Transcript Perinatal CMV Infection - Eesti Perinatoloogia Selts

Perinatal CMV
Infection
Kadri Matt
Karin Asser
Tartu University Women`s Clinic
Tallinn 2006
Non - Human CMV
What about CMV Infection in
Humans?
 The knowledge about the
virus and its pathogenity
has increased
 A majority of CMV infections
are asymptomatic
 Some symptomatic cases
have tremendous clinical
importance
Combination of
lesions: HSV and
CMV
Descriription of a Case
 The patient was 20 years
of age, unmarried
 During the first trimester of
pregnancy she was
treated for
- Chlamydiosis
urogenitalis
- Anaemia gravidarum
Description of a Case
 The patient was referred to Tartu University
Women`s Hospital for a second opinion
ultrasound because of suspected fetal
hydrocephaly
 At the gestational age of 18 weeks and 6 days
the fetal cerebral lateral ventricles were within
a normal range, 9 mm
 The patient was asked to come back in 2
weeks
 The next ultrasound at our hospital was
performed at 24 weeks and 2 days: it showed
bilateral fetal cerebral ventriculomegaly
(posterior horns 1.2 cm)
 Cordocentesis revealed normal fetal karyotype
46xy
 Maternal blood analysis showed fresh CMV
infection (positive IgG and IgM antibodies)
Ultrasound at 30 weeks and 2
days
 Estimated fetal weight (EFW) 1150 g
(corresponding to 28 weeks)
 Ventriculomegaly: posterior horns of fetal
cerebral ventricles 1.4 cm,
and periventricular hyperechogenic foci
 Polyhydramnios: amniotic fluid index (AFI) 27
 Normal blood flow in arteria umbilicalis
Fetal cerebral ventriculomegaly at 30 weeks 2 days
Ex consilio:

Graviditas in hebdomines 30+5
Infectio cytomegaloviralis congenita
Hydrocephalus
Polyhydramnion
Retardatio incrementi foetalis intrauterina
Decision:
to terminate the pregnancy by induction in
the 36th week of gestation or earlier in the
case of maternal/fetal indications.
Ultrasound at 36 weeks and 3
days
 Intrauterine growth retardation:
EFW 1830 g (corresponding to 32 weeks),
BPD 7.3 cm (29 weeks)
 Fetal cerebral lateral ventricles 1.7 cm
 AFI 28
 Reduced diastolic blood flow in arteria
umbilicalis: PI 1.78
Delivery at 36 weeks and
5 days
• Stimulatio partus cum Oxytocini
- male neonate 2000g/42cm
- Apgar score: 3 - 5 - 6
- cord blood:
pH 7.13
pCO2 58.3
pO2 16.2
BE – 9.0
• The neonate was intubated 5 minutes
after birth and was taken into the neonatal
intensive care unit.
In the NICU
 The newborn is pallid, with
petechial rash and with
multiple deformities,
abnormal build, and
arthrogryposis. Movements
absent, consciousness
disorder, insufficient
hemodynamics.
 Ultrasound: developed
hydrocephaly
 Blood at PCR: CMV
positive
In the NICU
 X-ray: arthro-sceletal athrogryposis
Ex consilio in the NICU
 Prognosis for neonate`s life is absent due
to congenital multiorgan insufficiency.
 The parents share the same opinion.
 After 6 hours artificial ventilation is
stopped – exitus letalis
Pathoanatomical diagnosis
 Primary diseases:
Infectio cytomegaloviralis congenita:
meningoencephalitis, hepatitis, pancreatitis,
nephritis et pneumonitis cytomegaloviralis et ex
descriptionibus clinicis.
 Complications:
Hydrocephalus et arthrogryposis totalis ex
infectionis cytomegaloviralis. Retardatio
incrementi foetalis intrauterina. Asphyxia
perinatalis:hyperaemia venosa acuta
organorum parenhymatosum et ex
descriptionibus clinicic.
CMV infection
 Is rarely of
consequence to the
pregnant woman
herself
 Intrauterine infection
may result in
devastating congenital
disease
Congenital CMV infection
• The incidence of congenital CMV
infection among live births
0.2 – 2.0%
• 6-20% of neonates with congenital
CMV infection are symptomatic
at birth – cytomegalic inclusion
disease develops
• In asymptomatic newborns
it is the common cause of
sensorineural hearing loss and
mental retardation
Congenital CMV – Cytomegalic
Inclusion Disease
• Clinical findings are
variable:
hepatosplenomegaly
jaundice
thrombocytopenia with
purpura
chorioretinitis
cerebral calcifications
microcephaly
hydrocephaly
Cytomegaloviruses are
• Among the oldest known
viruses
• Belong to the group of
herpes viruses
• Incl. DNA viruses
The virus is
•
Intranuclear and is assembled
in the nucleus of the host
• Individuals can be infected by
more than one strain – recurrent
infections may develop
• This makes diagnosis and
management difficult
Risk factors, transmission
• The highest prevalence of antibodies
is found among lower socioeconomic
groups
• Most frequently transmission occurs
by the ororespiratory route…
• Seroconversion in Estonia is 90%
CMV in pregnancy
• Pregnancy per se does
not alter the incidence of
primary disease
• The virus is transmitted in
the absence of specific
T-immunity
• CMV transmission is possible
during pregnancy, delivery and
lactation
possibly by placental route
Transmission
 Maternal CMV-specific IgG have a
protective effect against fetal infection
 Transmission depends on the preconceptional serological status of the
mother
• Transmission rate is 1.2 % for seropositive
and 12.9 % for seronegative women
Prenatal counselling of the
gravida with evidence of primary
infection
 Counselling of a gravida with primary CMV
infection is difficult
 Negative amniocentesis fluid analyses by viral
culture and PCR confirm a reasonably high
probability that the fetus is not infected
 Vertical transmission is possible in later
gestation
Diagnosis of Infection in
Pregnant Women
• Serologic tests for CMV specific
IgG and IgM antibody from
maternal or fetal sera using
ELISA, ABBOT IM or IMMULITE
• CMV – DNA tests by PCR (BCMV-DNA) from , maternal/fetal
blood, sera, amniotic fluid,
neonate`s urine
Prenatal Diagnosis of Congenital
CMV Infection
 A reliable prenatal diagnosis of congenital CMV
infection is based on PCR from amniocentesis
samples
 Best sensitivity and 100% specificity by PCR
from amniotic fluid is after 21 gestational weeks
 Mean interval between the diagnosis of
maternal infection and antenatal procedure is 7
weeks
 CMV- specific IgM antibody detection from cord
blood samples has a sensitivity of 60%
Prenatal Diagnosis of
Congenital CMV Infection
 Ultrasound has limited
sensitivity in detection of
fetal infection
 Pregnancies with evidence
of vertical transmission and
definite ultrasound findings
indicating suspected fetal
damage are at significant
risk of abnormal sequelae
Summary
• Primary maternal infection is difficult to diagnose
unless identified by seroconversion.
• Routine serologic screening for CMV infection
during pregnancy cannot be recommended.
• The documentation of maternal disease during
pregnancy or confirmed congenital fetal CMV
infection may be an indication for therapeutic
abortion/ termination of pregnancy.
Thank You