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Gilad N, Agrawal S, Philippopoulos E, Murphy KE, Shinar S. Is a Higher Amniotic Fluid Viral Load Associated with a Greater Risk of Fetal Injury in Congenital Cytomegalovirus Infection-A Systematic Review and Meta-Analysis. J Clin Med 2024; 13:2136. [PMID: 38610901 PMCID: PMC11012373 DOI: 10.3390/jcm13072136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 03/28/2024] [Accepted: 03/30/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Numerous studies have aimed to predict prenatal and neonatal outcomes for pregnancies complicated by congenital cytomegalovirus (CMV). Presently, assessing CMV severity prenatally relies largely on fetal imaging. A controversy exists regarding CMV viral load (VL) and its association with fetal and neonatal sequelae. Objective: To perform a systematic review and meta-analysis investigating the association between CMV DNA VL in amniotic fluid and fetal and neonatal outcomes in pregnancies with congenital CMV. Results: All cohort, case-control and observational studies that compared outcomes of fetuses with congenital CMV and provided information on individual patient CMV VL quantified in copies per milliliter (c/mL) from inception to January 2023 were included, with no geographical or language restrictions. A total of 1251 citations were reviewed with eight studies meeting inclusion criteria and included in meta-analysis. Affected pregnancies had a higher VL in the amniotic fluid compared to those unaffected with a mean difference of 2.2e+7 (range 1.5e+7 to 2.8e+7). In subgroup analysis, the VL was significantly higher in the fetuses, with imaging findings related to CMV compared to asymptomatic fetuses with a mean difference of 4.1e+7 (95% CI 2.8e+7-5.4e+7). However, among babies with congenital CMV, the VL was not significantly different between symptomatic and asymptomatic babies. Conclusions: Amniotic fluid CMV VL is associated with fetal sequalae in congenital CMV, with a higher VL conferring a greater risk for prenatal injury.
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Affiliation(s)
- Noa Gilad
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON M5G 1E2, Canada; (N.G.); (E.P.); (K.E.M.)
| | - Swati Agrawal
- Department of Obstetrics and Gynecology, University of McMaster, Hamilton, ON L8S 4K1, Canada;
| | - Eleni Philippopoulos
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON M5G 1E2, Canada; (N.G.); (E.P.); (K.E.M.)
| | - Kellie E. Murphy
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON M5G 1E2, Canada; (N.G.); (E.P.); (K.E.M.)
| | - Shiri Shinar
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON M5G 1E2, Canada; (N.G.); (E.P.); (K.E.M.)
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2
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Pomar L, Contier A, Stojanov M, Guenot C, Sichitiu J, Truttmann AC, Vial Y, Baud D. Contribution of fetal blood sampling to determining the prognosis of congenital cytomegalovirus infections: a case-cohort study in Switzerland. Am J Obstet Gynecol 2024:S0002-9378(24)00468-X. [PMID: 38527603 DOI: 10.1016/j.ajog.2024.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Cytomegalovirus is responsible for the most common congenital infection, affecting 0.5% to 1.0% of live births in Europe. Congenital cytomegalovirus infection can be diagnosed during pregnancy by viral DNA amplification in the amniotic fluid, but the prognosis of fetuses without severe brain abnormalities remains difficult to establish on the basis of prenatal imaging alone. OBJECTIVE To identify predictors of moderate to severe symptomatic cytomegalovirus infection among fetal blood parameters and to propose an algorithm on the basis of these parameters and on prenatal imaging that would provide the best positive and negative predictive values. STUDY DESIGN Fetal blood sampling at 21-28 weeks gestation was performed in fetuses with congenital cytomegalovirus infection confirmed by amniocentesis after maternal infection in the first-trimester or periconceptional period. We compared the levels of hemoglobin, thrombocytes, γ-glutamyl transpeptidase, aspartate aminotransferase, alanine aminotransferase, β2-microglobulin, immunoglobulins G and M, and cytomegalovirus DNA viral loads in amniotic fluid and fetal blood between those with moderate to severe symptomatic infection and those with asymptomatic to mild infection (median follow-up of 36 months for live births). RESULTS Among 58 fetuses included, 25 (43%) had a moderate to severe symptomatic infection: 16 with severe cerebral abnormalities, 5 with multiple signs or symptoms at birth, 2 with bilateral sensorineural hearing loss, and 2 with neurodevelopmental delay. The values of thrombocytes, aspartate aminotransferase, β2 microglobulin, Immunoglobulin M, and cytomegalovirus viral loads differed significantly between fetuses with moderate to severe symptomatic infection and those with asymptomatic to mild infection. The optimal strategy to predict moderate to severe symptomatic infection was to first perform fetal brain imaging, followed by fetal blood sampling with the following cutoffs: thrombocytes <120,000/mL, viremia ≥5 log10/mL, and β2 microglobulin ≥12 mg/L). This recursive algorithm had a negative predictive value of 100% for moderately to severely symptomatic infection. CONCLUSION The combination of thrombocytes, β2-microglobulin, and cytomegalovirus viral load in fetal blood can be used for prognosis determination, particularly in cytomegalovirus-infected fetuses without severe brain abnormalities at the time of prenatal diagnosis. Future studies should evaluate whether these parameters remain useful in infected fetuses who have been treated with valacyclovir before fetal blood sampling.
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Affiliation(s)
- Léo Pomar
- Ultrasound and Fetal Medicine Unit, Department Woman-Mother-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland.
| | - Agathe Contier
- Ultrasound and Fetal Medicine Unit, Department Woman-Mother-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Milos Stojanov
- Ultrasound and Fetal Medicine Unit, Department Woman-Mother-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Cécile Guenot
- Ultrasound and Fetal Medicine Unit, Department Woman-Mother-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Joanna Sichitiu
- Ultrasound and Fetal Medicine Unit, Department Woman-Mother-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Anita C Truttmann
- Clinic of Neonatology, Department Woman-Mother-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Yvan Vial
- Ultrasound and Fetal Medicine Unit, Department Woman-Mother-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - David Baud
- Ultrasound and Fetal Medicine Unit, Department Woman-Mother-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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3
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Nigro G, Muselli M. Prevention of Congenital Cytomegalovirus Infection: Review and Case Series of Valaciclovir versus Hyperimmune Globulin Therapy. Viruses 2023; 15:1376. [PMID: 37376675 PMCID: PMC10302477 DOI: 10.3390/v15061376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/05/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
Cytomegalovirus (CMV) is the most common cause of congenital infections in developed countries because is capable of infecting the fetus after both primary and recurrent maternal infection, and because the virus may be spread for years through infected children. Moreover, CMV is the most serious congenital infection associated with severe neurological and sensorineural sequelae, which can occur at birth or develop later on. Hygienic measures can prevent CMV transmission, which mainly involve contact with children under 3 years of age and attending a nursery or daycare. In animal and human pregnancies, many observational and controlled studies have shown that CMV-specific hyperimmune globulin (HIG) is safe and can significantly decrease maternal-fetal transmission of CMV infection and, mostly, the occurrence of CMV disease. Recently, valaciclovir at the dosage of 8 g/day was also reported to be capable of decreasing the rates of congenital infection and disease. However, comparing the results of our two recent case series, the infants born to women treated with HIG showed significantly lower rates of CMV DNA positivity in urine (9.7% vs. 75.0%; p < 0.0001) and abnormalities after follow-up (0.0% vs. 41.7%; p < 0.0001). The implementation of CMV screening would enable primary prevention via hygiene counseling, improve the understanding and awareness of congenital CMV infection, and increase the knowledge of the potential efficacy of preventive or therapeutic HIG or antiviral administration.
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Affiliation(s)
- Giovanni Nigro
- Non-Profit Association Mother-Infant Cytomegalovirus Infection (AMICI), 00198 Rome, Italy
| | - Mario Muselli
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy;
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4
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Sartori P, Egloff C, Hcini N, Vauloup Fellous C, Périllaud-Dubois C, Picone O, Pomar L. Primary, Secondary, and Tertiary Prevention of Congenital Cytomegalovirus Infection. Viruses 2023; 15:v15040819. [PMID: 37112800 PMCID: PMC10146889 DOI: 10.3390/v15040819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/11/2023] [Accepted: 03/20/2023] [Indexed: 04/29/2023] Open
Abstract
Cytomegalovirus infection is the most common congenital infection, affecting about 1% of births worldwide. Several primary, secondary, and tertiary prevention strategies are already available during the prenatal period to help mitigate the immediate and long-term consequences of this infection. In this review, we aim to present and assess the efficacy of these strategies, including educating pregnant women and women of childbearing age on their knowledge of hygiene measures, development of vaccines, screening for cytomegalovirus infection during pregnancy (systematic versus targeted), prenatal diagnosis and prognostic assessments, and preventive and curative treatments in utero.
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Affiliation(s)
- Pauline Sartori
- School of Health Sciences (HESAV), University of Applied Sciences and Arts Western Switzerland, 1011 Lausanne, Switzerland
- Department Woman-Mother-Child, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Charles Egloff
- Assistance Publique-Hôpitaux de Paris APHP, Nord, Service de Gynécologie Obstétrique, Hôpital Louis Mourier, 92700 Colombes, France
- Université de Paris, 75006 Paris, France
- INSERM, IAME, B.P. 416, 75870 Paris, France
| | - Najeh Hcini
- Department of Obstetrics and Gynaecology, West French Guiana Hospital Center, French 97320, Guyana
- CIC Inserm 1424 et DFR Santé Université Guyane, 97320 ST Laurent du Maroni, France
| | - Christelle Vauloup Fellous
- Université Paris-Saclay, INSERM U1193, 94804 Villejuif, France
- Laboratoire de Virologie, AP-HP, Hôpital Paul-Brousse, 94804 Villejuif, France
- Groupe de Recherche sur les Infections Pendant la Grossesse (GRIG), 75000 Paris, France
| | - Claire Périllaud-Dubois
- Université de Paris, 75006 Paris, France
- INSERM, IAME, B.P. 416, 75870 Paris, France
- Virology Laboratory, AP-HP, Sorbonne Université, Hôpital Saint-Antoine, F-75012 Paris, France
| | - Olivier Picone
- Assistance Publique-Hôpitaux de Paris APHP, Nord, Service de Gynécologie Obstétrique, Hôpital Louis Mourier, 92700 Colombes, France
- Université de Paris, 75006 Paris, France
- INSERM, IAME, B.P. 416, 75870 Paris, France
- Groupe de Recherche sur les Infections Pendant la Grossesse (GRIG), 75000 Paris, France
| | - Léo Pomar
- School of Health Sciences (HESAV), University of Applied Sciences and Arts Western Switzerland, 1011 Lausanne, Switzerland
- Department Woman-Mother-Child, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
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5
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Fourgeaud J, Magny JF, Couderc S, Garcia P, Maillotte AM, Benard M, Pinquier D, Minodier P, Astruc D, Patural H, Ugolin M, Parat S, Guillois B, Garenne A, Guilleminot T, Parodi M, Bussières L, Ville Y, Leruez-Ville M. Clinical Value of Serial Quantitative Analysis of Cytomegalovirus DNA in Blood and Saliva Over the First 24 Months of Life in Congenital Infection: The French Cymepedia Cohort. J Pediatr 2023; 253:197-204.e5. [PMID: 36181870 DOI: 10.1016/j.jpeds.2022.09.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 09/21/2022] [Accepted: 09/23/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate cytomegalovirus (CMV) viral load dynamics in blood and saliva during the first 2 years of life in symptomatic and asymptomatic infected infants and to identify whether these kinetics could have practical clinical implications. STUDY DESIGN The Cymepedia cohort prospectively included 256 congenitally infected neonates followed for 2 years. Whole blood and saliva were collected at inclusion and months 4 and 12, and saliva at months 18 and 24. Real-time CMV polymerase chain reaction (PCR) was performed, results expressed as log10 IU/mL in blood and in copies per milliliter in saliva. RESULTS Viral load in saliva progressively decreased from 7.5 log10 at birth to 3.3 log10 at month 24. CMV PCR in saliva was positive in 100% and 96% of infants at 6 and 12 months, respectively. In the first month of life, neonatal saliva viral load of less than 5 log10 was related to a late CMV transplacental passage. Detection in blood was positive in 92% of neonates (147/159) in the first month of life. No viral load threshold values in blood or saliva could be associated with a high risk of sequelae. Neonatal blood viral load of less than 3 log10 IU/mL had a 100% negative predictive value for long-term sequelae. CONCLUSIONS Viral loads in blood and saliva by CMV PCR testing in congenital infection fall over the first 24 months. In this study of infants affected mainly after primary maternal infection during pregnancy, all salivary samples were positive in the first 6 months of life and sequelae were not seen in infants with neonatal blood viral load of less than 3 log10 IU/mL.
