Is CMV infection during pregnancy serious for the child? (CMV i graviditeten)

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­Hei,


My wife gave birth on 24th of February this year in Belgrade, Serbia. After leaving the hospital she was feeling weak and constantly sleepy and tired, but doctor found this to be due to stressful delivery. She also had throat inflammation and for that her doctor prescribed her antibiotics. She was taking antibiotics for breast inflammation as well. In Jun her gland behind ear gets swollen and her doctor prescribed her antibiotics one more time.


She had her last menstrual period on 6th of august. On 22nd of August her throat is very sore and her doctor puts her on penicillin. After 12 injections her throat gets better but just after few days she gets bad again. Her throat is even worse that before, she can’t swallow food and her body temperature is higher (37.5).

On 8th of September doctor does her leukocyte formula and lymphocytes were 2 times higher than normal. On suspicion of mononucleosis doctor does blood analysis:

CMV Igg 1.29 (0.4-0.6 normal)
CMV Igm 10.02 (18-22 normal)
EBV Igg 83.3 (up to 13 normal)
EBV Igm 75.49 ( up to 13 normal)

After this she gets total of 8 injections ( 1 gr ) as a prevention for bacterial inflammation.

ALT i AST values are higher than normal.
AST 54 ( 0-32 )
ALT 45 (0-33 )

We were also told that she is pregnant.

On 12th of September doctor does her leukocyte formula. Lymphocytes were in a normal while monocytes amounted to 13.7% (from 2-10 normal)

On 19th of September
ALT and AST values changed again
Ast 33,
Alt 44,
lymphocytes 52.8%,
Monocytes 9%.

From 15th of September she feels better. Her throat is not sore. She takes a lot of fluids and vitamins.

Does EBV in her case have any effect on baby in this early stage? If it does, what kind of complications can occur? Is it possible that virus reactivates and how negative affects that could have? Is it possible that because of weak immune system, CMV reactivates?

Thanks

Doktor Pål Branæs

Svar fra legen (Pål Branæs)

Sist endret 25. september 2012, klokken 20:54

The reason for your wifes sleepiness and tiredness could be due to the delivery, the mastitis (breast inflammation), the throatinflammation or all. Its hard to tell.


6th of august she gets symptoms of throat infection and receives antibiotics again. There are certain criterias for when to give antibiotics against a throat infection: The person must have lymphnodeswelling in the neck (collum), fever, painful swallowing and enlarged tonsills (with or without pus), and, at the same time no cough or rinning nose (rinorrhea). It can be helpful with a throat sampling called streptest (for demonstrating whether or not there are streptococcus bacterias in her mouth) and CRP (differentiates roughly between bacterial and viral infections). If CRP is low (below 50), she is coughing and/or suffers from rinorrhea, and has no fever, enlarged tonsills, glandular swelling or especially painful swallowing (just discomfort) the cause of her throatinflammation is most probably viral and she should not receive any kind of antibiotics against it.


Though, some viruses can cause severe throatinflammations and -problems as well; the Cytomegalovirus and the Epstein Barr virus. These viruses, first of all EBV can cause mononucleosis. A mononucleosis mimics a bacterial (streptococcal) throatinfection very much, in addition to sometimes cause enlargement of liver/spleen, rashes, malaise and sometimes icterus, that is yellowish discolorization of the skin. Liverenzymes are often elevated, as was the case for her (AST, ALT somewhat higher than normal). The bloodsmear can be quite typical.


She has tested positive for IgM-antibodies regarding EBV. The fact that EBV IgM can be detected in her blood means that she must have got the EBV within the latest months. Furthermore she must have had her CMV mononucleosis earlier in life some time, but more than some months ago, since only IgG is elevated (IgG means previous disease, IgM means ongoing or recent disease). She also counts more than 50% lymphocytes, which confirms the diagnosis of mononucleosis.


When it comes to EBV, this should lead to no kinds of concern regarding to the pregnancy and/or fetus. But when it comes to CMV, the virus may affect the fetus in the way of causing nerve system damage, hearing problems and cognitive impairment. The risk of affecting the fetus is by far greatest if her infection is ongoing ( then she should test positive for IgM CMV antibodies, which she doesn´t), while a reinfection is not as far as serious, if serious at all. Anyway, the blood test shows that she has no infection of CMV going on at this moment; the testparameters are most certainly caused by the ongoing EBV-infection, and that virus has no impact on the pregnancy/fetus. Unfortunately there are no good tests for detecting reactivation of viruses by means of blood sampling, so, if you for some reason want to make more sure than you already are you must discuss with your doctor whether or not to send a sample of urine or a sample from the tonsills, to detect the virus, parts of the virus or the virus DNA. In Norway these investigations are performed by the laboratories at Rikshospitalet-Radiumhospitalet HF.


To demonstrate the small chance of being infected with CMV during pregnancy we can remind that we don´t screen (don`t test routinely) for CMV in pregnancy at the one hand, and on the other pregnant women do not have to avoid people with CMV-infection even though the infected is having an active infection, meaning that the infected person is able to infect other people at that instant. What is recommended, though, is that pregnant women which hasn`t had CMV themselves (your wife has had the infection) should avoid close contact with children younger than 1 year old if the child has an active infection at that time.


Summary:


There are no blood test for detecting reactivation of CMV. CMV can reactivate at the end of pregnancy, and the child can be infected during the labour, but at that time it will not cause disease for the child. The fetus has to be infected at an earlier stage of pregnancy than the time of labour/delivery, and this requires most probably a new (first time) infection, even though there is a theoretical possibility that even a reinfection in the mother can cause infection of the fetus. Your wife has already had the infection and is immune to new infections, even if she is in close contact with persons with active CMV-infection, even those less than 1 year of age. For those women who hasn´t had the CMV infetion yet (approximately 30 % of the women) there is a risk of aquiring a new infection, and a risk of transferring the virus to the fetus arises. Despite this the risk of the fetus taking any damage from this is far from 100 %, and the risk is greater the earlier in the pregnancy the fetus is being infected. The overall risk is about 10-20%, usually reduced hearing. Especially premature run the higher risk of developing symptoms from the infection. In those cases it is actual to check if infection could have been transferred to the fetus (requires an infected mother) the amniotic fluid must be sampled. Treatment can´t be given until after birth.


Even though the risk of CMV infection seems unlikely in this case (your wife is immun) I cannot take the responsibility for your actions from where I am situated. But I hope you have enough information to be able to discuss further with your familydoctor.


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