There is limited evidence to support testing for cytomegalovirus during pregnancy. As cytomegalovirus may be transmitted to the baby and can have serious consequences, the focus is on giving women advice about hygiene measures that reduce their risk of infection.
Cytomegalovirus is a member of the herpes virus family transmitted by contact with saliva, urine or genital secretions. Most people who acquire the virus after birth experience few or no symptoms. Cytomegalovirus remains latent in the host after primary infection and may become active again, particularly during times of compromised immunity including pregnancy.
- Maternal immunity: European studies estimate an incidence of cytomegalovirus immunity in pregnant women of 41–56%, with incidence as high as 98.3% among Turkish women and 100% among Pakistani immigrants in Norway . A Japanese study found an incidence of 87.3%.
- Transmission: Rates of mother-to-child transmission vary depending on whether the maternal infection was primary or secondary. Low-level evidence suggests a transmission rate of 30–50% after primary infection, and 0.5–3.0% following secondary infection .
- Congenital infection: The overall prevalence of congenital cytomegalovirus infection at birth is estimated to be 0.62–0.70% . Congenital cytomegalovirus in Australia is diagnosed in 4.02 per 100,000 live births, with confirmed diagnoses in 15 infants in 2007 and 34 infants in 2008 .
- Risk factors: The evidence suggests that cytomegalovirus infection during pregnancy is more common among women of lower socioeconomic status (1.2%) than among women of higher socioeconomic status (0.39%) . Evidence of primary infection (seroconversion) is also more likely in this group . Frequent and prolonged contact with a child less than 3 years of age (eg as parent or child care worker) increases the risk of infection as cytomegalovirus is shed for long periods of time by children in this age group .
44.1.2 Risks associated with cytomegalovirus during pregnancy
- The most common cause of congenital infection in developed countries, mother-to-child transmission of cytomegalovirus, occurs in around 40% of primary infections during pregnancy . Adverse effects on the developing baby include late miscarriage and growth restriction . About 10% of infants with congenital cytomegalovirus infection display manifestations at birth (including growth restriction, abnormal brain development, impaired hearing, inflammation of the choroid and retina) and are at risk of neurological consequences, including cognitive and motor deficits, hearing and visual impairments .
- While the risk of transmission increases with gestational age, babies infected early in pregnancy have a greater risk of severe symptoms .
44.2 Testing for cytomegalovirus
Conclusions on the value of antenatal testing for cytomegalovirus are limited by a lack of evidence on the appropriate timing of testing, the prognosis for an infected baby and the efficacy of treatments in preventing mother-to-child transmission. Routine maternal testing for cytomegalovirus is not recommended in the United States, Canada or the United Kingdom .
44.2.1 Diagnostic accuracy of tests
Cytomegalovirus is diagnosed by isolation of the virus from body fluids, molecular testing for cytomegalovirus genome by PCR and detection of cytomegalovirus antibodies . To determine whether primary infection occurred before or during pregnancy, antibody detection needs to occur at around 12–16 weeks . The heterogeneity of studies identified makes it difficult to comment on the diagnostic accuracy of one approach to testing over another.
44.2.2 Risks and benefits of testing
There is no high-level evidence on the benefits and risks of testing. Narrative reviews suggest that:
- possible benefits include
- identification of women at risk of primary infection enabling provision of prevention advice
- diagnosis of infection during pregnancy
- monitoring of the pregnancy and the option of diagnostic testing of the baby for women with known infection
- the opportunity to terminate the pregnancy if fetal infection is detected early in the pregnancy
- early commencement of neonatal antiviral treatment
- risks or limitations include
- maternal anxiety
- lack of evidence on the appropriate timing of testing as the virus may be acquired and affect the developing baby throughout pregnancy
- the potential for false positive results
- difficulties in determining whether maternal infection is primary or secondary
- lack of an effective vaccine or treatment
- potential harm from diagnostic testing of the baby (eg amniocentesis-related miscarriage)
- lack of predictive certainty that an infected baby will be symptomatic at birth.
Conclusions on the cost-effectiveness of testing for cytomegalovirus are limited by insufficient evidence on the effectiveness of treatments in preventing congenital cytomegalovirus.
Only offer testing for cytomegalovirus to pregnant women if they come into frequent contact with large numbers of very young children (eg child care workers).
Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW
44.2.3 Availability of safe and effective treatments
The evidence is insufficient to assess whether any interventions prevent mother-to child transmission or adverse outcomes for the congenitally infected infant. Low-level evidence suggests some benefit from maternal intravenous hyperimmunoglobulin in preventing and treating congenital cytomegalovirus infection . Two RCTs to test the efficacy of hyperimmunoglobulin as passive immunisation are in progress.
44.3 Discussing cytomegalovirus prevention
Studies have identified low levels of knowledge about cytomegalovirus and its prevention among womenand that health professionals may not give advice about prevention .
A systematic reviewfound that infection rates consistently decreased as cytomegalovirus education and support increased. These findings are supported by other lower level studies .
Providing advice to pregnant women about preventing cytomegalovirus acquisition through hygiene measures is recommended in the United States NHMRC recommends that women of childbearing age working with children pay particular attention to good hand hygiene after contact with urine or saliva, especially after changing nappies or assisting in toilet care .. The
Advise pregnant women about hygiene measures to prevent cytomegalovirus infection such as frequent hand washing, particularly after exposure to a child’s saliva or urine.
Approved by NHMRC in June 2014; expires June 2019 UNDER REVIEW
44.4 Practice summary: cytomegalovirus
Early in pregnancy.
- Aboriginal and Torres Strait Islander Health Practitioner
- Aboriginal and Torres Strait Islander Health Worker
- multicultural health worker
- infectious disease specialist.
- Discuss transmission of cytomegalovirus
Explain that becoming infected with cytomegalovirus during pregnancy can lead to the infection being transmitted to the baby.
- Take a holistic approach
Explain that frequent hand washing is the most important measure in controlling the spread of cytomegalovirus and is especially important after contact with articles contaminated with urine or saliva.
- Document and follow-up
If a woman is tested for cytomegalovirus, tell her the results and note them in her antenatal record. If a woman has a positive result, seek advice or referral to a health professional with appropriate expertise.
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