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Affiliation(s)
- Jacques Fourgeaud
- Research Unit 73-28, Université Paris Cité, Paris, France; Virology Laboratory, Reference Laboratory for Cytomegalovirus Infections, AP-HP, Hôpital Necker Enfants Malades, Paris, France.
| | - Jean-François Magny
- Research Unit 73-28, Université Paris Cité, Paris, France; Neonatal Intensive Care Unit, AP-HP, Hôpital Necker Enfants Malades, Paris, France
| | - Sophie Couderc
- Maternity, Hospital Intercommunal Poissy-Saint Germain, Poissy, France
| | - Patricia Garcia
- Neonatology and Intensive Care Department, AP-HM, Hospital La Conception, Marseille, France
| | | | - Melinda Benard
- Department of Neonatalogy, Toulouse University Hospital, Toulouse, France
| | - Didier Pinquier
- Department of Neonatology, Rouen University Hospital, Rouen, France
| | | | - Dominique Astruc
- Department of Neonatology, Strasbourg University Hospital, Strasbourg, France
| | - Hugues Patural
- Neonatal Intensive Care Unit, University Hospital, Saint-Etienne, France
| | - Melissa Ugolin
- Pediatric Department, Neonatology, CHU Rennes and CIC1414, Rennes, France
| | - Sophie Parat
- Maternity, AP-HP, Hospital Cochin, Paris, France
| | - Bernard Guillois
- Department of Neonatalogy, CHU de Caen, Caen, France; Medical School, Université Caen Normandie, Caen, France
| | - Armelle Garenne
- Neonatal and Pediatric Intensive Care Unit, CHRU Brest, Brest, France
| | - Tiffany Guilleminot
- Research Unit 73-28, Université Paris Cité, Paris, France; Virology Laboratory, Reference Laboratory for Cytomegalovirus Infections, AP-HP, Hôpital Necker Enfants Malades, Paris, France
| | - Marine Parodi
- Otology Department, AP-HP, Hôpital Necker Enfants Malades, Paris, France
| | - Laurence Bussières
- Research Unit 73-28, Université Paris Cité, Paris, France; Clinical Research Unit, AP-HP, Hôpital Necker Enfants Malades, Paris, France
| | - Yves Ville
- Research Unit 73-28, Université Paris Cité, Paris, France; Maternity, AP-HP, Hôpital Necker Enfants Malades, Paris, France
| | - Marianne Leruez-Ville
- Research Unit 73-28, Université Paris Cité, Paris, France; Virology Laboratory, Reference Laboratory for Cytomegalovirus Infections, AP-HP, Hôpital Necker Enfants Malades, Paris, France
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6
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Wang H, Yang GX, Hu Y, Lam P, Sangha K, Siciliano D, Swenerton A, Miller R, Tilley P, Von Dadelszen P, Kalyan S, Tang P, Patel MS. Comprehensive human amniotic fluid metagenomics supports the sterile womb hypothesis. Sci Rep 2022; 12:6875. [PMID: 35477737 PMCID: PMC9046152 DOI: 10.1038/s41598-022-10869-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 04/04/2022] [Indexed: 11/17/2022] Open
Abstract
As metagenomic approaches for detecting infectious agents have improved, each tissue that was once thought to be sterile has been found to harbor a variety of microorganisms. Controversy still exists over the status of amniotic fluid, which is part of an immunologically privileged zone that is required to prevent maternal immune system rejection of the fetus. Due to this privilege, the exclusion of microbes has been proposed to be mandatory, leading to the sterile womb hypothesis. Since nucleic acid yields from amniotic fluid are very low, contaminating nucleic acid found in water, reagents and the laboratory environment frequently confound attempts to address this hypothesis. Here we present metagenomic criteria for microorganism detection and a metagenomic method able to be performed with small volumes of starting material, while controlling for exogenous contamination, to circumvent these and other pitfalls. We use this method to show that human mid-gestational amniotic fluid has no detectable virome or microbiome, supporting the sterile womb hypothesis.
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Affiliation(s)
- HanChen Wang
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada.,Department of Physiology, McGill University, Montreal, QC, Canada
| | - Gui Xiang Yang
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| | - Yuxiang Hu
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,CureImmune Therapeutics Inc., Vancouver, BC, Canada
| | - Patricia Lam
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada.,Center for Gene Therapy, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
| | - Karan Sangha
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| | - Dawn Siciliano
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| | - Anne Swenerton
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| | - Ruth Miller
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada.,British Columbia Centre for Disease Control, Vancouver, BC, Canada.,Contextual Genomics Inc., Vancouver, BC, Canada
| | - Peter Tilley
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada.,British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Peter Von Dadelszen
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Shirin Kalyan
- Division of Endocrinology and Metabolism, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Patrick Tang
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada.,British Columbia Centre for Disease Control, Vancouver, BC, Canada.,Department of Pathology, Sidra Medical and Research Center, Doha, Qatar
| | - Millan S Patel
- BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada. .,Department of Medical Genetics, University of British Columbia, 4500 Oak St., Rm. C234, Vancouver, BC, V6H 3N1, Canada.
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7
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New evidence on prognostic features, prevention and treatment of congenital Cytomegalovirus infection. Curr Opin Obstet Gynecol 2021; 32:342-350. [PMID: 32739974 DOI: 10.1097/gco.0000000000000651] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Congenital Cytomegalovirus (CMV) infection remains a major cause of lifelong disability, with no systematic screening implemented in pregnancy or the postnatal period. In this review article, we outline the preventive strategies, antenatal prognostic features and experimental therapies as well as evidence of efficacy from recent trials. RECENT FINDINGS A recent randomized, double blinded, placebo-controlled study investigated the efficacy of Valaciclovir in women contracting primary CMV in the periconception period or first trimester. They concluded that Valaciclovir at a dose of 8 g/day is effective in reducing the rate of foetal CMV infection following early maternal primary infection. Administration of CMV hyperimmune globulin (HIG) was investigated in a recent randomized double-masked controlled trial. This study concluded that CMV HIG was ineffective at reducing the risk of congenital CMV among women with primary CMV in early pregnancy. SUMMARY Congenital CMV infection remains a significant cause of disability. There is currently no vaccine available, with the best preventive strategy being patient education on transmission as well as hygiene measures to reduce risk of exposure. Experimental therapies have been investigated in recent years and there is evidence supporting the use of Valaciclovir. Data for the efficacy of CMV HIG remains inconsistent and administration is currently limited to clinical trial settings.
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8
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Buca D, Di Mascio D, Rizzo G, Giancotti A, D'Amico A, Leombroni M, Makatsarya A, Familiari A, Liberati M, Nappi L, Flacco ME, Manzoli L, Salomon LJ, Scambia G, D'Antonio F. Outcome of fetuses with congenital cytomegalovirus infection and normal ultrasound at diagnosis: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:551-559. [PMID: 33030767 DOI: 10.1002/uog.23143] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 08/23/2020] [Accepted: 09/25/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To report the outcome of fetuses with congenital cytomegalovirus (CMV) infection and normal ultrasound at the time of diagnosis, and to evaluate the rate of an additional anomaly detected only on magnetic resonance imaging (MRI). METHODS Medline, EMBASE, CINAHL and Cochrane databases were searched for studies reporting on the outcome of fetuses with congenital CMV infection. Inclusion criteria were fetuses with confirmed CMV infection and normal ultrasound assessment at the time of the initial evaluation. The outcomes observed were an anomaly detected on a follow-up ultrasound scan, an anomaly detected on prenatal MRI but missed on ultrasound, an anomaly detected on postnatal assessment but missed prenatally, perinatal mortality, symptomatic infection at birth, neurodevelopmental outcome and hearing and visual deficits. Neurodevelopmental outcome was assessed only in cases of isolated CMV infection confirmed at birth. Subgroup analysis was performed according to the trimester in which maternal infection occurred. Random-effects meta-analysis of proportions was used to analyze the data. RESULTS Twenty-six studies were included, comprising 2603 fetuses with congenital CMV infection, of which 1178 (45.3%) had normal ultrasound at the time of diagnosis and were included in the analysis. The overall rate of an associated central nervous system (CNS) anomaly detected on a follow-up ultrasound scan was 4.4% (95% CI, 1.4-8.8%) (32/523; 15 studies), while the rates of those detected exclusively on prenatal MRI or on postnatal imaging were 5.8% (95% CI, 1.9-11.5%) (19/357; 11 studies) and 3.2% (95% CI, 0.3-9.0%) (50/660; 17 studies), respectively. The rate of an associated extra-CNS anomaly detected on a follow-up ultrasound scan was 2.9% (95% CI, 0.8-6.3%) (19/523; 15 studies), while the rates of those detected exclusively on MRI or on postnatal imaging were 0% (95% CI, 0.0-1.7%) (0/357; 11 studies) and 0.9% (95% CI, 0.3-1.8%) (4/660; 17 studies), respectively. Intrauterine death and perinatal death each occurred in 0.7% (95% CI, 0.3-1.4%) (2/824; 23 studies) of cases. In cases without an associated anomaly detected pre- or postnatally, symptomatic infection was found in 1.5% (95% CI, 0.7-2.7%) (6/548; 19 studies) of infants, the overall rate of a neurodevelopmental anomaly was 3.1% (95% CI, 1.6-5.1%) (16/550; 19 studies), and hearing problems affected 6.5% (95% CI, 3.8-10.0%) (36/550; 19 studies) of children. Subanalyses according to the trimester in which maternal infection occurred were affected by the very small number of included cases and lack of comparison of the observed outcomes in the original studies. Compared with fetuses infected in the second or third trimester, those infected in the first trimester had a relatively higher risk of having an additional anomaly detected on follow-up ultrasound or MRI, abnormal neurodevelopmental outcome and hearing problems. CONCLUSIONS In fetuses with congenital CMV infection in which no anomalies are detected on prenatal ultrasound or MRI, the risk of adverse postnatal outcome is lower than that reported previously in the published literature when not considering the role of antenatal imaging assessment. The results from this review also highlight the potential role of MRI, even in fetuses with no anomalies detected on ultrasound, as an anomaly can be detected exclusively on MRI in about 6% of cases. The findings from this study could enhance prenatal counseling of pregnancies with congenital CMV infection with normal prenatal imaging. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- D Buca
- Centre for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Italy
| | - D Di Mascio
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - G Rizzo
- Division of Maternal and Fetal Medicine, Ospedale Cristo Re, University of Rome Tor Vergata, Rome, Italy
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - A Giancotti
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - A D'Amico
- Centre for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Italy
| | - M Leombroni
- Centre for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Italy
| | - A Makatsarya
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - A Familiari
- Department of Clinical and Community Sciences, University of Milan, and Department of Woman Child and Neonate, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - M Liberati
- Centre for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Italy
| | - L Nappi
- Department of Obstetrics and Gynecology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - M E Flacco
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - L Manzoli
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - L J Salomon
- Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes and Fetus & LUMIERE team, Paris, France
| | - G Scambia
- Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli, Rome, Italy
| | - F D'Antonio
- Department of Obstetrics and Gynecology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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Leruez-Ville M, Foulon I, Pass R, Ville Y. Cytomegalovirus infection during pregnancy: state of the science. Am J Obstet Gynecol 2020; 223:330-349. [PMID: 32105678 DOI: 10.1016/j.ajog.2020.02.018] [Citation(s) in RCA: 116] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 02/06/2020] [Accepted: 02/10/2020] [Indexed: 12/25/2022]
Abstract
Cytomegalovirus is the most common congenital infection, affecting 0.5-2% of all live births and the main nongenetic cause of congenital sensorineural hearing loss and neurological damage. Congenital cytomegalovirus can follow maternal primary infection or nonprimary infection. Sensorineurological morbidity is confined to the first trimester with up to 40-50% of infected neonates developing sequelae after first-trimester primary infection. Serological testing before 14 weeks is critical to identify primary infection within 3 months around conception but is not informative in women already immune before pregnancy. In Europe and the United States, primary infection in the first trimester are mainly seen in young parous women with a previous child younger than 3 years. Congenital cytomegalovirus should be evoked on prenatal ultrasound when the fetus is small for gestation and shows echogenic bowel, effusions, or any cerebral anomaly. Although the sensitivity of routine ultrasound in predicting neonatal symptoms is around 25%, serial targeted ultrasound and magnetic resonance imaging of known infected fetuses show greater than 95% sensitivity for brain anomalies. Fetal diagnosis is done by amniocentesis from 17 weeks. Prevention consists of both parents avoiding contact with body fluids from infected individuals, especially toddlers, from before conception until 14 weeks. Candidate vaccines failed to provide more than 75% protection for >2 years in preventing cytomegalovirus infection. Medical therapies such as cytomegalovirus hyperimmune globulins aim to reduce the risk of vertical transmission but 2 randomized controlled trials have not found any benefit. Valaciclovir given from the diagnosis of primary infection up to amniocentesis decreased vertical transmission rates from 29.8% to 11.1% in the treatment group in a randomized controlled trial of 90 pregnant women. In a phase II open-label trial, oral valaciclovir (8 g/d) given to pregnant women with a mildly symptomatic fetus was associated with a higher chance of delivering an asymptomatic neonate (82%), compared with an untreated historical cohort (43%). Valganciclovir given to symptomatic neonates is likely to improve hearing and neurological symptoms, the extent of which and the duration of treatment are still debated. In conclusion, congenital cytomegalovirus infection is a public health challenge. In view of recent knowledge on diagnosis and pre- and postnatal management, health care providers should reevaluate screening programs in early pregnancy and at birth.
