Cmv in Pregnancy-Ak Februari 2013

7/29/2019 Cmv in Pregnancy-Ak Februari 2013

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A. Kurdi Syamsuri

Department of Obstetrics and GynaecologyUniversity of Sriwijaya / dr. M. Hoesin Hospital

Palembang - Indonesia


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Congenital CMV infection

2007


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2007


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2007


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95% clinically inapparent

35% transmitted to fetus

No clear relationship between gestational ageand transmission

Fetal damage more likely in first 26 weeks, (32%)than later (15%)

Pongjitsiri S, Congenital CMV Infection, 2007


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Primary maternal infection leads to fetal infectionin 30-50% of cases--10-15% of these have overtclinical disease

Secondary maternal infection less likely to lead tofetal infection (1-2% ) but can do so and may leadto severe disease (Boppana et al, NEJM 2001, 344: 1366)


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Rates of primary CMV infection

during pregnancy

Study (Location) Rate as % of Rate as % of % cong CMV,Pregnancies Seronegatives primary mat infStern 1.1 4.1 45

(London)Grant (Scotland) 0.29 0.71 38

Stagno (USA, 0.57 1.4 47

mid-income)

Ahlfors (Sweden) 0.32 1.4 43

Griffiths (London) 0.30 0.86 20



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Factors Associated With Delivering a Newborn

With Congenital CMV Infection

in Multiparous Women

JAMA. 2003;289:1008-1011


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Following a diagnosis of fetal CMV infection,

serial ultrasound examinations should be

performed every 2 to 4 weeks to detect

sonographic abnormalities, which may aid indetermining the prognosis of the fetus, although it

is important to be aware that the absence of

sonographic findings does not guarantee a

normal outcome. (II-2B)

J Obstet Gynaecol Can 2010;32(4):348354

SOGC CLINICAL PRACTICE GUIDELINE


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Jaundice (67%) Petechiae (76%)

Hepatosplenomegaly (60%) Microcephaly (53%) Chorioretinitis (20%) Seizure (7%) Fatal outcome (10%)

Boppana et al. (1999) Pediatrics 104:55Pongjitsiri S, Congenital CMV Infection, 2007


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IUGR Cerebral ventriculomegaly

Microcephaly Intracranial calcifications Ascites/pleural effusion Hydrop fetalis Oligohydramnios/polyhydramnios Hyperechogenic bowel Liver calcifications



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Neurological sequelae are the most common, and mostsevere: >90% of newborns with symptomatic congenital CMV

infection have visual, audiologic and/or other neurologicalsequelae

- 5-17% of newborns with asymptomatic congenitalCMV infection develop neurological sequelae (esp.hearing loss)



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In case of primary maternal infection, parents

should be informed about a 30% to 40% risk or

intrauterine transmission and fetal infection, anda risk of 20% to 25% for development of

sequelae postnatally if the fetus is infected.

(II-2A)




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Seizures

Chorioretinitis

Periventricular calcifications

Sensorineural hearing loss motor deficits



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Primary maternal infection

Symptomatic congenital CMV infection

Presence of neonatal neurologicalabnormalities

Abnormal head CT scan

Chorioretinitis in the newborn



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Frequency of sequelae

Symptomatic (7%) Asymptomatic (93%)

Infant death 10% 0

Hearing loss 60% 715%

Mental retardation 45% 210%

Cerebral palsy 35%


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Isolation of CMV from urine or other body fluid(CSF, blood, saliva) in the first 21 days of life isconsidered proof of congenital infection

Serologic tests are unreliable; IgM tests currentlyavailable have both false positive and false negativeresults

PCR may be useful in selected cases



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Detection: screening formaternalCMV infection

CMV IgG antibody sensitive and specific

screen for past infection

CMV IgM antibody variable sensitivity and

specificity

Antibody avidity testing can increase accuracy

of detection of primary infection No test for immune mothers who will transmit



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Advanced CMV diagnosis

IgM confirmation by Western blot

Determination of the IgG avidity

index

Isolation of the virus from urine,saliva and blood



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Evaluation of mothers at risk of

transmitting CMV to the fetus

Negative,no further testing

Positive =primary infection

Test for IgM Antibody

Positive

IgG Positive =Seroconversion

Negative,no further tests

Retest later

Negative

Test for IgG antibody

at first prenatal visit

Refer for prenatal diagnosis



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Diagnosis of primary maternal cytomegalovirus

(CMV) infection in pregnancy should be based on

de-novo appearance of virus-specific IgG in the

serum of a pregnant woman who was previouslyseronegative, or on detection of specific IgM

antibody associated with low IgG avidity. (II-2A)


354



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The prenatal diagnosis of fetal CMV infection

should be based on amniocentesis, which should

be done at least 7 weeks after presumed time of

maternal infection and after 21 weeks ofgestation. This interval is important because it

takes 5 to 7 weeks following fetal infection and

subsequent replication of the virus in the kidney

for a detectable quantity of the virus to besecreted to the amniotic fluid. (II-2A)


354



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The diagnosis of secondary infection should be

based on a significant rise of IgG antibody titre

with or without the presence of IgM and high IgG

avidity.

In cases of proven secondary infection,

amniocentesis may be considered, but the risk

benefit ratio is different because of the lowtransmission rate. (III-C)


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26/33J Obstet G naecol Can 2010 32 4 :348354

ALGO

RITHMF

OR

PRENATAL

DIAGNO

SISOFCONGENITALCMV


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Ganciclovir has been shown to be effective therapy

for certain CMV infections in immunocompromisedhosts (e.g., retinitis or enterocolitis in HIV-infected

patients) Neonatal experience with ganciclovir is limited, the

toxicity of the drug is considerable (e.g., platelets,

neutrophils), and oral bioavailability unreliable



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A six week course of IV ganciclovir may reduce therate of long-term hearing loss in neonates withsymptomatic CMV infection

However, this regimen is associated with significanttoxicity, long-term followup data are lacking, andthe optimal duration of therapy (if any) is unknown

Potential benefits of antiviral therapy for

asymptomatically infected neonates may begreater



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A vaccine to prevent CMV infections is

desperately needed Trials of candidate vaccines are underway CMV Vaccine development a Level One

priority !!



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Many different ways toprevent CMV

Our approach:

Hygiene

Avoiding intimate contact with salivarysecretions and urine from young children

Careful hand washing after changing diapersand wiping secretions.

Education about CMV and how to prevent it

through hygiene


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Cmv in Pregnancy-Ak Februari 2013

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