The accuracy of fetal ultrasound for predicting sequelae in fetuses infected with congenital cytomegalovirus after primary maternal infection. 

PROBLEM STATEMENT:
Cytomegalovirus infection is the most common fetal viral infection worldwide that can lead to severe long-term medical conditions. Antenatal diagnosis of primary cytomegalovirus infections with proven fetal transmission and so potential adverse perinatal outcomes and long-term complications, is a major challenge in perinatology. In cases of proven primary cytomegalovirus infection there is a need to improve the prenatal counseling offered to patients and guide future clinical management decisions. The aim of the study was to evaluate the accuracy of fetal ultrasound for predicting sequelae in fetuses infected with congenital cytomegalovirus after maternal primary infection.

METHODS:
A prospective observational study was conducted from 1996 through 2012 in pregnant women with serological evidence of primary cytomegalovirus infection and proven vertical transmission to the fetus, based on viral load in the amniotic fluid. All patient underwent a prenatal ultrasound. Termination of pregnancy was offered in patients with proven fetal cytomegalovirus infection. Live-born, congenitally infected infants underwent hearing and neurological clinical assessments to detect symptoms of cytomegalovirus infection. 

RESULTS: 
Among a cohort of 355 pregnant women with primary cytomegalovirus infection, a total of 67 patients with proven vertical transmission were included in this study, including 64 singleton and 3 twin pregnancies (69 fetuses). Eight fetuses were lost to follow-up and so a total of 61 congenitally infected fetuses were included in the final analysis. 
Of these remaining 61 fetuses, termination of the pregnancy was performed for 26. In 11 of these 26 cases ultrasound demonstrated abnormal findings. Autopsy provided in all 26 cases histological evidence of fetal cytomegalovirus infection. In the 15 terminated fetuses without ultrasound anomalies, autopsy revealed histopathological cytomegalovirus lesions in 13 cases, including 6 anomalies in the central nervous system and 7 cytomegalovirus inclusions in the lung, liver, pancreas and adrenal glands. Isolated placental cytomegalovirus inclusions were reported in 2 fetuses. Among the 35 live-born infants, targeted prenatal ultrasound revealed abnormal findings suggestive of congenital infection in 12 fetuses. Of these 12 infants, 6 had normal clinical evaluations, whereas 6 presented with either hearing and/or neurological anomalies, classified as severe in 4 cases. Among the other 23 live-born infants with no abnormalities during their prenatal ultrasounds, 5 presented with audiological sequelae and 1 was diagnosed with neurological developmental delay.

CONCLUSION: 
Fetal ultrasound anomalies were detected in 37.7% of pregnant women with primary cytomegalovirus infection acquired in early pregnancy and proven fetal infection, and were confirmed by autopsy or postnatal clinical evaluation in 73.9%. Cytomegalovirus-related anomalies were also detected by autopsy or postnatal clinical evaluation in 55% of infants with normal fetal ultrasound evaluations. These results confirm the correlation between prenatal ultrasound anomalies and postnatal clinical sequelae in fetuses with congenital cytomegalovirus. Though, it is important to realize that, a completely normal prenatal ultrasound assessment does not guarantee a normal clinical outcome.

The Accuracy Of Fetal Ultrasound For Predicting Sequelae In Fetuses Infected With Congenital Cytomegalovirus After Primary Maternal Infection.