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Affiliation(s)
- Marianne Leruez-Ville
- Assistance Publique-Hôpitaux de Paris, Hôpital Necker Enfants-Malade, Laboratoire de Virologie, Centre National de Reference des Herpes Virus-Laboratoire Associé Infection Congénitale à Cytomégalovirus, Paris, France; EA Fetus, Paris Descartes Université, Université de Paris, Paris, France.
| | - Ina Foulon
- Department of Otolaryngology-Head and Neck Surgery, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium; De Poolster Rehabilitation Centre, Brussels, Belgium
| | - Robert Pass
- Department of Pediatrics, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Yves Ville
- EA Fetus, Paris Descartes Université, Université de Paris, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Necker Enfants-Malade, Maternité, Paris, France
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Khalil A, Sotiriadis A, Chaoui R, da Silva Costa F, D'Antonio F, Heath PT, Jones C, Malinger G, Odibo A, Prefumo F, Salomon LJ, Wood S, Ville Y. ISUOG Practice Guidelines: role of ultrasound in congenital infection. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:128-151. [PMID: 32400006 DOI: 10.1002/uog.21991] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 01/27/2020] [Indexed: 06/11/2023]
Affiliation(s)
- A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - A Sotiriadis
- Second Department of Obstetrics and Gynecology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - R Chaoui
- Center for Prenatal Diagnosis and Human Genetics, Berlin, Germany
| | - F da Silva Costa
- Department of Gynecology and Obstetrics, Ribeirao Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - F D'Antonio
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
- Department of Obstetrics and Gynecology, University Hospital of Northern Norway, Tromsø, Norway
| | - P T Heath
- Paediatric Infectious Diseases Research Group and Vaccine Institute, St George's University of London and St George's University Hospitals NHS Trust, London, UK
| | - C Jones
- Faculty of Medicine and Institute for Life Sciences, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - G Malinger
- Ultrasound Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A Odibo
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - F Prefumo
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - L J Salomon
- Department of Obstetrics and Fetal Medicine, Hopital Necker-Enfants Malades, Assistance Publique-Hopitaux de Paris, Paris Descartes University, Paris, France
| | | | - Y Ville
- Department of Obstetrics and Fetal Medicine, Hopital Necker-Enfants Malades, Assistance Publique-Hopitaux de Paris, Paris Descartes University, Paris, France
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Billette de Villemeur A, Tattevin P, Salmi LR. Hygiene promotion might be better than serological screening to deal with Cytomegalovirus infection during pregnancy: a methodological appraisal and decision analysis. BMC Infect Dis 2020; 20:418. [PMID: 32546244 PMCID: PMC7298945 DOI: 10.1186/s12879-020-05139-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 06/05/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Cytomegalovirus infection is the most frequent viral congenital infection, with possible consequences such as deafness, or psychomotor retardation. In 2016, the French High Council of Public Health was mandated to update recommendations regarding prevention of cytomegalovirus infection in pregnant women. We summarize a critical appraisal of knowledge and deterministic decision analysis comparing the current no-screening situation to serological screening during pregnancy, and to hygiene promotion. METHODS Screening was defined as systematic serological testing, during the first trimester, with repeated tests as needed, to all pregnant women. Outcomes were: 1) severe sequela: intellectual deficiency with IQ ≤ 50 or hearing impairment < 70 dB or sight impairment (≤ 3/10 at best eye); 2) moderate sequela: any level of intellectual, hearing or sight deficiency; and 3) death or termination of pregnancy. We simulated the one-year course of cytomegalovirus infection in a cohort of 800,000 pregnant women. We developed a deterministic decision model, using best and min-max estimates, extracted from systematic reviews or original studies. RESULTS Relevant data were scarce or imprecise. We estimated that 4352 maternal primary infections would result in 1741 foetal infections, and an unknown number of maternal reinfections would result in 1699 foetal infections. There would be 788 cytomegalovirus-related consequences, including 316 foetal deaths or terminations of pregnancy, and 424 moderate and 48 severe sequelae. Screening would result in a 1.66-fold increase of poor outcomes, mostly related to a 2.93-fold increase in deaths and terminations of pregnancy, not compensated by the decrease in severe symptomatic newborns. The promotion of hygiene would result in a 0.75-fold decrease of poor outcomes, related to both a decrease in severe sequelae among symptomatic newborns (RR = 0.75; min-max: 1.00-0.68), and in deaths and terminations of pregnancy (RR = 0.75; min-max: 0.97-0.68). CONCLUSIONS Prevention of cytomegalovirus infection during pregnancy should promote hygiene; serological screening should not be recommended.
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Affiliation(s)
| | - Pierre Tattevin
- CHU de Rennes, Service de maladies infectieuses et médecine tropicale, F-35000, Rennes, France
| | - Louis-Rachid Salmi
- CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, F-33000, Bordeaux, France.
- Univ. Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, F-33000, Bordeaux, France.
- INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, F-33000, Bordeaux, France.
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12
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Camacho Ortega SJ, Bohorquez Avila SDP, Velandia Romero ML, Castellanos Parra JE. Isolation of the Human Cytomegalovirus from bodily fluids. ACTA BIOLÓGICA COLOMBIANA 2019. [DOI: 10.15446/abc.v24n3.79406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
In vitro studies on the pathogenesis of the human cytomegalovirus (HCMV) are conducted regularly using laboratory adapted strains that lose some characteristics during the adaptation process. Since HCMV is excreted from bodily fluids during infection or reactivation, this work aimed to isolate and culture HCMV from the MRC-5 human cells found in the urine, bronchoalveolar lavage, saliva, and plasma samples of pediatric patients with probable or confirmed infection. The samples were inoculated on cell cultures either for 14 days or until a cytopathic effect (CPE) of 80 % was observed. The cell lysates and supernatants were used to perform successive viral passages. Besides HCMV, the herpes simplex virus was detected from all the saliva samples. Inoculation of the HCMV positive sera induced cell clustering and immediate monolayer damage that restricted their use. One sample of bronchoalveolar lavage induced a CPE after inoculation like that of the HCMV reference strains (Towne and Merlin), which was consequently propagated and titrated. A second viral isolate derived from the urine sample of a patient with congenital infection did not demonstrate a CPE, although presence of the virus had been confirmed using PCR. The viral isolates were examined and found to be negative for adenoviruses or enteroviruses. Despite the evident difficulty encountered for the isolation and harvesting of the HCMV, this work shows that it was possible to obtain a low passage viral strain using a modified shell vial method and inoculation protocol with extended follow-up and confirmation.
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Cytomegalovirus encephalitis in immunocompetent infants: A 15-year retrospective study at a single center. Int J Infect Dis 2019; 82:106-110. [DOI: 10.1016/j.ijid.2019.02.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 12/27/2018] [Accepted: 02/26/2019] [Indexed: 11/23/2022] Open
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[A review on the prevention and treatment of congenital cytomegalovirus infection in mothers and infants]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2018; 20. [PMID: 30369367 PMCID: PMC7389047 DOI: 10.7499/j.issn.1008-8830.2018.10.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Human cytomegalovirus (HCMV) has a high infection rate worldwide, and 85%-90% of congenital cytomegalovirus (CMV) infections are asymptomatic at birth, with the clinical manifestations of hearing loss, psychomotor retardation, and learning disabilities, while 10%-15% are symptomatic infections. Some preterm infants develop CMV infection after birth, which can cause sepsis-like syndrome, thrombocytopenia, neutropenia, liver injury, and lung injury. However at present, women of childbearing age have a lack of awareness of CMV. CMV education and hygiene precautions for pregnant women can prevent CMV infections in themselves and congenital CMV infections in their infants. No definite results have been obtained from the studies on the effect of CMV vaccine and high-titer immunoglobulin in preventing congenital CMV infection in fetuses. Recent studies have confirmed that the specificity and sensitivity of urinary or salivary CMV-DNA detection have reached more than 98%, which contributes to the early diagnosis of congenital CMV infection. In addition to short-term treatment with ganciclovir, long-term treatment with oral valganciclovir is safe for symptomatic congenital CMV infection and appears to have a better clinical effect than the short-term treatment. In the future, it is necessary to strengthen the health education for pregnant women, enhance the mother-to-child management of CMV infection, conduct the research on CMV vaccine, and further standardize treatment regimens.
