types of congenital abnormalities. Many studied
erformed on the maternal infections of the fetus which play an important role in miscarriage and congenital abnormalities cases (Abdel-
Denoj et al.,2008; Goncalves et al., 2010;Al-Hindi et al., 2010 ;Jasim et al., 2011;Vilibic-Cavlek et al., 2011). ...
omen with BOH with CMV was found, followed by HSV-2 infections (7.07%) and the lowest rates were with T. gondii 4 (2.17%) and Rubella
d only 3 cases were seropositive for anti T .gondii plus anti CMV IgM antibodies .These results were in agreement with those of Denoj et
India in which they observed that cross infections with more than one of the TORCH agents were reported at a rate of 40.8% among
en against any one of TORCH agents, multiple positivity observed against two pathogens in 31%and ...
n TORCH screening is routinely preferred by physicians for detecting the infection among women during pregnancy period. The physicians
on women with previous cases of BOH such as miscarriages and other types of congenital abnormalities, and many researchers have
maternal infections of the fetus which play an important role in miscarriage and congenital abnormality cases (AbdelFattah,2005; Denoj et
ncalves et al., 2010;Al-Hindi et al., 2010 ;Jasim et al., 2011;Vilibic-Cavlek et al., 2011). ...

Outcome on Pregnancy and Fetus in Women with Bod in Duhok Province – Kurdistan Region – Iraq
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ile the rest results from reactivation of an old infection [27, 28] . Despite the higher risk of transmission of HSV from mother experiencing
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