Cytomegalovirus (CMV) Reprise
Sunday, November 18, 2007
Kenneth F. Trofatter, Jr., MD, PhD
Anonymous has left a new comment on your post "Cytomegalovirus (CMV): Common and Confusing":
I have had reoccurring miscarriages and my OB did a TORCH blood test which showed my CMV levels were slightly elevated. I’m supposed to go back in two weeks for another test to recheck the levels. Could this virus have caused my miscarriages? Is there a period of time I should wait before trying to conceive again? If I do become pregnant again am I at risk of having a baby affected by CMV?
To Anonymous: All of your questions are answered at the very end of this post. You can jump to there if you would like or read on for more information…
The TORCH test looks for antibodies in your blood specific for TOxoplasmosis, Rubella (German measles), Cytomegalovirus, and Herpes simplex virus. It is not unusual to include a screen for syphilis and human immunodeficiency virus (HIV) at the same time. All of these can cause infections of a baby during pregnancy (congenital infections) but by far, CMV is the most common. If antibodies to a specific organism(s) are present, this indicates you have been infected with that organism at some time in the past. Let me elaborate on that point a bit so that you have a better understanding of the tests when you discuss them with your doctor.
Usually, when we contract a virus infection like the flu, our immune systems react by first producing specific antibodies of the IgM class. These usually hang around only for no more than 2-4 weeks after the infection has been cleared. Shortly after IgM antibodies begin to be made, our bodies switch to the production of a second class of specific antibodies called IgG. IgG antibodies generally hang around for a long time after the infection is cleared and provide us with a source of 'permanent immunity' to the organism, helping to prevent reinfection, or decrease the severity of a secondary infection, with the same or similar organisms with which the antibodies might 'cross-react.' It is these IgG antibodies that also afford protective immunity to the baby because they can cross the placenta whereas IgM antibodies cannot.
We can use this information to help us to characterize the status of an infection. If neither IgM nor IgG is present, the individual has probably never been exposed to the organism of concern (or is too early in the course of the infection to have mounted any antibody response). If IgM is present and there is no IgG, then the infection is probably a 'primary' infection, indicating first time exposure to the organism, usually very early in its course. If both IgM and IgG are present, this also usually reflects a primary infection, but later in the course of the disease. And, if only IgG is present, then this indicates a state of permanent immunity established from an infection that occurred at some time in the past. In any of the first three circumstances, if an infection with a specific organism is suspected and could be of concern for a pregnancy, it is probably worth repeating the antibody titers in 4-6 weeks.
Things can be a little confusing with CMV infections. CMV grows very slowly and the incubation period from the time of exposure to onset of symptoms, or asymptomatic excretion of the virus, is on the order of 4-12 weeks. IgG antibodies usually can be detected by 1-2 weeks after the onset of symptomatic infections, but because of the long incubation period of CMV, this might be a month or more after actual exposure to the virus. The presence of IgM in the absence of IgG and in the presence of symptomatic disease (or a history of recent exposure to a known carrier) is highly presumptive of a true 'primary infection.' Similarly, the findings of both IgM and IgG with a significant rise (four-fold or more) in IgG titers (with or without a fall in IgM titers) on a follow-up screen 4-6 weeks later, usually (but not always in the case of CMV) indicates a recent primary infection. Also useful, the presence of IgG in the absence of IgM, is highly suggestive of a remote exposure to the virus, often greater than 6 months previously.
The rub with serology in classifying CMV infections comes in most often when IgM is present but IgG titers are relatively stable or mildly fluctuating. Unlike most common viral infections, CMV-specific IgM can sometimes persist 6-9 months following its appearance. And to make things even more confusing, IgM has been found to reappear on occasion with reactivation of latent CMV infections. In other words, except in the circumstances detailed above, we may not be able to use the presence of IgM in our counseling to tell patients that they have had a primary or recurrent infection during the pregnancy or if the infection might have occurred even prior to the current pregnancy.
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CMV is the MOST common congenitally (fetal) and perinatally (newborn) acquired virus disease in humans and the single most important infectious cause of mental retardation and congenital deafness in the U.S. and other industrialized nations. CMV is a member of the herpes family and human CMV is restricted to humans with no known animal reservoir. At least 80-90% of all individuals are infected with CMV during their lives, but infection may occur in the absence of clinical symptoms or without recognizing that an illness is the result of CMV. As with other herpes viruses, once an individual is infected with CMV, 'recurrences' can result from periodic reactivation of virus replication at various sites in which the virus is latently harbored in the body. During periods of reactivation, the virus can be more readily transmitted to individuals who have not been previously infected. Although probably not that common, secondary infections can also occur with other strains of CMV.
Transmission of CMV can occur from exposure to just about any body fluid, most commonly via saliva, respiratory, and venereal routes or by contact with infected urine or breast milk. Exposure tends to occur at earlier ages in lower socioeconomic groups, promiscuous individuals, and children at day care centers. Antibodies to CMV (seropositivity), indicating a history of infection with the virus, in women during the common childbearing years (18-35) can be found in about 50% of those in middle and upper, and 90% in lower, socioeconomic groups. Among previously noninfected (seronegative) women, the chance of becoming infected with the virus (seroconversion) is about 1-3% per year, however, this is as high as 10-20%in women who work in day care settings and 50% in women with infected children under two years of age!