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Penka L, Kagan KO, Goelz R, Hamprecht K. Comparison of quantitative real-time PCR and short-term (18-hour) microculture in diagnosis of fetal cytomegalovirus infection: Impact of hyperimmunoglobulin treatment. Prenat Diagn 2018; 38:936-942. [PMID: 30068023 DOI: 10.1002/pd.5338] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 07/11/2018] [Accepted: 07/18/2018] [Indexed: 01/02/2023]
Abstract
OBJECTIVE The prognostic value of human cytomegalovirus detection (HCMV) DNA levels from amniotic fluid (AF) for the outcome of the infected newborn is still a matter of debate, especially if the onset of maternal primary infection at amniocentesis is unknown. The objective of this study was to investigate the analytical performance in short-term (18-hour) microculture from preconcentrated samples and quantitative real-time PCR (rtPCR) for diagnosis of fetal HCMV infection. METHODS A retrospective diagnostic study was conducted on 51 AF samples taken from women that transmitted HCMV prenatally. Amniocentesis was performed around 22-week gestation. The samples were tested for HCMV viral load via quantitative rtPCR and additionally with quantitative short-term (18-hour) microculture following preconcentration via a 50 000 g centrifugation step prior to inoculation to fibroblast monolayers. RESULTS Both methods show correlating results (ρ = 0.903). In 25 samples, the women received intravenous hyperimmunoglobulin prior to amniocentesis resulting in a lower correlation of both quantitative methods (ρ = 0.445), in reduced median copy numbers of HCMV DNA (P = .037) and reduced viral infectivity in short-term microculture (P = .025). CONCLUSION Both methods lead to correlating results using AF samples from HIG-naïve women. Human cytomegalovirus viral load and infectivity in cell culture are reduced in samples following maternal hyperimmunoglobulin treatment.
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Affiliation(s)
- Lukas Penka
- Institute for Medical Virology and Epidemiology of Viral Diseases, University Hospital of Tuebingen, Tübingen, Germany
| | - Karl-Oliver Kagan
- Department of Obstetrics and Gynaecology, University Hospital of Tuebingen, Tübingen, Germany
| | - Rangmar Goelz
- Department of Neonatology, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Klaus Hamprecht
- Institute for Medical Virology and Epidemiology of Viral Diseases, University Hospital of Tuebingen, Tübingen, Germany
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Abstract
Congenital cytomegalovirus is the most common viral congenital infection, and affects up to 2% of neonates. Significant sequelae may develop after congenital cytomegalovirus, including hearing loss, cognitive defects, seizures, and death. Zika virus is an emerging virus with perinatal implications; a congenital Zika virus syndrome has been identified, and includes findings such as microcephaly, fetal nervous system abnormalities, and neurologic sequelae after birth. Screening, diagnosis, prevention, and treatment of these perinatal infections are reviewed in this article.
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Fatima T, Siddiqui H, Ghildiyal S, Baluni M, Singh DV, Zia A, Dhole T. Cytomegalovirus infection in pregnant women and its association with bad obstetric outcomes in Northern India. Microb Pathog 2017; 113:282-285. [DOI: 10.1016/j.micpath.2017.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 08/17/2017] [Accepted: 10/12/2017] [Indexed: 11/26/2022]
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Chiereghin A, Pavia C, Gabrielli L, Piccirilli G, Squarzoni D, Turello G, Gibertoni D, Simonazzi G, Capretti MG, Lanari M, Lazzarotto T. Clinical evaluation of the new Roche platform of serological and molecular cytomegalovirus-specific assays in the diagnosis and prognosis of congenital cytomegalovirus infection. J Virol Methods 2017; 248:250-254. [DOI: 10.1016/j.jviromet.2017.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/03/2017] [Accepted: 08/06/2017] [Indexed: 10/19/2022]
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19
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Davis NL, King CC, Kourtis AP. Cytomegalovirus infection in pregnancy. Birth Defects Res 2017; 109:336-346. [PMID: 28398680 PMCID: PMC11063757 DOI: 10.1002/bdra.23601] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 08/17/2016] [Accepted: 11/07/2016] [Indexed: 11/06/2022]
Abstract
Cytomegalovirus (CMV) is a DNA herpesvirus that is common worldwide. The two known main sources of primary CMV infection during pregnancy are through sexual activity and contact with young children. Primary infection occurs in approximately 1 to 4% of pregnancies, and is mostly asymptomatic in immunocompetent adults. However, primary infection may manifest as a mild mononucleosis or flu-like syndrome with persistent fever and fatigue. CMV can be transmitted from mother-to-child in utero, intrapartum, or during breastfeeding. Intrauterine transmission can lead to congenital CMV infection, a leading cause of permanent hearing and vision loss and neurological disability among children. Congenital CMV transmission rates are as high as 50% in women who acquire primary CMV infection during pregnancy, and less than 2% in women with nonprimary infection. There is no licensed CMV vaccine. Good hygiene practices and avoiding intimate contact with young children (e.g., kissing on the mouth and sharing utensils) have been suggested as an approach to prevent maternal primary CMV infection during pregnancy, but remains an unproven method of reducing the risk of congenital CMV infection. Approximately 1 in 10 infants who acquire CMV in utero will have clinical signs at birth, and an additional 10 to 15% will go on to develop late-onset sequelae. Antiviral treatment prenatally and postnatally has not proven effective at preventing congenital or postnatal CMV infection, and is not recommended for routine clinical care. However, antiviral treatment when initiated in the first month of life for symptomatic congenital CMV infection is recommended for improved neurodevelopmental and audiologic outcomes. Birth Defects Research 109:336-346, 2017. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Nicole L. Davis
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Caroline C. King
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Athena P. Kourtis
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Abstract
Congenital cytomegalovirus (CMV) remains a leading cause of disability in children. Understanding the pathogenesis of infection from the mother via the placenta to the neonate is crucial if we are to produce new interventions and provide supportive mechanisms to improve the outcome of congenitally infected children. In recent years, some major goals have been achieved, including the diagnosis of primary maternal CMV infection in pregnant women by using the anti-CMV IgG avidity test and the diagnosis and prognosis of foetal CMV infection by using polymerase chain reaction real-time tests to detect and quantify the virus in amniotic fluid. This review summarises recent advances in our understanding and highlights where challenges remain, especially in vaccine development and anti-viral therapy of the pregnant woman and the neonate. Currently, no therapeutic options during pregnancy are available except those undergoing clinical trials, whereas valganciclovir treatment is recommended for congenitally infected neonates with moderately to severely symptomatic disease.
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Affiliation(s)
- Vincent C Emery
- Department of Microbial and Cellular Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, Surrey, UK
| | - Tiziana Lazzarotto
- Department of Specialized, Experimental and Diagnostic Medicine, University of Bologna, Bologna, Italy
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Fetal cytomegalovirus infection. Best Pract Res Clin Obstet Gynaecol 2016; 38:97-107. [PMID: 27923540 DOI: 10.1016/j.bpobgyn.2016.10.005] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 10/10/2016] [Accepted: 10/10/2016] [Indexed: 01/06/2023]
Abstract
Cytomegalovirus (CMV) congenital infection affects 0.7% of live births worldwide and is the leading cause of congenital neurological handicap of infectious origin. However, systematic screening for this infection has not been implemented in pregnancy or at birth in any country. This apparent paradox had been justified by persisting gaps in the knowledge of this congenital infection: uncertain epidemiological data, difficulty in the diagnosis of maternal infection, absence of validated prenatal prognostic markers, unavailability of an efficient vaccine and scarcity of data available on the treatment. However, in the last decade, new data have emerged towards better management of this congenital infection, including solid epidemiological data, good evidence for the accuracy of diagnosis of maternal CMV infection and good evidence for the feasibility of predicting the outcome of fetal infection by a combination of fetal imaging and fetal laboratory parameters. There is also some evidence that valaciclovir treatment of mothers carrying an infected fetus is feasible, safe and might be effective. This review provides an update on the evidence for diagnosis, prognosis and treatment of congenital infection in the antenatal period. These suggest a benefit to a proactive approach for prenatal congenital infections.
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Study of Soluble HLA-G in Congenital Human Cytomegalovirus Infection. J Immunol Res 2016; 2016:3890306. [PMID: 27699182 PMCID: PMC5029053 DOI: 10.1155/2016/3890306] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 08/09/2016] [Accepted: 08/16/2016] [Indexed: 11/30/2022] Open
Abstract
Human leukocyte antigen-G (HLA-G) is a nonclassical HLA class I antigen that is expressed during pregnancy contributing to maternal-fetal tolerance. HLA-G can be expressed as membrane-bound and soluble forms. HLA-G expression increases strongly during viral infections such as congenital human cytomegalovirus (HCMV) infections, with functional consequences in immunoregulation. In this work we investigated the expression of soluble (s)HLA-G and beta-2 microglobulin (component of HLA) molecules in correlation with the risk of transmission and severity of congenital HCMV infection. We analyzed 182 blood samples from 130 pregnant women and 52 nonpregnant women and 56 amniotic fluid samples from women experiencing primary HCMV infection. The median levels of sHLA-G in maternal serum of women with primary HCMV infection were higher in comparison with nonprimary and uninfected pregnant women (p < 0.001). AF from HCMV symptomatic fetuses presented higher sHLA-G levels in comparison with infected asymptomatic fetuses (p < 0.001), presence of HLA-G free-heavy chain, and a concentration gradient from amniotic fluid to maternal blood. No significant statistical difference of beta-2 microglobulin median levels was observed between all different groups. Our results suggest the determination of sHLA-G molecules in both maternal blood and amniotic fluid as a promising biomarker of diagnosis of maternal HCMV primary infection and fetal HCMV disease.
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Feasibility of predicting the outcome of fetal infection with cytomegalovirus at the time of prenatal diagnosis. Am J Obstet Gynecol 2016; 215:342.e1-9. [PMID: 27063062 DOI: 10.1016/j.ajog.2016.03.052] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 03/31/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Congenital cytomegalovirus infection occurs in 0.7% of live births with 15-20% of infected children developing long-term disability including hearing loss and cognitive deficit. Fetal cytomegalovirus infection is established by viral DNA amplification by polymerase chain reaction in amniotic fluid obtained by amniocentesis following maternal seroconversion or after the diagnosis of ultrasound features suggestive of fetal infection. Severe brain ultrasound anomalies are associated with a poor prognosis. The prognosis of an infected fetus showing either no ultrasound features or nonsevere ultrasound anomalies is difficult to establish up until late in the second or third trimester of pregnancy. OBJECTIVE We sought to evaluate the prognostic value of fetal ultrasound, amniotic fluid, and fetal blood analysis at the time of prenatal diagnosis of fetal infection. STUDY DESIGN We reviewed all cases of fetal cytomegalovirus infection with a sample of amniotic fluid positive for viral DNA and/or fetal blood analyzed in our laboratory from 2008 through 2013. Prenatal ultrasound features along with cytomegalovirus DNA loads in amniotic fluid and in fetal blood and fetal platelet counts were reviewed in relation to gestational age at maternal infection, neonatal examination, and postnatal follow-up or postmortem examination. RESULTS In all, 82 fetuses were infected following maternal infection mainly in the first trimester. At the time of prenatal diagnosis at a median of 23 weeks, 19, 22, and 41 fetuses showed severe brain ultrasound abnormalities, nonsevere ultrasound features, and normal ultrasound examination, respectively. Nonsevere ultrasound features, higher DNA load in amniotic fluid, fetal platelet count ≤114,000/mm(3), and DNA load ≥4.93 log10 IU/mL in fetal blood were associated with a symptomatic status at birth in univariate analysis (P < .001, P = .001, and P = .018, respectively). Bivariate analysis combining ultrasound results and either adjusted viral load in amniotic fluid or fetal blood profile showed that these were independent prognostic factors of a symptomatic status at birth. Both fetal blood parameters were better predictors than amniotic fluid viral load. At the time of prenatal diagnosis, the ultrasound negative predictive value for symptoms at birth or at termination of pregnancy was 93%. The combined negative predictive values of ultrasound and viral load in amniotic fluid and that of ultrasound and fetal blood parameters were 95% and 100%, respectively. In fetuses presenting with nonsevere ultrasound features, the positive predictive values of ultrasound alone and in combination with amniotic fluid viral load or with fetal blood parameters were 60%, 78%, and 79%, respectively. CONCLUSION Risk assessment of infected fetuses for being symptomatic at birth is possible as early as the time of diagnosis by using a combination of targeted ultrasound examination along with viral load in amniotic fluid and in fetal blood together with platelet count. The advantage of using amniotic fluid is that it is available at prenatal diagnosis. One may wonder if increasing the negative predictive value of the overall assessment of an infected fetus from 95-100% is worth the additional risk of cordocentesis for fetal blood sampling. This can only be an individual decision made by well-informed women and it seems therefore appropriate to use the figures presented here and their confidence intervals for counseling.
