CMV in pregnancy: Difference between revisions
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==Background== |
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* |
*Infection with [[cytomegalovirus]] during pregnancy |
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*Infection can be primary infection, non-primary reinfection with another strain, or non-primary reactivation of latent virus |
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*Mainly of concern because of the risk of causing [[congenital CMV]] |
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=== |
===Epidemiology=== |
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*Maternal seroconversion in about 2% of pregnancies |
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** |
**Higher in childcare workers |
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* Risk of transmission to fetus |
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*Risk of transmission to fetus is highest with maternal primary infection, and much lower for non-primary infection |
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** |
**'''Primary infection''': 30% risk of congenital CMV |
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**Non-primary: |
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***'''Reinfection''': 5% risk |
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***'''Reactivation''': 1% risk |
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*However, due to the much higher number of non-primary infections and reactivations, 75% of congenital CMV occurs in mothers who had non-primary infection |
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*Risk of transmission to fetus following primary infection increases with gestational age, but risk of neurological sequelae decreases substantially[[CiteRef::enders2011in]] |
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{| class="wikitable" |
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| ⚫ | |||
! rowspan="2" |Maternal Serostatus |
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! rowspan="2" |Trimester |
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! rowspan="2" |Transmission to Fetus |
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! colspan="3" |Severity of Neurological Disease |
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! rowspan="2" |Overall Probability |
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(of any neurological disease) |
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|- |
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!Severe |
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!Mild/Transient |
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!None |
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|- |
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| rowspan="5" |Primary |
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|periconception |
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|5% |
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|- |
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|first |
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|30% |
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|5% |
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|30% |
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|65% |
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|10% |
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|- |
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|second |
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|40% |
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|0% |
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|15% |
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|85% |
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|6% |
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|- |
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|third |
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|70% |
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|0% |
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|0% |
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|100% |
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|0% |
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|- |
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|overall |
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|40% |
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| colspan="2" |13% |
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|78% |
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| |
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|- |
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|Reinfection |
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|overall |
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|5% |
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| colspan="3" | |
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|<1% |
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|- |
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|Reactivation |
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|overall |
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|1% |
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| colspan="3" | |
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|<1% |
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|} |
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*Overall, 20% of infected babies will have permanent neurological sequelae[[CiteRef::dollard2007ne]] |
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**50% of those symptomatic at birth and 15% of those asymptomatic |
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* |
*Serology with IgM and IgG |
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**IgM usually positive for 6 weeks after primary infection, but can remain positive for as long as 12 months |
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** |
**IgM has false positives, including from [[rheumatoid factor]], [[EBV]] infection, [[lupus]] |
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{| class="wikitable" |
{| class="wikitable" |
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* |
*Fetal infection is confirmed by amniocentesis sent for PCR |
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** |
**To minimized the risk of a false-negative result, it should be be done after 17 weeks gestation and at least 7 weeks after maternal infection |
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==Management== |
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*No clear benefit to use of CMV-targetted antivirals ([[ganciclovir]] or [[valganciclovir]]), and possible risk of gonadal dysgenesis and hematologic toxicity |
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*CMV hyperimmune globulin is promising but not yet in widespread use |
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| ⚫ | |||
| ⚫ | |||
== |
== Prevention == |
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* Prevention focusses on lifestyle or behavioural changes that can decrease the risk of primary or non-primary infection |
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| ⚫ | |||
** Not sharing food, drink, utensils with young children |
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| ⚫ | |||
** Not putting a child pacifier in the mouth |
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** Avoiding saliva when kissing a child |
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** Washing hands properly with soap and water after changing diapers, feeding children, or wiping children's nose or mouth |
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** Not sharing toothbrushes |
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** Cleaning surfaces and toys contaminated with children's urine or saliva |
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* Screening for CMV immunity is not routinely recommended, since 75% of infants with congenital CMV are born to infants with non-primary infection |
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[[Category:Infectious diseases]] |
[[Category:Infectious diseases]] |
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Latest revision as of 12:37, 5 November 2021
Background
- Infection with cytomegalovirus during pregnancy
- Infection can be primary infection, non-primary reinfection with another strain, or non-primary reactivation of latent virus
- Mainly of concern because of the risk of causing congenital CMV
Epidemiology
- Maternal seroconversion in about 2% of pregnancies
- Higher in childcare workers
- Affects about 1 in 200 live births in US
- Risk of transmission to fetus is highest with maternal primary infection, and much lower for non-primary infection
- Primary infection: 30% risk of congenital CMV
- Non-primary:
- Reinfection: 5% risk
- Reactivation: 1% risk
- However, due to the much higher number of non-primary infections and reactivations, 75% of congenital CMV occurs in mothers who had non-primary infection
- Risk of transmission to fetus following primary infection increases with gestational age, but risk of neurological sequelae decreases substantially1
| Maternal Serostatus | Trimester | Transmission to Fetus | Severity of Neurological Disease | Overall Probability
(of any neurological disease) | ||
|---|---|---|---|---|---|---|
| Severe | Mild/Transient | None | ||||
| Primary | periconception | 5% | ||||
| first | 30% | 5% | 30% | 65% | 10% | |
| second | 40% | 0% | 15% | 85% | 6% | |
| third | 70% | 0% | 0% | 100% | 0% | |
| overall | 40% | 13% | 78% | |||
| Reinfection | overall | 5% | <1% | |||
| Reactivation | overall | 1% | <1% | |||
- Overall, 20% of infected babies will have permanent neurological sequelae2
- 50% of those symptomatic at birth and 15% of those asymptomatic
Diagnosis
- Serology with IgM and IgG
- IgM usually positive for 6 weeks after primary infection, but can remain positive for as long as 12 months
- IgM has false positives, including from rheumatoid factor, EBV infection, lupus
| IgG | IgM | Avidity | Interpretation |
|---|---|---|---|
| + | β | N/A | past infection, low risk for congenital infection |
| + | + | high | past infection, low risk for congenital infection |
| + | + | low | primary maternal infection within the past 3 months |
| β | β | N/A | either no infection, or repeat in 4 weeks |
- Fetal infection is confirmed by amniocentesis sent for PCR
- To minimized the risk of a false-negative result, it should be be done after 17 weeks gestation and at least 7 weeks after maternal infection
Management
- No clear benefit to use of CMV-targetted antivirals (ganciclovir or valganciclovir), and possible risk of gonadal dysgenesis and hematologic toxicity
- CMV hyperimmune globulin is promising but not yet in widespread use
- Counsel mother on risk of fetal infection and subsequent development of congenital CMV
- If they would terminate if CMV-positive due to those risks, then proceed with amniocentesis to diagnose
Prevention
- Prevention focusses on lifestyle or behavioural changes that can decrease the risk of primary or non-primary infection
- Not sharing food, drink, utensils with young children
- Not putting a child pacifier in the mouth
- Avoiding saliva when kissing a child
- Washing hands properly with soap and water after changing diapers, feeding children, or wiping children's nose or mouth
- Not sharing toothbrushes
- Cleaning surfaces and toys contaminated with children's urine or saliva
- Screening for CMV immunity is not routinely recommended, since 75% of infants with congenital CMV are born to infants with non-primary infection
References
- ^ Gisela Enders, Anja Daiminger, Ursula BΓ€der, Simone Exler, Martin Enders. Intrauterine transmission and clinical outcome of 248 pregnancies with primary cytomegalovirus infection in relation to gestational age. Journal of Clinical Virology. 2011;52(3):244-246. doi:10.1016/j.jcv.2011.07.005.