Congenital infections with CMV occur in 1-2% of ALL pregnancies, accounting for 40-50,000 cases per year, indicating the virus can cross the placenta with relative ease compared to other herpes and most other common virus infections. Transmission of CMV to the fetus can occur with both primary and recurrent infections despite maternal immunity and has been documented in consecutive pregnancies. However, congenital infection rarely results in a poor outcome unless the congenital infection is the result of a primary (first time) infection in the mother during the pregnancy. Overall, among seronegative women, there is about a 0.5-1% risk of a primary CMV infection in each pregnancy, although this is much higher in 'at risk' groups such as day care workers, health care providers, and women with young children. Primary maternal infections carry an overall transmission risk to the baby of 25-50% and recurrent infections about 2-3%. Maternal antibody to CMV is incompletely protective against transmission to the baby, but it does play a major role in reducing the severity of infection in both fetus and newborn.
A high percentage of primary maternal infections are asymptomatic, or simply confused with another illness, or even written off as normal symptoms of pregnancy, so usually the diagnosis is not considered. Indeed, perhaps, the hardest part of making the diagnosis of CMV infection during pregnancy in mother and baby is simply suspecting that it might be a problem. If a woman develops a prolonged (weeks) illness with fever, resembling infectious mononucleosis (caused by another herpes virus, Epstein-Barr virus (EBV)), and the latter cannot be confirmed by routine testing, then CMV should be high on the differential diagnosis. The ante goes up considerably if the mother is a young teen having her first baby (especially if she conceived shortly after becoming sexually active or changing partners), or if she works, or has another young child, in a high risk setting such as a daycare center.
Serologic testing, as we discussed at the outset, can often help to confirm a primary infection when it is obtained coincident with maternal symptoms. Virus detection by culture, immunofluorescent, or polymerase chain reaction (PCR) techniques, best done by sampling maternal urine, may be positive (and almost always will be for months after a primary infection), but this alone does not tell us if this is a primary symptomatic CMV infection or a recurrent infection accompanying another illness. Unfortunately, in most cases maternal infection with CMV is usually not suspected until the baby is found to be growth restricted or has subtle physical abnormalities, or a thickened placenta, to suggest it has either a chromosomal abnormality or a congenital infection, sometimes months after the maternal exposure. Under these circumstances, maternal serologic testing might not be helpful in establishing either the fetal diagnosis or the diagnosis of a primary maternal infection during pregnancy.
Congenital CMV infections associated with primary maternal infections early in pregnancy and accompanied by growth restriction and detectable abnormalities by fetal ultrasound, generally, have a very poor prognosis, but even then, the outcome is not entirely predictable. Establishing the presence of fetal infection, when fetal abnormalities are identified, requires an 'invasive' procedure. Performing a simple amniocentesis, and using a CMV-specific PCR or shell vial culture technique, can confirm fetal infection with CMV in nearly 100% of cases. (Remember, the amniotic fluid from midtrimester on is mostly fetal urine, and CMV is excreted in large amounts from the kidneys following congenital infection, and often for years afterwards, even in 'asymptomatic' cases). However, unless we have confirmatory maternal serologic information, or symptomatic infection confirmed to be the result of CMV during the pregnancy, we still may not know if the congenital infection is the result of primary or recurrent maternal disease. If the diagnosis of CMV is not suspected until late in pregnancy, or not until after the birth of the baby, detection of CMV in a urine sample taken from the baby within the first two weeks'(preferably, the first 48-72 hours) of life also suffices to confirm congenital infection. CMV is a VERY slow growing virus, so any detection of virus in this time frame most certainly represents intrauterine infection.
Congenital CMV infections are asymptomatic or unrecognized in about 90% of cases, including 85-90% of babies acquiring the virus as a consequence of primary maternal infection and 99% of those resulting from recurrent infections. Most of the asymptomatic infections pose no immediate life threat, but 10-15% of these babies are at risk for long-term complications such as sensorineural hearing loss, chorioretinitis, and dental abnormalities, usually apparent by two years' of age. Of these, the hearing loss is by far the most significant because delay in its detection can contribute to psychomotor retardation. More than 90% of congenitally infected infants, regardless of the severity of their infection, will shed infectious virus at birth, and may do so for 6 or more years longer, even in the presence of specific immunity.
About 5-10% of congenitally infected babies will have significant evidence of infection at birth. Approximately half of these will have classic 'cytomegalic inclusion disease (CMID)' (described below) and half will have atypical involvement. Virtually 100% of these infants excrete CMV at birth and will continue to do so for many years afterwards. Infants in this group have a 20-30% eventual mortality and account for 90% of the significant mental and psychomotor retardation associated with congenital CMV infections. The most severely affected children are usually the result of primary maternal infections during pregnancy and should be suspected in instances of unexplained intrauterine growth restriction and fetal death beyond 20 weeks' gestation.