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Fattuoni C, Palmas F, Noto A, Barberini L, Mussap M, Grapov D, Dessì A, Casu M, Casanova A, Furione M, Arossa A, Spinillo A, Baldanti F, Fanos V, Zavattoni M. Primary HCMV infection in pregnancy from classic data towards metabolomics: An exploratory analysis. Clin Chim Acta 2016; 460:23-32. [PMID: 27288986 DOI: 10.1016/j.cca.2016.06.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 05/30/2016] [Accepted: 06/06/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Human cytomegalovirus (HCMV) is one of the most frequent risk of viral infections during pregnancy. The aim of this study was to evaluate the metabolic profile in amniotic fluid (AF) samples obtained from HCMV-infected, and uninfected fetuses in order to elucidate changes in metabolic pathways during congenital HCMV infection and to recognize new potential diagnostic and/or prognostic biomarkers. METHODS A retrospective cohort study was conducted on 63 pregnant women: 20 contracted primary HCMV infection during pregnancy and, subsequently, transmitted the virus to the fetus (transmitters); 20 contracted the infection without transmitting the virus to the fetus (non-transmitters); 23 who underwent amniocentesis for cytogenetic-based diagnosis were considered controls. Metabolomics analysis was performed by using the hyphenated technique Gas chromatography-mass spectrometry (GC-MS) followed by a multivariate statistical approach. Four PLS-DA models were generated: controls vs. transmitters; controls vs. non-transmitters; transmitters vs. non-transmitters; and asymptomatic infected vs. symptomatic infected newborns. Subsequently, these models were exploited for network mapping. RESULTS Compared with controls, HCMV transmitters showed significantly increased levels in glutamine, glycine, serine, pyruvic acid, threonine, threonic acid, and cystine; conversely, unknown U1715 and U1804, glutamic acid, U1437, fructose, sugar-like A203003 and A203005, and tyrosine levels were found decreased. In non-transmitters, glutamine, serine, glycine, threonic acid, threonine, 1-monostearin, urea, and cystine were found increased, while sorbitol, unknown U1804, sugar-like A203003, U1751, xylitol, leucine and fructose were decreased. The comparison between transmitters and non-transmitters did not produce a statistically significant model. Unlike controls' profile, a common feature of HCMV infected subjects (transmitters and non-transmitters) was the activation of glutamine-glutamate and pyrimidine metabolic pathways. In addition, a clusterization for asymptomatic vs. symptomatic outcome was also observed due to alteration of fatty acids biosynthesis. CONCLUSIONS Metabolomics approach could highlight the significant modification of maternal and placental status during HCMV infection for both transmitter and non-transmitter subjects. A further separation was observed for asymptomatic vs. symptomatic HCMV congenital infections model. Therefore, metabolomics may be a promising tool to improve the accuracy of an early diagnosis, and the management of HCMV pregnancy-related infections.
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Affiliation(s)
- Claudia Fattuoni
- Department of Chemical and Geological Sciences, University of Cagliari, Cagliari I-09042, Italy
| | - Francesco Palmas
- Department of Chemical and Geological Sciences, University of Cagliari, Cagliari I-09042, Italy
| | - Antonio Noto
- Department of Surgical Sciences, University of Cagliari and Neonatal Intensive Care Unit, Puericulture Institute and Neonatal Section, Azienda Ospedaliera Universitaria, Cagliari I-09042, Italy
| | - Luigi Barberini
- Department of Public Health Clinical and Molecular Medicine, University of Cagliari, Cagliari I-09042, Italy
| | - Michele Mussap
- Laboratory Medicine Service, IRCCS AOU San Martino-IST, University-Hospital, Genoa, Italy.
| | | | - Angelica Dessì
- Department of Surgical Sciences, University of Cagliari and Neonatal Intensive Care Unit, Puericulture Institute and Neonatal Section, Azienda Ospedaliera Universitaria, Cagliari I-09042, Italy
| | - Mariano Casu
- Department of Chemical and Geological Sciences, University of Cagliari, Cagliari I-09042, Italy
| | - Andrea Casanova
- Department of Public Health Clinical and Molecular Medicine, University of Cagliari, Cagliari I-09042, Italy
| | - Milena Furione
- Molecular Virology Unit, Microbiology and VirologyDepartment, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
| | - Alessia Arossa
- Departments of Obstetrics and Gynecology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
| | - Arsenio Spinillo
- Departments of Obstetrics and Gynecology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
| | - Fausto Baldanti
- Molecular Virology Unit, Microbiology and VirologyDepartment, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
| | - Vassilios Fanos
- Department of Surgical Sciences, University of Cagliari and Neonatal Intensive Care Unit, Puericulture Institute and Neonatal Section, Azienda Ospedaliera Universitaria, Cagliari I-09042, Italy
| | - Maurizio Zavattoni
- Molecular Virology Unit, Microbiology and VirologyDepartment, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
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Naing ZW, Scott GM, Shand A, Hamilton ST, van Zuylen WJ, Basha J, Hall B, Craig ME, Rawlinson WD. Congenital cytomegalovirus infection in pregnancy: a review of prevalence, clinical features, diagnosis and prevention. Aust N Z J Obstet Gynaecol 2015; 56:9-18. [PMID: 26391432 DOI: 10.1111/ajo.12408] [Citation(s) in RCA: 131] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 08/17/2015] [Indexed: 11/30/2022]
Abstract
Human cytomegalovirus (CMV) is under-recognised, despite being the leading infectious cause of congenital malformation, affecting ~0.3% of Australian live births. Approximately 11% of infants born with congenital CMV infection are symptomatic, resulting in clinical manifestations, including jaundice, hepatosplenomegaly, petechiae, microcephaly, intrauterine growth restriction and death. Congenital CMV infection may cause severe long-term sequelae, including progressive sensorineural hearing loss and developmental delay in 40-58% of symptomatic neonates, and ~14% of initially asymptomatic infected neonates. Up to 50% of maternal CMV infections have nonspecific clinical manifestations, and most remain undetected unless specific serological testing is undertaken. The combination of serology tests for CMV-specific IgM, IgG and IgG avidity provide improved distinction between primary and secondary maternal infections. In pregnancies with confirmed primary maternal CMV infection, amniocentesis with CMV-PCR performed on amniotic fluid, undertaken after 21-22 weeks gestation, may determine whether maternofetal virus transmission has occurred. Ultrasound and, to a lesser extent, magnetic resonance imaging are valuable tools to assess fetal structural and growth abnormalities, although the absence of fetal abnormalities does not exclude fetal damage. Diagnosis of congenital CMV infection at birth or in the first 3 weeks of an infant's life is crucial, as this should prompt interventions for prevention of delayed-onset hearing loss and neurodevelopmental delay in affected infants. Prevention strategies should also target mothers because increased awareness and hygiene measures may reduce maternal infection. Recognition of the importance of CMV in pregnancy and in neonates is increasingly needed, particularly as therapeutic and preventive interventions expand for this serious problem.
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Affiliation(s)
- Zin W Naing
- Serology and Virology Division (SAViD), Department of Microbiology, SEALS, Prince of Wales Hospital, Randwick, Australia.,School of Medical Sciences, Faculty of Medicine, University of New South Wales, Randwick, Australia.,Australian Centre for Perinatal Science, University of New South Wales, Randwick, Australia
| | - Gillian M Scott
- Serology and Virology Division (SAViD), Department of Microbiology, SEALS, Prince of Wales Hospital, Randwick, Australia.,School of Biotechnology and Biomolecular Sciences, Faculty of Science, University of New South Wales, Randwick, Australia
| | - Antonia Shand
- Department of Maternal Fetal Medicine, Royal Hospital for Women, Randwick, Australia
| | - Stuart T Hamilton
- Serology and Virology Division (SAViD), Department of Microbiology, SEALS, Prince of Wales Hospital, Randwick, Australia.,School of Biotechnology and Biomolecular Sciences, Faculty of Science, University of New South Wales, Randwick, Australia
| | - Wendy J van Zuylen
- Serology and Virology Division (SAViD), Department of Microbiology, SEALS, Prince of Wales Hospital, Randwick, Australia.,School of Medical Sciences, Faculty of Medicine, University of New South Wales, Randwick, Australia
| | - James Basha
- Serology and Virology Division (SAViD), Department of Microbiology, SEALS, Prince of Wales Hospital, Randwick, Australia
| | - Beverly Hall
- Serology and Virology Division (SAViD), Department of Microbiology, SEALS, Prince of Wales Hospital, Randwick, Australia
| | - Maria E Craig
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Westmead, Sydney, New South Wales, Australia
| | - William D Rawlinson
- Serology and Virology Division (SAViD), Department of Microbiology, SEALS, Prince of Wales Hospital, Randwick, Australia.,School of Medical Sciences, Faculty of Medicine, University of New South Wales, Randwick, Australia.,Australian Centre for Perinatal Science, University of New South Wales, Randwick, Australia.,School of Biotechnology and Biomolecular Sciences, Faculty of Science, University of New South Wales, Randwick, Australia
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Zavattoni M, Rustico M, Tassis B, Lombardi G, Furione M, Piralla A, Baldanti F. Risk of congenital disease in 46 infected fetuses according to gestational age of primary human cytomegalovirus infection in the mother. J Med Virol 2015; 88:120-6. [PMID: 26118464 DOI: 10.1002/jmv.24313] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2015] [Indexed: 11/10/2022]
Abstract
Given the difficulty in establishing the exact time of HCMV transmission from mother to fetus, HCMV intrauterine infection was investigated in 46 infected fetuses/newborns by correlating maternal and fetal parameters with clinical outcome according to the time interval between the onset of maternal infection and prenatal diagnosis. In detail, 17/28 (60.7%) asymptomatic and 18/18 (100%) symptomatic fetuses/newborns were infected as a consequence of a primary maternal HCMV infection acquired ≤8 weeks of gestational age, while 11/28 (39.3%) asymptomatic and 0/18 (0%) symptomatic fetuses/newborns were congenitally infected when maternal infection was acquired >8 weeks' gestation. Symptomatic fetal infections appeared to be associated with a maternal primary infection occurring at ≤ 8 weeks' gestation. Cordocentesis performed at 20 weeks' gestation should be restricted to high risk infected fetuses.
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Affiliation(s)
- Maurizio Zavattoni
- Department of Microbiology and Virology, Molecular Virology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Mariangela Rustico
- Departments of Obstetrics and Gynecology, "V.Buzzi" Hospital, ICP, University of Milan, Milan, Italy
| | - Beatrice Tassis
- Obstetric and Gynecology Unit, Fondazione IRCCS Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Giuseppina Lombardi
- Neonatology and Neonatal Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Milena Furione
- Department of Microbiology and Virology, Molecular Virology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Antonio Piralla
- Department of Microbiology and Virology, Molecular Virology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fausto Baldanti
- Department of Microbiology and Virology, Molecular Virology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Clinical, Section of Microbiology, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
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27
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Saldan A, Forner G, Mengoli C, Gussetti N, Palù G, Abate D. Strong Cell-Mediated Immune Response to Human Cytomegalovirus Is Associated With Increased Risk of Fetal Infection in Primarily Infected Pregnant Women. Clin Infect Dis 2015; 61:1228-34. [PMID: 26175520 DOI: 10.1093/cid/civ561] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 06/24/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Human cytomegalovirus (CMV) represents one of the leading causes of congenital infections worldwide. Early diagnosis of fetal infection and consequent rapid therapeutic intervention with immunoglobulin treatment may prevent fetal transmission and virus-related sequelae. In this study, the cell-mediated immunity and immunoglobulin avidity were evaluated as potential predictors of congenital transmission of the infection. METHODS CMV immunoglobulin G (IgG) avidity and CMV enzyme-linked immunospot (ELISpot) assays were employed in 80 pregnant women including 57 primary and 23 nonprimary CMV infections. Congenital infection was assessed using CMV DNA quantitative polymerase chain reaction on amniotic fluid or offspring urine. Logistic regression and receiver operating characteristic statistical methods were employed to determine the association with congenital infection. RESULTS Low CMV IgG avidity (25%) alone correlated with a probability of congenital transmission of 18.2% (95% confidence interval, 7.7%-28.8%). In contrast to the expectations, an increase in CMV ELISpot levels was statistically associated with congenital transmission (P = .006). The combined use of CMV ELISpot and low CMV IgG avidity resulted in a higher level of association than either method alone with the incidence of fetal transmission (area under the curve, 0.8685). CONCLUSIONS CMV-specific cell-mediated immunity represents a relevant marker in assessing the likelihood of congenital CMV transmission, particularly in combination with CMV IgG avidity.
