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Fetal Medicine and Ultrasound > Cytomegalovirus > Flashcards

Cytomegalovirus Flashcards

Ref: Evidence-Based MFM, Creasy & Resnik, Dr. Gibbs' lecture

1
Q

What is the structure of CMV?

A

Double-stranded virus of herpes family

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2
Q

What is the most common cause of viral intrauterine infection?

A

CMV. Affects 0.5 - 2.5% of all neonates in different parts of the world.

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3
Q

How is CMV transmitted?

A

Contamination from urine, saliva, blood, semen, cervical excretions.

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4
Q

Risk factors for CMV infection?

A 
Low SES
Exposure to infected individuals
Multiple partners
Extremes of age
Multiparity
Blood transfusion
0.1-0.4% per unit of cellular blood products containing leukocytes
In most cases, pregnant women acquire CMV by exposure to children in their home or occupational exposure to children
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5
Q

Symptoms of CMV infection

A

Usually asymptomatic, or symptoms so mild that it goes undiagnosed. May include a mononucleosis-like or flu-like syndrome, malaise, fatigue, lymphadenopathy, persistent fever, lymphocytosis, incr transaminases
Rarely - HSM, cough, headache, rash, GI sx

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6
Q

CMV incubation period

A

4-8w

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7
Q

CMV viremia period

A

3-12 months (infants can shed virus for up to 6 yrs)

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8
Q

In whom does serious CMV disease occur?

A

Fetuses

Immunocompromised adults

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9
Q

Does CMV transmission occur with primary or recurrent infection?

A

Both, but 99.5% of infections occur following primary maternal infection.

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10
Q

What percentage of IgG negative women will acquire CMV infection during pregnancy?

A

2%

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11
Q

What percentage of pregnant women with a primary CMV infection transmit it to their fetus?

A

1/3 (range 30-75%)

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12
Q

When is the transmission rate of CMV highest in pregnancy?

A

3rd trimester

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13
Q

The severity of CMV disease is highest in what trimester of pregnancy?

A

1st trimester

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14
Q

What percentage of CMV-infected infants develop sequelae?

A

15-20% (about 5-8% of infants of infected mothers develop sequelae)

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15
Q

How does recurrent CMV infection occur?

A

Occurs w/ immunosuppression and during pregnancy
Recurrent infxn in pregnancy is usu asx and primarily caused by reactivation of the endogenous virus, but can also be caused by a low-grade chronic infection or reinfection by a different CMV strain.

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16
Q

What is the risk of vertical transmission with recurrent CMV infection?

A

1.4%

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17
Q

What percentage of neonates infected from recurrent maternal infection will have sequelae?

A

<10% (usu have no sx at birth, and do not have CMV+ urine)

18
Q

What are the clinical neonatal findings of symptomatic congenital CMV infection?

A 
Jaundice
Petechiae ("blueberry muffin baby")
Thrombocytopenia
Hepatosplenomegaly
Growth restriction
Microcephaly
Intracranial calcifications
Nonimmune hydrops
Preterm birth
19
Q

What are the late complications of neonatal CMV disease?

A 
Hearing loss
Mental retardation
Delay in psychomotor development
Chorioretinitis
Optic atrophy
Seizures
Expressive language delays
Learning disabilities
20
Q

What is the most common cause of congenital sensorineural hearing loss?

A

CMV

21
Q

What is the long-term mortality rate in neonatal CMV disease?

A

10-30%

22
Q

Diagnosis of congenital CMV infection in amniotic fluid

A

Quantitative PCR count of >/= 10^3 genome equivalents/mL is a certain sign of infxn
>/= genome equivalents/mL can predict symptomatic infection

23
Q

If no ultrasonographic abnl due to CMV are seen, what is the incidence of postnatal neurologic abnormalities?

A

15-20%

24
Q

How effective is hygiene in preventing CMV seroconversion in pregnancy?

A

Avoiding intimate contact w/ children, frequent handwashing, and glove use is associated with an 84% decrease in CMV seroconversion during pregnancy, esp in women who work in day care.

25
Q

Is there a vaccine available for CMV?

A

A live-attenuated CMV vaccine is available, but may be reactivated, and safety issues have not been resolved. In a trial including CMV-seronegative women of childbearing age, a glycoprotein B vaccine demonstrated a 50% efficacy in preventing CMV infection.

26
Q

What is chance of an affected neonate after maternal seroconversion, with a nl US?

A

5%

27
Q

What is chance of an affected neonate after maternal seroconversion, with an abnl US?

A

35%

28
Q

What is chance of an affected neonate after maternal seroconversion, with positive AF PCR and a nl US?

A

15%

29
Q

What is chance of an affected neonate after maternal seroconversion, with a positive AF PCR and an abnl US?

A

80%

30
Q

How long does CMV IgM persist after seroconversion?

A

4-8 months

31
Q

How sensitive is CMV IgM testing?

A

75%. If first test is negative, consider a second test at 18-20w, and a third, if needed, at 30-32w.

32
Q

How can CMV IgM/IgG testing be used to assure no risk of primary infection?

A

IgM negative, IgG positive, with a high IgG avidity index (>65%).

33
Q

Fetal ultrasound findings in congenital CMV infection

A 
Growth restriction
Oligohydramnios
Ventriculomegaly
Choroid plexus cyst (unilateral)
Pleural effusion
Brain and liver calcification
Fetal hydrops
34
Q

What are US findings that increase the risk for neonatal CMV infection?

A

Microcephaly
Hydrocephaly
Intracranial calcifications
Periventricular “halo” - assoc w/ white-matter lesions

35
Q

Ultrasound detects fetal abnormalities in what percent of congenitally CMV-infected fetuses?

A

Only 15%

36
Q

Is CMV-specific IgM+ only found in primary disease?

A

No, CMV IgM can be found in 10% of women with recurrent disease

37
Q

What is the sensitivity of CMV PCR in amniotic fluid?

A

80-100%. It increases after 21w, and after a minimum of 6w interval following maternal primary infxn, so if amnio performed before this interval, it should be repeated later.

38
Q

How is CMV infection diagnosed in the neonate?

A

Based on CMV PCR in body fluids, esp urine.

39
Q

Is there therapy to prevent fetal CMV infxn in pregnancy?

A
  • No randomized trials exist (yet). In a nonrandomized study, CMV hyperimmune globulin IV 100 U/kg q mo until delivery to the mother w/ primary CMV infection was associated with a decrease in infected neonates from 40% to 16%.
  • Maternal CMV hyperimmune globulin 200 U/kg IV to the mother (with additional AF or umbilical cord infusions for persistent US findings) for CMV DNA + fetuses was associated with a decrease in symptomatic CMV disease at birth from 50% in controls to 3%.
  • A trial demonstrated reduction of hearing loss in neonates with proven congenital CMV infection with CNS involvement when tx was begun within one month of birth.
  • Valacyclovir (8g/day orally for 7 weeks) given to women with congenitally CMV-infected fetuses at about 30w was associated with about a 50% normal child outcome at 1 to 5 years of age in one study.
40
Q

How is CMV transmitted perinatally?

A

Transplacentally, in the birth canal, through breast milk

Fetal Medicine and Ultrasound (8 decks)

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