The most common findings in babies with CMID include symmetrical growth restriction, multiple small skin hemorrhages (petechiae), enlargement of the liver and spleen (hepatosplenomegaly), jaundice, microcephaly (small head), abnormalities of the dental enamel, and chorioretinitis. They can have numerous associated birth defects involving virtually any organ system, a catalog of which is not necessary for our discussion today. Prenatal detection by ultrasound of fetal growth delay and gross or subtle, nonspecific physical abnormalities of the baby may be the only clues that a congenital CMV infection has occurred. Unfortunately, these often manifest themselves only weeks or even months after fetal infection has occurred because the virus is very slow growing, and it is relatively nondestructive, compared to other herpes viruses.
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With the above information as background, let me answer our reader’s questions:
Could this virus have caused my miscarriages? It is unlikely. Although I did not address this specific point above, many people over many years have tried to implicate CMV in recurrent miscarriages and I have never seen an article that found good evidence to do so.
Is there a period of time I should wait before trying to conceive again? The TORCH screen and your CMV seropositivity should not preclude your getting pregnant again soon. You already have ‘protective immunity’ and you will probably have the virus for the rest of your life. However, if you have had recurring miscarriages, perhaps you should wait to conceive until you have had a more thorough evaluation for that.
If I do become pregnant again am I at risk of having a baby affected by CMV? Yes, you have a 2-3% chance of having a baby with a congenital CMV infection. But, the presence of your antibody to CMV will decrease the risk of serious complications from the infection. Most (99%) babies who get CMV as the result of a recurrent maternal infection are asymptomatic, but 10-15% of these babies are at risk for long-term complications such as sensorineural hearing loss, chorioretinitis, and dental abnormalities, usually apparent by two years' of age. Your baby can be screened within 48-72 hours of birth by simply checking his/her urine for CMV to determine if there was a congenital infection. Almost all babies with a congenital CMV infection will excrete the virus in their urine. If CMV is present, the baby simply needs to be followed more closely for the hearing and eye problems noted above to prevent correctible sources of developmental delay. These children usually do not have problems with growth or mental retardation.
Labels: CMV, cytomegalovirus, RPL
59 Comments:
At Tue Dec 04, 10:43:00 AM 2007,
Anonymous said…
I had a primary cmv infection with my last pregnancy which led to the baby being still born. How long should I wait before trying to conceive again?
At Wed Dec 12, 01:26:00 PM 2007,
Anonymous said…
I had the same thing happen to me in November. I was wondering the same thing?
At Fri Dec 14, 01:06:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymouses(?) Dec 4 and Dec 1: Both of you are now immune, so serious complications related to CMV are low. Your babies could still a get a congenital infection and be at risk for hearing loss and chorioretinitis, but the chances of losing another baby related to CMV infection are low. Sorry for your losses and let us know how things turn out the next time around. Thanks for reading. Dr T
At Sun Feb 03, 01:05:00 PM 2008,
Anonymous said…
my son was born with congenital CMV and has many problems,: deafness, brain loss, cp, siezures, global developement delay... What are the chances of my future children comming out with the same? please email me at copperpony_84@yahoo.com
At Wed Feb 06, 05:07:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous feb 3: Your chances are very low that you would have another baby with the severe problems your son had. These problems usually occur only with first time infections before your own body has had a chance to develop immunity to CMV. You could still have another baby with CMV, but even if that happened, that child really only needs regular eye and hearing screening. Sorry for your problems the first time around, but odds are in your favor everything will be fine the next time. Dr T
At Mon Feb 18, 09:50:00 AM 2008,
Judy said…
Hi Doctor,
I am currently 24 weeks pregnant.
I was diagnosed with having a recent CMV infection at around 6 weeks into my pregnancy. I had a amniocentesis done at 17 weeks showing no sign of the virus in the amniotic fluid. In your opinion, am I safe from this point on from transmitting the virus to my unborn baby?
Thank you.
At Thu Feb 28, 06:11:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Judy Feb 18: You are STILL at risk for having a baby with congenital CMV, but it is very unlikely that the baby has it now. Therefore, now that you have 'immunity', even if the baby catches it later on in the pregnancy, there is a very low risk that it will have significant complications related to the virus. The baby's urine can be tested after birth and if it has CMV detected then, it did get a 'congenital infection' but simply needs careful follow-up of growth, developmental milestones, hearing and eye checks. Good luck and please let us know how things turn out! Dr T
At Mon Mar 17, 02:13:00 PM 2008,
Gina said…
Hello Doctor,
I have had a recent stillbirth due to CMV and was wondering if I should wait to conceive again? Some reports and CDC recommend a 6 month wait, do you know why?? Does it lower the risk of transmission? Currently my IgM was negative and urine testing also negative, but my IgG levels have been well over 250 AU/mL(both at delivery on 2/17/08 and again on 3/10/08) should I therefore wait for IgG levels to start decreasing?? any advice would be greatly appreciated or others that can help in this specialty my email is ginazmailbox@gmail.com
Sorry if this repeats, I am new to this blog.