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Affiliation(s)
| | | | | | - Nadia Gussetti
- Padua Reference Center for Infections in Pregnancy, Padua General Hospital, University of Padua, Italy
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28
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Zhou Y, Bian G, Zhou Q, Gao Z, Liao P, Liu Y, He M. Detection of cytomegalovirus, human parvovirus B19, and herpes simplex virus-1/2 in women with first-trimester spontaneous abortions. J Med Virol 2015; 87:1749-53. [DOI: 10.1002/jmv.24218] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Ya Zhou
- Institute of Blood Transfusion; Chinese Academy of Medical Sciences; Chengdu China
| | - Guohui Bian
- Institute of Blood Transfusion; Chinese Academy of Medical Sciences; Chengdu China
| | - Qiongxiu Zhou
- Institute of Blood Transfusion; Chinese Academy of Medical Sciences; Chengdu China
| | - Zhan Gao
- Institute of Blood Transfusion; Chinese Academy of Medical Sciences; Chengdu China
| | - Pu Liao
- The Third People's Hospital of Chongqing; Chongqing China
| | - Yu Liu
- Institute of Blood Transfusion; Chinese Academy of Medical Sciences; Chengdu China
| | - Miao He
- Institute of Blood Transfusion; Chinese Academy of Medical Sciences; Chengdu China
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29
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Margioula-Siarkou C, Kalogiannidis I, Petousis S, Prapa S, Dagklis T, Mamopoulos A, Prapas N, Rousso D. Cytomegalovirus, Toxoplasma gondii and Rubella Vertical Transmission Rates According to Mid-trimester Amniocentesis: A Retrospective Study. Int J Prev Med 2015; 6:32. [PMID: 25949782 PMCID: PMC4410442 DOI: 10.4103/2008-7802.154774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 01/22/2015] [Indexed: 11/20/2022] Open
Abstract
Objective: To examine vertical transmission rates of Cytomegalovirus, Toxoplasma Gondii and Rubella infections according to amniotic fluid PCR analysis. Methods: A retrospective analysis of mid-trimester amniocenteses performed in in pregnancies with diagnosed maternal infection by Cytomegavirus (CMV), Rubella or Toxoplasma gondii during 1994-2008 was performed. Vertical transmission rates were observed according to the presence of the infectious agent's DNA in the amniotic fluid. A univariate regression model was also performed to investigate possible correlations between transmission and epidemiological parameters. Results: Overall, 7033 amniocenteses were performed during study's period, of which 166 (2.4%) with the indication of maternal infection by CMV, Rubella or Toxoplasma. Mean maternal age was 27.4 ± 2.5 years and the mean gestational age at amniocentesis was 18.7 ± 2.5 weeks. Vertical transmission was observed in 21 cases (12.7%). Transmission rate was 17.3% in cases with infection from CMV, 9.5% from Toxoplasma gondii and 7.8% from Rubella (P = .05). Maternal age was the only parameter being significantly associated with increased risk for vertical transmission (P = .04). Conclusions: According to our results, overall vertical transmission rate marginally exceeds 10%. CMV infection is characterized by relatively higher transplacental transmission rate, while increased maternal age appears to be associated with a higher risk for vertical transmission
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Affiliation(s)
- Chrysoula Margioula-Siarkou
- 3 Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece ; Iakentro Advanced Medical Center, Thessaloniki, Greece
| | - Ioannis Kalogiannidis
- 3 Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece ; Iakentro Advanced Medical Center, Thessaloniki, Greece
| | - Stamatios Petousis
- 3 Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece ; Iakentro Advanced Medical Center, Thessaloniki, Greece
| | - Stella Prapa
- Iakentro Advanced Medical Center, Thessaloniki, Greece
| | - Themistoklis Dagklis
- 3 Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece ; Iakentro Advanced Medical Center, Thessaloniki, Greece
| | - Apostolos Mamopoulos
- 3 Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikos Prapas
- 3 Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece ; Iakentro Advanced Medical Center, Thessaloniki, Greece
| | - David Rousso
- 3 Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
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30
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Ding ZY, Xu F, Chen DZ, Meng XN, Xu TS, Lu MD, Zhuge HX. A multifactorial analysis of the pregnancy outcomes in cytomegalovirus-infected women. Gynecol Obstet Invest 2015; 80:106-12. [PMID: 25792174 DOI: 10.1159/000370333] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 12/03/2014] [Indexed: 11/19/2022]
Abstract
AIMS To investigate the impacts of cytomegalovirus (CMV) viral load, TORCH (toxoplasmosis, others, rubella, CMV and herpes) coinfections, CMV glycoprotein B (gB) genotypes and maternal genetic polymorphisms on pregnancy outcomes among CMV-infected women. METHODS A total of 731 CMV-infected pregnant women (634 and 97 with normal and adverse pregnancy outcomes, respectively) were recruited. CMV load quantification and screening of TORCH coinfections were performed by using real-time polymerase chain reaction (PCR) and immunodetection techniques, respectively. Genotyping of CMV gB and maternal NFKB1 -94 ins/del, NFKBIA -826C/T and -881A/G polymorphisms was performed by using PCR-restriction fragment length polymorphism. RESULTS We found that the mean CMV viral load in women with adverse pregnancy outcomes was significantly higher than that in women with normal outcomes at all pregnancy stages (p < 0.01). We also found that TORCH coinfections resulted in a 1.65-fold (95% CI = 1.00-2.73) increase in the risk of adverse pregnancy outcomes (p = 0.05). Additionally, we noticed no significant difference in the distribution of CMV gB genotypes between women with normal and adverse pregnancy outcomes (p = 0.42). We also observed that the ins/ins variant genotype of the NFKB1 polymorphism could reduce the risk of adverse pregnancy outcomes (OR = 0.38, 95% CI = 0.15-0.98; p = 0.04). CONCLUSION CMV viral load, TORCH coinfections and maternal NFKB1 polymorphism could influence pregnancy outcomes among CMV-infected women.
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Affiliation(s)
- Zhong-Yang Ding
- Department of General Surgery, Traditional Chinese Medicine University, Wuxi, PR China
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31
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Ebina Y, Minematsu T, Morioka I, Deguchi M, Tairaku S, Tanimura K, Sonoyama A, Nagamata S, Morizane M, Yamada H. Rapid increase in the serum Cytomegalovirus IgG avidity index in women with a congenitally infected fetus. J Clin Virol 2015; 66:44-7. [PMID: 25866335 DOI: 10.1016/j.jcv.2015.03.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 02/23/2015] [Accepted: 03/04/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND Human Cytomegalovirus (CMV) is the virus most frequently responsible for severe diseases of the fetus and newborn. The reported intrauterine transmission rate of CMV following primary maternal infection is approximately 40%. Invasive techniques are needed for the prenatal diagnosis of congenital CMV infection. OBJECTIVES The aim of this study was to evaluate whether the rapidity of change in the CMV IgG avidity index (AI) is associated with the presence of congenital CMV infection among mothers with suspected primary CMV infection. STUDY DESIGN The serum CMV IgG AI was repeatedly measured in 17 pregnant women with positive or borderline test results for CMV IgM together with an initial IgG AI value of <40%. Their neonates underwent polymerase chain reaction analyses for the presence of CMV DNA in the urine. The rapidity of change in the IgG AI per 4 weeks was defined as the ΔAI (%). The ΔAI of women with congenital CMV infection was compared with that of women with no infection. RESULTS The ΔAI of nine mothers with congenital CMV infection (median,15.7%; range,7.8-42.8%) was significantly higher than that of eight mothers with no infection (median, 6.5%, range, 2.0-8.8%; p<0.001). The incidences of congenital CMV infection were 100.0%, 16.7%, and 0.0% among mothers with a ΔAI of >10, 5-10, and <5%, respectively. CONCLUSIONS Measurement of the ΔAI in pregnant women might be useful for estimating the risk of mother-to-neonate CMV transmission.
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Affiliation(s)
- Yasuhiko Ebina
- Department of Obstetrics and Gynecology, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Toshio Minematsu
- Research Center for Disease Control, Aisenkai Nichinan Hospital, Miyazaki, Japan
| | - Ichiro Morioka
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masashi Deguchi
- Department of Obstetrics and Gynecology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shinya Tairaku
- Department of Obstetrics and Gynecology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kenji Tanimura
- Department of Obstetrics and Gynecology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ayako Sonoyama
- Department of Obstetrics and Gynecology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Satoshi Nagamata
- Department of Obstetrics and Gynecology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Mayumi Morizane
- Department of Obstetrics and Gynecology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hideto Yamada
- Department of Obstetrics and Gynecology, Kobe University Graduate School of Medicine, Kobe, Japan
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Leruez-Ville M, Ville Y. [Cytomegalovirus infection in pregnancy]. Presse Med 2014; 43:683-90. [PMID: 24791602 DOI: 10.1016/j.lpm.2014.02.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 02/05/2014] [Indexed: 11/24/2022] Open
Abstract
Cytomegalovirus is the main cause of neurosensorial deficit due to a congenital infection. Fetal infection may follow a maternal primary infection or a maternal secondary infection. The diagnosis of maternal primary infection remains tricky because the interpretation of IgG avidity test may be difficult. The diagnosis of maternal secondary infections is impossible with usual routine assays. The virological diagnosis of fetal infection is very reliable with a sensitivity over 90% and a specificity next to 100%. In the context of a proven intrauterine infection, the negative predictive value of ultrasound coupled with fetal brain RMI is over 85%. No antenatal treatment is yet validated, two treatments (hyperimmune therapy and antival therapy) are under evaluation. Six months treatment course with valganciclovir improves audiologic and neurodevelopmental outcomes of symptomatic neonates.
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Affiliation(s)
- Marianne Leruez-Ville
- Université Paris Descartes, Sorbonne Paris Cité, hôpital Necker-enfants malades, laboratoire de virologie, 75015 Paris, France.
| | - Yves Ville
- université Paris Descartes, Sorbonne Paris Cité, hôpital Necker-enfants malades, service d'obstétrique et médecine fœtale, 75015 Paris, France
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Pillet S, Roblin X, Cornillon J, Mariat C, Pozzetto B. Quantification of cytomegalovirus viral load. Expert Rev Anti Infect Ther 2013; 12:193-210. [PMID: 24341395 DOI: 10.1586/14787210.2014.870887] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cytomegalovirus (CMV), a member of the Herpesviridae family, is worldwide distributed. After the primary infection, CMV induces a latent infection with possible reactivation(s). It is responsible for severe to life-threatening diseases in immunocompromised patients and in foetuses and newborns of infected mothers. For monitoring CMV load, classical techniques based on rapid culture or pp65 antigenemia are progressively replaced by quantitative nuclear acid tests (QNAT), easier to implement and standardize. A large variety of QNAT are available from laboratory-developed assays to fully-automated commercial tests. The indications of CMV quantification include CMV infection during pregnancy and in newborns, and viral surveillance of grafted and non-grafted immunocompromised patients, patients with bowel inflammatory diseases and those hospitalised in intensive care unit. A close cooperation between virologists and clinicians is essential for optimizing the benefit of CMV DNA monitoring.