At Wed Mar 19, 06:51:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Gina: If you wait for your IgG levels to drop, you may never be able to have another baby. You are now immune and do not understand why you couldn't try to have another baby when you are ready. It is sometimes good to wait 6 months to 'recover' from a previous pregnancy, but from the standpoint of risk for a severe CMV infection in your next baby, I don't think that is necessary. Dr T
At Wed Mar 19, 08:45:00 PM 2008,
Gina said…
Thanks Dr. T,
Thanks for clearing this up. I was unsure about the antibodies and what they do in the body. I appreciate your advice and your dedication to the blog.
Gina
At Thu Mar 20, 06:04:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Gina: You are welcome and best wishes to you! Dr T
At Fri Mar 21, 10:11:00 AM 2008,
Judy said…
Hi Dr.T,
My last blog was "Judy Feb 18" I failed to include some helpful information on my last blog. My concern is transmission of the cmv virus to my unborn baby after the amnio to the time of delivery. In Nov my Igg was at 22.1 and my Igm was equivical, then in Dec Igg was 18.1 and Igm was negative. With in a week my specialist did an amnio at about 15 wks. The amnio detected no virus in the amniotic fluid. My specialist then did a sonogram at 17 wks showing no abnormalities. And felt that I did not need to come back for anymore follow ups with him. However I'm a worrier and I'm still worried that I could still pass the virus on to my unborn baby. Hopefully this additional info will be helpful in sharing more of your oppinion.
Thank you for your continued advice.
Judy
At Tue Mar 25, 06:47:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Judy Mar 21. 2-3% of ALL women with CMV will pass it along to their babies at some time during the pregnancy during times of reactivation/recurrences. The important thing is this (and please hear me loud and clear), even if you do pass it on to the baby, there will probably be no evidence of that at birth except if you have the baby's urine screened for CMV right after delivery. The chance of bad complications for your baby from CMV, now that you are immune, are very rare. The antibodies you have formed will protect the baby in almost all circumstances. Relax and enjoy the rest of your pregnancy! Dr T
At Sat Apr 05, 02:32:00 PM 2008,
Anonymous said…
Hi Dr.T,
I just lost a child but it was not due to CMV- it was due to anursuym of the vein of Galen- a very rare condiditon. When they were trying to determine the cause at the time they had done a test for CMV. I had IgM antibodies and no IgG antibodies. It was the primary infection that I was effected by. I was induced because there was no heart beat. I am really scared to have any future children now because I do not want a child who is blind or deaf due to CMV- are the chances high for this now high? What would be that chances? I am just now really worried- will I have normal children?
At Mon Apr 07, 07:06:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Apr 5: Go back and read (slowly and carefully) all my blogs on CMV (follow the blue links). Many, many, many more people have CMV than realize it and many have had had babies with congenital CMV infections, resulting reactivation of the maternal CMV, than have had children with ANY problems. The chance of a severe infection in a baby, once you are immune to CMV, is very very LOW. The overwhelming odds are that you can and will have perfectly normal children. Sorry for your recent loss and feel free to write back if you other questions. dr T
At Wed Apr 09, 08:15:00 PM 2008,
Anonymous said…
Dear Dr. T,
I have another quick question- even there would be no severe infection in reactivated or reinfection of an immumne CMV carrier would there still be a chance for deafness in the next child? Or would the chances of any hearing deficit be very low or less severe? And if there is any sort of deficit is there any treatment that can be undertaken?
At Tue Apr 15, 06:07:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Apr 9: First, let me clarify one point. Nothing is 100% in medicine and although the risk of a 'severe infection' with a subsequent pregnancy is low, there are instances when this has occurred. Some believe it is more common when you actually get infected with a different strain of CMV against which you and your baby are not completely protected by the antibody you have.
Congenital CMV infection occcurs in 0.5-1.5% of all babies. The chance of a baby who is born with an asymptomatic congenital CMV infection developing sensorineural hearing loss during the first 6 years of life is about 15% in studies coordinated by the University of Alabama in the 1980's and 90's. The hearing loss can be progressive, bilateral and severe if it occurs.
Congenital CMV is probably the most common cause of sensorineural hearing loss and probably accounts for more than 40% of otherwise 'unexplained hearing loss' in children. When it is identified, treatment is usually done initially with hearing aids and then if the loss becomes more profound, cochlear implants. No one really understands how CMV contributes to the hearing loss, but in many ways, it is a very 'treatable' condition. Thanks for the questions and good luck in the future. Dr T
At Sat May 03, 07:46:00 AM 2008,
Anonymous said…
I am 20 wks pregnant, just found out because of an echogenic bowel found on the u/s that I am - for Downs and Cystic FIb. however I am + for cmv and both Igg and Igm were +, what are the chances of baby being affected and okay?
At Tue May 06, 04:02:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous May 3: What are the CMV IgG and IgM titers? Have you been sick at all this pregnancy? Do you have, or do you work around, young children? Is your baby normally grown to this point in the pregnancy? Did they see any other abnormalities of the baby? Answer me these questions and then I will tell you my thoughts! Dr T
At Fri Jun 06, 01:52:00 PM 2008,
Squaw said…
I have recently been diagnosed with what appears to be primary CMV. I am not pregnant but would very like to begin trying. On March 31 (day 12 of a 22 day fever) my results were IGM 2.30 (>.9 is positive) and IGG <4 (>6 is positive). A second round of testing on June 6 showed IGM 1.97 (>.9 is positive) and IGG 39 (>6 is positive). My OB is recommending waiting 3-6 months after infection to try to concieve. Do you agree? Does it appear that my immunity is rising in a way that might protect a fetus?
At Sat Jun 07, 10:13:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To squaw: you are now "immune" to CMV and that immunity should help to protect your next baby. How long to wait is controversial. The longer you do wait, the less likely it is that you will be excreting CMV during early pregnancy and, perhaps, that might reduce your risk for having a baby with congenital CMV. Even with immunity, yo will intermittently have CMV and when those reactivations occur, the virus may be passed along to the baby. It is still unusual to have a severely affected baby under those circumstances because of your "immunity" as we have pointed out in our posts on this subject, but babies can still have the less sever consequences of congenital CMV infection. Dr T
At Sun Jun 15, 01:59:00 AM 2008,
Anonymous said…
Hi, Dr. Trofatter.
I have a 22-month-old son and plan to try for another baby soon. However, we participate in a co-op preschool two hours a week (all parents are "assistant teachers"), and I'm unsure of my CMV status. Should I be tested before trying to conceive? Is it safest for us to stop going to preschool altogether? Also, since I still breastfeed my son, would that be an additional CMV risk for me and an unborn child? Thanks! - Julie
At Mon Jun 16, 10:35:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Julie: The best thing to do is to be tested BEFORE you conceive. Then you can make decisions about whether or not you have your child tested, continuing the daycare situation, etc. If you are already immune, then there is probably nothing else you need to do except plan on getting pregnant again! Dr T
At Sat Jun 21, 05:40:00 PM 2008,
Anonymous said…
Dear Doc, I was diagnosed with CMV in February whilst pregnant. I miscarriaged at about 7weeks and have been advised not to get pregnant again for at least 4-6 months from infection. However, they have no idea when I may have been infected; I have had symptoms since last august which have continued on and off to date including lumps in neck and/or armpits and headaches, fatigue and lost of appetite. The last blood test results showed both IgG and IgM to be present and a low virus load of < 10 copies.
The question is: why am I still having symptoms and when will it actually be safe to conceive again in light of my persistent symptoms. Awaiting latest blood result due next week. What should I be looking for? Thanks River
At Sun Jun 22, 08:56:00 PM 2008,
Lana said…
Dear Dr T - you might remember me from the PAPP-A posts... now here I am trying to get some information about my daughters CMV infection that we suspect has caused her hearing loss. My paeditatrician seems to be reluctant to provide me with information at this stage (maybe she wants to get confirmation from the Guthrie test first??). The main things I want to understand are:
1. the pathology of the infection and how likely it is to cause problems in other areas of my daughters health.
2. Will her hearing get worse?
Also - I am very upset about the lack of public awareness of CMV - being the most common cause of hearing loss - in Australia, noone is screened for it! I believe pregnant women should be screened for it. And so should babies who have been found to have a hearing loss. Are there any reasons why this shouldnt be happening in Australia??
I found this article very useful: http://www.biomedcentral.com/1471-2458/5/70
Best regards and thanks again, Lana
At Tue Jun 24, 06:40:00 PM 2008,
Jaclyn said…
Hello. CMV findings are extremely confusing to me so I was hoping for some help. In March I was 35 weeks pregnant and went in to get a routine ultrasound to check the baby's position, size etc. The baby had IUGR, Severe Microcephaly, Brain calcifications which all pointed to CMV. I never felt sick, had a fever or had any other indication that I had a virus. I also had a 13 week and a 20 week ultrasound which were normal. My IgG level was 4.41 and my IgM level was 1.85. Does this mean that I had a Primary infection early on in the pregnancy1st Trimester) that was not detected? Also, do you want your IgG result to be positive and your IgM result to be negative? Should both be negative? Sadly our son was stillborn on April 1st. We did have his blood tested and he had a very high level of the virus. Thank you for your time and wish everyone good luck!!