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Affiliation(s)
- Sylvie Pillet
- Faculty of Medicine of Saint-Etienne, University of Lyon, Groupe Immunité des Muqueuses et Agents Pathogènes (GIMAP)-EA3064, 42023 Saint-Etienne, France
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Benoist G, Leruez-Ville M, Magny JF, Jacquemard F, Salomon LJ, Ville Y. Management of pregnancies with confirmed cytomegalovirus fetal infection. Fetal Diagn Ther 2013; 33:203-14. [PMID: 23571413 DOI: 10.1159/000342752] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 07/11/2012] [Indexed: 11/19/2022]
Abstract
Systematic screening for cytomegalovirus (CMV) maternal infection is not recommended in most countries. Nevertheless, primary CMV infection will occur in around 1% of women. The vertical transmission rate is estimated to be around 30-50%. Newborns with congenital CMV infection remain asymptomatic in the majority of cases and around 10% will present with a wide range of abnormalities. Fetal infection can be diagnosed by amniocentesis with amplification of the viral genome in the amniotic fluid by polymerase chain reaction. This prenatal diagnosis is mainly performed when ultrasound abnormalities are observed. The purpose of this mini-review is to describe the management options when a fetus is known to be infected.
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Affiliation(s)
- Guillaume Benoist
- Department of Obstetrics and Maternal-Fetal Medicine, GHU Necker-Enfants Malades, AP-HP, Université Paris Descartes, Paris, France
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35
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Leruez-Ville M, Sellier Y, Salomon LJ, Stirnemann JJ, Jacquemard F, Ville Y. Prediction of Fetal Infection in Cases With Cytomegalovirus Immunoglobulin M in the First Trimester of Pregnancy: A Retrospective Cohort. Clin Infect Dis 2013; 56:1428-35. [DOI: 10.1093/cid/cit059] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Manicklal S, Emery VC, Lazzarotto T, Boppana SB, Gupta RK. The "silent" global burden of congenital cytomegalovirus. Clin Microbiol Rev 2013; 26:86-102. [PMID: 23297260 PMCID: PMC3553672 DOI: 10.1128/cmr.00062-12] [Citation(s) in RCA: 654] [Impact Index Per Article: 59.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Human cytomegalovirus (CMV) is a leading cause of congenital infections worldwide. In the developed world, following the virtual elimination of circulating rubella, it is the commonest nongenetic cause of childhood hearing loss and an important cause of neurodevelopmental delay. The seroprevalence of CMV in adults and the incidence of congenital CMV infection are highest in developing countries (1 to 5% of births) and are most likely driven by nonprimary maternal infections. However, reliable estimates of prevalence and outcome from developing countries are not available. This is largely due to the dogma that maternal preexisting seroimmunity virtually eliminates the risk for sequelae. However, recent data demonstrating similar rates of sequelae, especially hearing loss, following primary and nonprimary maternal infection have underscored the importance of congenital CMV infection in resource-poor settings. Although a significant proportion of congenital CMV infections are attributable to maternal primary infection in well-resourced settings, the absence of specific interventions for seronegative mothers and uncertainty about fetal prognosis have discouraged routine maternal antibody screening. Despite these challenges, encouraging results from prototype vaccines have been reported, and the first randomized phase III trials of prenatal interventions and prolonged postnatal antiviral therapy are under way. Successful implementation of strategies to prevent or reduce the burden of congenital CMV infection will require heightened global awareness among clinicians and the general population. In this review, we highlight the global epidemiology of congenital CMV and the implications of growing knowledge in areas of prevention, diagnosis, prognosis, and management for both low (50 to 70%)- and high (>70%)-seroprevalence settings.
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Affiliation(s)
- Sheetal Manicklal
- Division of Medical Virology, Department of Clinical Laboratory Sciences, National Health Laboratory Service, Groote Schuur Hospital/University of Cape Town, Cape Town, South Africa
| | - Vincent C. Emery
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - Tiziana Lazzarotto
- Operative Unit of Microbiology, St. Orsola Malpighi General Hospital/University of Bologna, Bologna, Italy
| | - Suresh B. Boppana
- Pediatrics and Microbiology, University of Alabama School of Medicine, Birmingham, Alabama, USA
| | - Ravindra K. Gupta
- Division of Infection and Immunity, University College London, London, United Kingdom
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Ross SA, Novak Z, Pati S, Boppana SB. Overview of the diagnosis of cytomegalovirus infection. Infect Disord Drug Targets 2012; 11:466-74. [PMID: 21827433 DOI: 10.2174/187152611797636703] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2010] [Accepted: 07/19/2010] [Indexed: 02/06/2023]
Abstract
Cytomegalovirus (CMV) is recognized as the most common congenital viral infection in humans and an important cause of morbidity and mortality in immunocompromised hosts. This recognition of the clinical importance of invasive CMV disease in the setting of immunodeficiency and in children with congenital CMV infection has led to the development of new diagnostic procedures for the rapid identification of CMV. Diagnosis of acute maternal CMV infection by the presence of immunoglobulin (Ig)M and low-avidity IgG requires confirmation of fetal infection, which is typically performed using polymerase chain reaction (PCR) assays for CMV on amniotic fluid. Viral culture of the urine and saliva obtained within the first two weeks of life continues to be the gold standard for diagnosis of congenitally-infected infants. PCR assays of dried blood spots from newborns have been shown to lack sufficient sensitivity for the identification of most neonates with congenital CMV infection for universal screening purposes. However, saliva PCR assays are currently being assessed as a useful screening method for congenital CMV infection. In the immunocompromised host, newer rapid diagnostic assays, such as phosphoprotein 65 antigenemia and CMV real-time PCR of blood or plasma have allowed for preemptive treatment, reducing morbidity and mortality. However, lack of standardized real-time PCR protocols hinders the comparison of data from different centers and the development of uniform guidelines for the management of invasive CMV infections in immunocompromised individuals.
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Affiliation(s)
- S A Ross
- Departments of Pediatrics, University of Alabama at Birmingham, Birmingham, AL 35233, USA.
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Visentin S, Manara R, Milanese L, Da Roit A, Forner G, Salviato E, Citton V, Magno FM, Orzan E, Morando C, Cusinato R, Mengoli C, Palu G, Ermani M, Rinaldi R, Cosmi E, Gussetti N. Early Primary Cytomegalovirus Infection in Pregnancy: Maternal Hyperimmunoglobulin Therapy Improves Outcomes Among Infants at 1 Year of Age. Clin Infect Dis 2012; 55:497-503. [DOI: 10.1093/cid/cis423] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Paradowska E, Studzińska M, Nowakowska D, Wilczyński J, Rycel M, Suski P, Gaj Z, Kaczmarek B, Zbróg Z, Leśnikowski ZJ. Distribution of UL144, US28 and UL55 genotypes in Polish newborns with congenital cytomegalovirus infections. Eur J Clin Microbiol Infect Dis 2011; 31:1335-45. [PMID: 22048843 DOI: 10.1007/s10096-011-1447-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Accepted: 10/01/2011] [Indexed: 12/23/2022]
Abstract
Human cytomegalovirus (HCMV) is the most common congenital infection. HCMV strains display genetic variability in different regions. Distribution of HCMV genotypes in the population of congenitally infected newborns from Central Poland and viral load in newborns' blood is described and discussed. HCMV isolates were analysed by sequencing at three sites on the genome: the UL144 tumour necrosis factor-alpha (TNFα)-like receptor gene, the US28 beta-chemokine receptor gene and the UL55 envelope glycoprotein B (gB) gene. The newborns' blood was examined for HCMV DNA with a nested (UL144, UL55) or heminested (US28) polymerase chain reaction, and the genotypes were determined by sequence analysis. HCMV DNA was detectable in 25 out of 55 examined newborns born by HCMV-infected mothers (45.5%). The blood viral load in mother-infant pairs was determined. Most of the newborns had identical virus genotype, gB2 (96%), UL144 B1 (88%) and US28 A2 (84%). These genotypes were detected in all newborns with asymptomatic congenital infection. The occurrence of UL144 B1 or US28 A2 genotypes in the babies examined was significant in comparison to other genotypes (p=0.0002 and p=0.040 respectively). There was no association between specific gB subtypes in all patients groups (p=0.463). There was no correlation between HCMV genotypes and the outcome.
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Affiliation(s)
- E Paradowska
- Institute of Medical Biology, Polish Academy of Sciences, Laboratory of Molecular Virology and Biological Chemistry, Lodowa 106, 93-232, Lodz, Poland.
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Screening for cytomegalovirus during pregnancy. Infect Dis Obstet Gynecol 2011; 2011:1-9. [PMID: 21836812 PMCID: PMC3152970 DOI: 10.1155/2011/942937] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 03/31/2011] [Accepted: 05/25/2011] [Indexed: 11/17/2022] Open
Abstract
The epidemiology and pathogenesis of CMV infections among pregnant women have been intensely studied over the last three decades. This paper highlights recent developments that make either universal or limited serologic screening for CMV during pregnancy potentially attractive. The developments include an understanding of the pathogenesis of CMV infections, a knowledge of high-risk women, the availability of accurate methods for the serologic diagnosis of a primary CMV infection using either single or serial blood samples, accurate methods for the diagnosis of fetal infection via amniotic fluid, sensitive fetal and placental indicators for neonatal outcomes, and the availability of potentially effective interventions.
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Abstract
UNLABELLED Congenital cytomegalovirus (CMV) is the most common intrauterine infection and the leading infectious cause of sensorineural hearing loss and mental retardation. This article reviews the issues that relate to the diagnosis and management of this disease, detailing the points that led to the recent published guidelines by the Society of Obstetricians and Gynaecologists of Canada. A MEDLINE/Cochrane search of CMV infection, pregnancy, and prenatal diagnosis found 195 studies between 1980 and 2010. Of these, we examined 59 relevant studies. The probability of intrauterine transmission following primary infection is 30% to 40%, but only 1% after secondary infection. About 10% to 15% of congenitally infected infants will have symptoms at birth, and 20% to 30% of them will die, whereas 5% to 15% of the asymptomatic infected neonates will develop sequelae later. Children with congenital CMV infection following first trimester infection are more likely to have central nervous system sequelae, whereas infection acquired in the third trimester has a high rate of intrauterine transmission but a favorable outcome. The prenatal diagnosis of fetal CMV infection should be based on amniocentesis performed 7 weeks after the presumed time of infection and after 21 weeks of gestation. Sonographic findings often imply poor prognosis, but their absence does not guarantee a normal outcome. The value of quantitative determination of CMV DNA in the amniotic fluid is not yet confirmed. The effectiveness of prenatal therapy for fetal CMV is not yet proven, although CMV-specific hyperimmune globulin may be beneficial. Routine serologic screening of pregnant women or newborns has never been recommended by any public health authority. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this educational activity, the obstetrician/gynecologist should be better able to evaluate the principles of prenatal diagnosis of congenital CMV infection so doctors will be familiar with the tests and procedures needed, in order to reach a diagnosis of congenital CMV; to assess the natural history and outcome of congenital CMV infection enabling obstetricians to counsel prenatally pregnant women with CMV; and to analyze the prognostic markers for fetal CMV, so managing physicians will be able to predict more accurately the outcomes of fetuses infected by CMV.