At Wed Jun 25, 12:51:00 PM 2008,
millie said…
i had a little girl in march this year born with cmv could you possibly tell me how long i should wait before conceiving again as it was 4 months ago my baby died because of the cmv virus
At Thu Jun 26, 07:04:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Julie June 15: Simply ask your doctor to perform a serologic screen for CMV IgG. If you have it, then you are already immune and it should be safe to continue working at the preschool. If you do not, I would recommend you not, if that is an option! The attack rate on seronegative women under those circumstances can be 25-50% per year! The breastfeeding should not cause any problems. Dr T
At Thu Jun 26, 07:08:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To River June 21: I am more worried about your enlarged lymph nodes and fatigue. If you have not been tested recentlly, you should be screened for HIV and EBV (the mononucleosis virus), You might also want to see a good hematologist who can decide if those lymph nodes need to be biopsied for evidence of a cancer or infection. Don't worry abot the CMV right now. If all of these other things are normal, you can get pregnant any time from that standpoint. Dr T
At Thu Jun 26, 07:13:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
Hello again Lana: Well how is Imani doing otherwise? She will obviously need to be followed carefully for growth and developmental milestones over time. Her hearing may or may not get worse. The virus is a very slow-growing one and tends to exert its damage by causing progressive loss of cells in the tissues that are chronically infected, but most children will eventually control it. although that can take many years. I wish there was a good CMV vaccine. Then we would not have to worry about the virus much at all. Thanks for keeping me posted and hang in there my friend! Dr T
At Thu Jun 26, 07:16:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Jaclyn: You clearly had a primary infection during that pregnancy. You should be at much lower risk for fetal complications the next time around because you are now immune (the IgG confers permanent immunity and helps to protect a baby in the womb). Ignore the IgM, it can come and go over time. Sorry for your loss. I am sure things will go better next time. Dr T
At Thu Jun 26, 07:17:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Millie: You should have permanent immunity (IgG) by now and that will help to protect another baby from serious infection. Sorry for your loss and best wishes for the future. Dr T
At Thu Jun 26, 08:38:00 PM 2008,
Lana said…
Dear Dr T,
Imani is otherwise doing great... she is small but gaining weight still and at 12 weeks (8.5 weeks corrected) is smiling and occasionally making some sweet sounds!
Thank you for the clarification - now that I understand that it is a chronic infection that will do its damage (or not) over time, I have some new questions:
Should my child be taking antiviral treatment to slow the CMV down?
Should I take anti-virals that she can get through breast milk?
Is it helpful if I take olive leaf extract so she can get some of its anti-viral benefits through breast milk?
Ultrasound has shown a normal sized liver and speen and an absence of calcifications on her brain - but will these things come up later? Does she need to be re-checked?
Also - where does the body store the virus and which organs/tissue are most likely to be affected?
How can I try and determine at which stage of gestation she was affected and what implications that may have?
I am taking a high dose Olive Leaf extract that I am hoping will be of benefit but I want to know what else I can do...
I am currently in touch with a health care advocacy group in Australia to try bring about more awareness of CMV to help protect pregant mums and give parents the option for their babies to be screened for it at birth.
Looks like you and I are going to be in touch for a while :o).
Thanks again, Lana
At Sat Jun 28, 03:07:00 AM 2008,
millie said…
Dear doctor T,
just wondering out of curiosity are you a doctor who undertakes this proffession because you seem to be a very good doctor.
what my question is for you today
is what are my chances of having another baby with the same problems as my little girl that was born 4 months ago and should i be entirely safe for being able to concieve again at this stage
At Fri Jul 04, 04:55:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Lana:
1. There is no good antiviral treatment for CMV yet. Ganciclovir can help in some cases to slow progression of problems in some individuals who are immunosuppressd, but it is a fairly toxic drug and probably should not be used in Imani based on what you have told me so far
2. Repeated ultrasounds or other imaging stucies are probably not necessary unless she develops evidence of new problems - neurologic, developmental, or otherwise. She will need her hearing and vision checked on an ongoing basis and the usual developmental milestones.
3. The virus can reside in almost any body tissue but prefers the kidneys, blood, liver, spleen, and brain. Most babies with congnital CMV infections have NO PROBLEMS whatsoever and the course of the infection both in the womb and after delivery is highly unpredictable. At this point you will not be able to figure out when you actually got it, but that really doesn't matter now anyway. Imani's immune system seems to be keeping the infection in check and that is the key to minimizing her risks for long-term complications.
4. I have no familiarity with the benefits of olive leaf extracts under these circumstances, but I will certainly look into that when I can!
5. I am glad you are going to become an advocacy for CMV awareness. We truly need a good vaccine that can be given to women before they ever think about getting pregnant. That would help to reduce the risk of congenital deafness, chorioretinitis, and the more severe complications generally associated with first-time infections during pregnancy.
Thank you for keeping us updated!
Regards,
Dr T
At Fri Jul 04, 05:49:00 AM 2008,
Lana said…
Dear Dr T,
The PCR on the Guthrie test was negative for CMV and we are very happy about that. I know the viral load in dried blood is very low - do you know the chances for a false negative?
I find it a strange coincidence that she has both the CMV in her urine and the hearing loss...
Also - my girlfriend is pregnant and has never developed immunity to CMV - Should I keep checking for shedding cells in Imani's urine?
Finally, my obstetrician things there is no point in screening for CMV because it is carried in droplets/airborne but I understood it to be through bodily fluids - can you clarify that?
A recent study in Australia has found CMV linked to a significant number of still births and more work is being done in this area.
Thanks SO VERY MUCH FOR SUCH GENEROSITY Best regards, Lana
At Fri Jul 04, 07:59:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To millie: Your risk of having another severly affected baby is VERY low because you are now immune to CMV and that will help to protect your baby. Dr T
At Sun Jul 06, 05:09:00 AM 2008,
Lana said…
Hi Dr T... another question...
I have a pregnant friend who is concerned about latent cmv... she has no antibodies. How long does it take for cmv to show up if its a first exposure?
Thanks, Lana
At Tue Jul 08, 01:06:00 PM 2008,
Anonymous said…
Dr. Dr. Trofatter,
If you might be able to help me understand my recent dilemma with CMV, I would be greatly appreciative. My OB seems to have no answers, and neither does a perinatologist I visited recently. I had a miscarriage at 12 weeks, and since I had shingles at the time, I was given a blood test, which revealed very high levels of CMV. My IGG was 9 and my IGM was 49. This was in February. In March my IGG was >10 and my IGM was 58.6...even greater of a number. I was told to wait a few months and hopefully my levels will go down. They said they should be under 30. Well today my test results came back and they numbers have not changed. IGG >10 and IGM 58.3. No one seems to be able to tell me what this means, and they just say to keep "waiting it out". That it could take up to a year. Is this true? Do I really need to wait this long? Why do my numbers seem so much higher than those other cases I have found on the internet? What are this risks to the baby if I were to conceive with such high numbers? Than you so much. Kelly
At Fri Jul 11, 11:26:00 AM 2008,
millie said…
hi dr t havent heard from you in a while i hope you are well i had a virology blood test done on monday and i was just wondering if you could tell me how long should i wait before trying to concieve again thanks very much for all of your support could you possibly send your response to my msn account m_j_snape@hotmail.com
At Sat Jul 12, 04:45:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Kelly: If you are young and you had shingles and you now appear to have chronic activation of CMV, my greater concern for you at this point is could you have some form of acquired or inherited immunosuppression? Do you have HIV, a hematologic malignancy, diabetes, thyroid disease, chronic Epstein-Barr virus infection, an autoimmune disease, etc. Please ask your doctors to look into this and once they have, please let me know. Then we can discuss your CMV and another pregnancy. Dr T
At Sat Jul 12, 04:46:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To millie: I really should not send responses to personal email accounts. But, I think it is safe enough anytime to go ahead and get pregnant again. You are now immune to CMV and that should help to protect a baby. Dr T
At Sat Jul 12, 07:33:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
Lana: Is she worried that she has CMV and has no antibodies detectable or that she has been exposed to your baby and may contract CMV? Anyway, the incubation time from infection to antibody production ranges between 1-3 months. It is a very slow growing virus. Dr T
At Sat Jul 12, 08:28:00 PM 2008,
Lana said…
Hi Dr T
Thanks once again - my friend is concerned she has picked up CMV and it hasnt shown up yet (she is 17 weeks pregnant) and was around my daughter since she was born (3rd April)...
Can you tell me how CMV is passed on? Is it aiborne (via droplets) or must it be bodily fluid exchange?
Thanks, Lana
At Sun Jul 13, 11:11:00 AM 2008,
Anonymous said…
Hi there. A question about the use of amnios for screening for a congential CMV infection.
I tested positive for both IgG and IgM CMV antibodies at approx. 6 weeks LMP (I dont have any levels as the lab my Doc uses doesnt provide this service). I will get an amnio done on July 30. At this time I will be approx. 15 weeks LMP and 9 weeks will have passed since I first tested positive for CMV IgM antibodies. However,some of the reading I have done indicates that an amnio may not accurately diagnoses congenital CMV before 21 weeks LMP. How accurate will my amnio be at at telling me if my baby has a congenital infection at 15 wks (9 wks past initial maternal diagnoses)?
Thank you Jo
At Mon Jul 14, 08:53:00 AM 2008,
Jackie said…
Hi Dr T.
I have one more comment/question about CMV and future pregnancy- You seem to be the only doctor I have found that can provide me clarification. From what I understand from your previous postings, a person who has already had a primary CMV infection still has a 2-3% chance of passing the virus/different strand of virus on to another fetus, although the effect on the fetus would be less severe. Are my chances of that happening higher, lower or the same as that of a mother who had a primary CMV infection 15 years ago or 20 years ago? I guess I am wondering if I am in a higher risk category of passing on to future fetus' b/c I had a primary CMV infection within the last year. Thank you so much for taking the time to answer my questions and giving a sense of hope for a future baby.
At Mon Jul 14, 05:00:00 PM 2008,
Anonymous said…
Hi, Dr. Trofatter.