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Egyed L, Sassi G, Tibold J, Mádl I, Szenci O. Symptomless intrauterine transmission of bovine herpesvirus 4 to bovine fetuses. Microb Pathog 2011; 50:322-5. [PMID: 21354299 DOI: 10.1016/j.micpath.2010.10.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2010] [Revised: 09/07/2010] [Accepted: 10/07/2010] [Indexed: 10/18/2022]
Abstract
Blood samples of 31 healthy calves and their dams taken immediately after calving before colostrum uptake, and at days 11, 23 and 8 weeks, spleens of seven stillborn calves were analysed in order to determine the source and time of bovine herpesvirus type 4 infection. All the calves were born as seronegatives, while all cattle were seropositives. Viral DNA were amplified by a nested PCR assay from 54.8% of peripheral blood leukocyte samples of newborn calves taken before colostrum uptake, and from all cattle and from their colostrums. Real time PCR detected higher virus level in peripheral blood leukocytes in adult cattle, then in their newborn calves. Bovine semen cells (spermatozoa and leukocyte fractions), spleens of stillborn calves also carried viral genomes. Our results prove, that bovine fetuses can be infected in utero by BoHV-4, but are born as seronegatives. After human examples this is the first report in veterinary virology on intrauterine transmission of a herpesvirus without acute consequences. This phenomenon could explain the low antigenicity of BoHV-4 proteins and lack of neutralizating antibodies. BoHV-4, a gammaherpesvirus, could serve as an animal model for studying inapparent herpesviral infections of human fetuses.
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Affiliation(s)
- László Egyed
- Veterinary Medical Research Institute of the Hungarian Academy of Sciences, P.O. Box 18. 1581 Budapest, Hungary.
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Bonalumi S, Trapanese A, Santamaria A, D’Emidio L, Mobili L. Cytomegalovirus infection in pregnancy: review of the literature. J Prenat Med 2011; 5:1-8. [PMID: 22439067 PMCID: PMC3279147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The aim of this review is to summarize the principles of cytomegalovirus (CMV) infection in pregnancy.In particular, the aim of this review is to evaluate:Incidence and mother-to-child transmissionThe value of screening of pregnant womenDiagnosis of CMV maternal infectionDiagnosis of fetal infection (evaluate the value of ultrasound examination and amniocentesis and evaluate whether the amniotic viral load of mothers with primary cytomegalovirus infection correlate with fetal or neonatal outcomes)Diagnosis of infection in newbornsTherapy in pregnancy, postnatal therapy and prevention.
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Affiliation(s)
- Silvia Bonalumi
- Department of Gynecology and Obstetrics, Istituti Ospitalieri di Verona, Verona, Italy
| | - Angelica Trapanese
- Department of Gynecology and Obstetrics, Istituti Ospitalieri di Verona, Verona, Italy
| | - Angelo Santamaria
- Department of Gynecology and Obstetrics, University of Messina, Messina, Italy
| | - Laura D’Emidio
- Artemisia Fetal Maternal Medical Centre, Department of Prenatal Diagnosis, Rome, Italy
| | - Luisa Mobili
- Artemisia Fetal Maternal Medical Centre, Department of Prenatal Diagnosis, Rome, Italy
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Fabbri E, Revello MG, Furione M, Zavattoni M, Lilleri D, Tassis B, Quarenghi A, Rustico M, Nicolini U, Ferrazzi E, Gerna G. Prognostic markers of symptomatic congenital human cytomegalovirus infection in fetal blood. BJOG 2010; 118:448-56. [PMID: 21199291 DOI: 10.1111/j.1471-0528.2010.02822.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To identify fetal cord blood prognostic markers of symptomatic congenital human cytomegalovirus infection (HCMV). DESIGN Retrospective observational study. SETTING Fetal medicine unit in Milan and Medical virology unit in Pavia, Italy. POPULATION HCMV-infected and -uninfected fetuses of mothers with primary HCMV infection during the period 1995-2009. METHODS Overall, 94 blood samples from as many fetuses of 93 pregnant women experiencing primary HCMV infection were examined for multiple immunological, haematological and biochemical markers as well as virological markers. Congenital HCMV infection was diagnosed by detection of virus in amniotic fluid, and symptomatic/asymptomatic infections were determined by ultrasound scans, nuclear magnetic resonance imaging, histopathology or clinical examination at birth. Blood sample markers were retrospectively compared in symptomatic and asymptomatic fetuses with congenital infection. MAIN OUTCOME MEASURES A statistical analysis was performed to determine the value of each parameter in predicting outcome. RESULTS Univariate analysis showed that most nonviral and viral markers were significantly different in symptomatic (n = 16) compared with asymptomatic (n = 31) fetuses. Receiver operator characteristics analysis indicated that, with reference to an established cutoff for each marker, the best nonviral factors for differentiation of symptomatic from asymptomatic congenital infection were β(2) -microglobulin and platelet count, and the best virological markers were immunoglobulin M antibody and DNAaemia. β(2) -Microglobulin alone or the combination of these four markers reached the optimal diagnostic efficacy. CONCLUSIONS The determination of multiple markers in fetal blood, following virus detection in amniotic fluid samples, is predictive of perinatal outcome in fetuses with HCMV infection.
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Affiliation(s)
- E Fabbri
- Ostetricia e Ginecologia, Ospedale Vittore Buzzi, Dipartimento di Scienze Cliniche, Università degli Studi di Milano, Italy
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Chen CP, Su YN, Chern SR, Wang TY, Tsai FJ, Lin HH, Wu PC, Wang W. Detection and comparison of cytomegalovirus DNA levels in amniotic fluid and fetal ascites in a second-trimester fetus with massive ascites, hyperechogenic bowel, ventriculomegaly and intrauterine growth restriction. Taiwan J Obstet Gynecol 2010; 49:206-10. [PMID: 20708531 DOI: 10.1016/s1028-4559(10)60044-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2010] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To present a prenatal diagnosis of congenital cytomegalovirus (CMV) infection in a pregnancy with fetal ascites. CASE REPORT A 33-year-old, gravida 6, para 2, woman was referred to a hospital at 20 weeks of gestation for management of fetal ascites. The woman had not experienced recent rubella or herpes simplex infections. The maternal blood group was O and Rh(D)-positive. The maternal serum thalassemia and syphilis screen results were negative. Fetal ascites was first noted at 17 weeks of gestation. At 18 weeks, she underwent amniocentesis revealing a 46,XX karyotype. At 20 weeks of gestation, maternal serum CMV IgG and CMV IgM were positive. At 21 gestational weeks, prenatal ultrasound showed fetal ascites, hyperechogenic bowel, ventriculomegaly, and intrauterine growth restriction. Repeated amniocentesis showed CMV DNA levels of 9.72 x 10(5) copies/mL and 6.03 x 10(5) copies/mL in amniocytes and amniotic fluid supernatant, respectively. Paracentesis showed CMV DNA levels of 1.64 x 10(3) copies/mL and 114 copies/mL in ascitic cells and ascitic supernatant, respectively. The pregnancy was terminated. Postnatally, CMV DNA was detected in the umbilical cord, amnion, placenta, cord blood, lungs, liver and brain by quantitative real-time polymerase chain reaction. CONCLUSION A prenatal diagnosis of fetal ascites in association with ventriculomegaly, hyperechogenic bowel and intrauterine growth restriction should alert physicians to congenital CMV infection in addition to aneuploidy. The present case provides evidence that CMV DNA levels are higher in amniotic fluid (amniocytes and amniotic fluid supernatant) than in ascites (ascitic cells and ascitic supernatant) in cases of congenital CMV infection.
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Affiliation(s)
- Chih-Ping Chen
- Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan.
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Molecular detection of cytomegalovirus, herpes simplex virus 2, human papillomavirus 16–18 in Turkish pregnants. Braz J Infect Dis 2010; 14:569-74. [DOI: 10.1016/s1413-8670(10)70114-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Accepted: 08/30/2010] [Indexed: 11/18/2022] Open
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Heterogeneous pathways of maternal-fetal transmission of human viruses (review). Pathol Oncol Res 2010; 15:451-65. [PMID: 19350418 DOI: 10.1007/s12253-009-9166-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Accepted: 03/24/2009] [Indexed: 12/18/2022]
Abstract
Several viruses can pass the maternal-fetal barrier, and cause diseases of the fetus or the newborn. Recently, however, it became obvious, that viruses may invade fetal cells and organs through different routes without acute consequences. Spermatozoa, seminal fluid and lymphocytes in the sperm may transfer viruses into the human zygotes. Viruses were shown to be integrated into human chromosomes and transferred into fetal tissues. The regular maternal-fetal transport of maternal cells has also been discovered. This transport might implicate that lymphotropic viruses can be released into the fetal organs following cellular invasion. It has been shown that many viruses may replicate in human trophoblasts and syncytiotrophoblast cells thus passing the barrier of the maternal-fetal interface. The transport of viral immunocomplexes had also been suggested, and the possibility has been put forward that even anti-idiotypes mimicking viral epitopes might be transferred by natural mechanisms into the fetal plasma, in spite of the selective mechanisms of apical to basolateral transcytosis in syncytiotrophoblast and basolateral to apical transcytosis in fetal capillary endothelium. The mechanisms of maternal-fetal transcytosis seem to be different of those observed in differentiated cells and tissue cultures. Membrane fusion and lipid rafts of high cholesterol content are probably the main requirements of fetal transcytosis. The long term presence of viruses in fetal tissues and their interactions with the fetal immune system might result in post partum consequences as far as increased risk of the development of malignancies and chronic pathologic conditions are discussed.
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Coll O, Benoist G, Ville Y, Weisman LE, Botet F, Anceschi MM, Greenough A, Gibbs RS, Carbonell-Estrany X. Guidelines on CMV congenital infection. J Perinat Med 2010; 37:433-45. [PMID: 19673682 DOI: 10.1515/jpm.2009.127] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Congenital cytomegalovirus (CMV) infection occurs in 0.6-0.7% of all newborns and is the most prevalent infection-related cause of congenital neurological handicap. Vertical transmission occurs in around 30% of cases, but the fetus is not always affected. Symptomatic newborns at birth have a much higher risk of suffering severe neurological sequelae. Detection of specific IgG and IgM and IgG avidity seem to be the most reliable tests to identify a primary infection but interpretation in a clinical context may be difficult. If a seroconversion is documented or a fetal infection is suspected by ultrasound markers, an amniocentesis should be performed to confirm a vertical transmission. In the absence of a confirmed fetal infection with fetal structural anomalies, a pregnancy termination should be discouraged. Fetal prognosis is mainly correlated to the presence of brain damage. Despite promising results with the use of antiviral drugs and CMV hyperimmune globulin (HIG), results have to be interpreted with caution. Pregnant women should not be systematically tested for CMV during pregnancy. Managing CMV screening should be restricted to pregnancies where a primary infection is suspected or among women at high risk. The magnitude of congenital CMV disease and the value of interventions to prevent its transmission or to decrease the sequelae need to be established before implementing public health interventions. In this paper, aspects of CMV infection in the pregnant woman and her infant are reviewed.
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Affiliation(s)
- Oriol Coll
- Department of Maternal-Fetal Medicine, Institut Clínic de Ginecologia, Obstetrícia i Neonatologia, Hospital Clinic, University of Barcelona, Barcelona, Spain
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Carlson A, Norwitz ER, Stiller RJ. Cytomegalovirus infection in pregnancy: should all women be screened? REVIEWS IN OBSTETRICS & GYNECOLOGY 2010; 3:172-179. [PMID: 21364849 PMCID: PMC3046747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Cytomegalovirus (CMV) is the most common cause of congenital infection and complicates approximately 1% of all live births. Primary maternal CMV infection carries a 30% to 40% risk of vertical transmission to the fetus. In cases where maternal CMV infection is suspected, it is important to evaluate the risk to the fetus to provide appropriate counseling and guidance to parents. This article reviews the published literature and summarizes current diagnostic and management recommendations to help answer the question, should all women be screened for CMV infection in pregnancy?
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