I wrote previously about planning a pregnancy, but said I was concerned because my son and I participate in a co-op preschool, which will soon be four hours per week. He's 24 months old. I was recently tested for CMV and the test result was negative. Is it safest for us to stop going to this preschool (where parents serve as assistant teachers) altogether? Also, since I still breastfeed my son, would that be an additional CMV risk for me and an unborn child? What precautions should I take, since we plan to start trying for a baby this month? Thanks! - Julie
At Tue Jul 15, 10:01:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Lana July 12: CMV can be spread by any body fluid - respiratory droplets, urine, saliva, blood, etc. The highest concentrations are usually found in urine. Dr T
At Tue Jul 15, 10:05:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous July 13: Why were you screened for CMV at 6 weeks and what were the titers of both IgG and IgM. Those are VERY important questions. The chance of picking up CMV by amniocentesis increases with gestational age, but all that tells you is that the baby has a congenital infection - it does NOT tell you whether or not the baby will be severely affected by the virus. Indeed, if you had significant IgG titers at 6 weeks, the baby probably will NOT be severely affected. Good luck and let us know what you find out. Dr T
At Tue Jul 15, 10:10:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Jackie: As far as I know, no one has looked at that specific question. Overall, the chance of having a severely affected child following one severely affected child is so low that there must be no real benefit to waiting for an extended period of time, presuming your immune system is healthy and has responded normally to the virus to begin with. Dr T
At Tue Jul 15, 10:13:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
Julie: Perhaps you should have your child tested for CMV! If he is negative, you might want to keep him out of daycare until you have had another pregnancy. If he is positive, there is a very good chance you will seroconvert sometime over the next year or so. That is frequently what puts a second pregnancy at risk. Dr T
At Tue Jul 15, 08:52:00 PM 2008,
Anonymous said…
I am a nurse in a nicu and was exposed to a cmv positive infant (ostomy care, placed urine bag, as well as breast milk exposure as he is fed by ng tube) at 11 weeks pregnant. I took care of this patient for three days before he was known to be postitive. I notified my OB/GYN who ordered TORCH titers which were done 7 days after exposure. The office nurse called me today with "good news" that I was negative for both IgG and IgM to cmv. My question is do I need follow up testing to make sure I don't develop the anti-bodies, since I am currently not immune? And if so how often should they be repeated? I did ask the nurse if I needed repeat testing and she said "well, have you been sick?"---It's only been 12 dys since exposure and from what I've read here I may never even have symptoms, and if I do, I would'nt this soon! I hope you can help answer my questions because I'm worried that my doctor feels there's no need for follow up.
At Wed Jul 16, 10:05:00 AM 2008,
Anonymous said…
I had extensive exposure to cmv at 9 weeks pregnant. I did not have IgG antiboies, which my OB tested for right away. To date, 4 weeks after exposure, I have not shown IgM antibodies and thus no sign of an acute exposure. Is it safe to assume I did not contract cmv 4 weeks ago, or do some people simply never develop IgM antibodies and if they do, not within 4 weeks? Thank you.
At Wed Jul 16, 11:11:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous july 15: You are correct. Not having immunity is not necessarily good news in the workplace setting where you will be exposed every day to CMV. You are also correct in understanding that you may have absoluetly no symptoms related to a primary CMV infection to guide further testing. But, you DO have the right to know if you seroconvert during the preggnancy. I suppose I would suggest rescreening at about 20 weeks. In the meantime, use well all the "blood and body fluid precautions" you have been taught! Best of luck! Dr T
At Wed Jul 16, 11:14:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous July 16: No, it is not safe to assume you have not been infected at this point. CMV is a very slow growing virus and it can take awhile before your immune system recognizes the infection. I would repeat the antibody screen at about 20 weeks. Good luck! Dr T
At Wed Jul 16, 04:07:00 PM 2008,
Anonymous said…
Hi, Dr. Trofatter. I really appreciate your answering my previous questions! I was wondering if you could offer any perspective on why so few people are made aware of the dangers of CMV infection during pregnancy. Do you think that careful handwashing can make a dent in the number of cases? Why are pregnant women routinely tested for rubella immunity (a seemingly lower risk), and not for CMV immunity? Do you think these policies will change in the U.S.? And, finally, does a mother's overall health influence how severe the effects of a congenital CMV infection will be? (I'm the mother of a toddler, and want to become pregnant again. I just found out I'm seronegative.) Thanks so much for your feedback! -- Julie
At Fri Jul 18, 11:54:00 AM 2008,
Anonymous said…
I was told by an infectious disease doctor that in a majority of cases (over 90%), the acute antibody is present within 6 weeks. Is that so?
At Fri Jul 18, 05:32:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Julie: Handwashing can certainly help, but remember, CMV can be transmitted by ANY body fluid. We test for rubella because it, too can be a devastating virus to catch during pregnancy, but we also have a vaccine for rubella. The main reason for testing is to identify women whose immunity to the vaccine has waned over time so that they can be revaccinated. I pray that some day we will be in the same situation with CMV. I would like to see routine testing for CMV, but many women are already immune by the time they enter their child-bearing years and the test results can often be difficult to interpret. You cannot count on your overall health to protect a baby if you have a primary CMV infection during pregnancy. Most congenital CMV infections occur in babies whose mothers have no symptoms related to their infection at all. Best wishes! Dr T
At Fri Jul 18, 05:34:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous July 18: That's probably accurate - but in some instances it may take longer. Dr T
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