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Salomè S, Corrado FR, Mazzarelli LL, Maruotti GM, Capasso L, Blazquez-Gamero D, Raimondi F. Congenital cytomegalovirus infection: the state of the art and future perspectives. Front Pediatr 2023; 11:1276912. [PMID: 38034830 PMCID: PMC10687293 DOI: 10.3389/fped.2023.1276912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 10/18/2023] [Indexed: 12/02/2023] Open
Abstract
Congenital cytomegalovirus (cCMV) infection is the most common congenital infection, with an estimated incidence of approximately one in 200 infants in high-income settings. Approximately one in four children may experience life-long consequences, including sensorineural hearing loss and neurodisability. Knowledge regarding prevention, diagnosis, and treatment increased in the recent years, but some challenges remain. In this review, we tried to summarize the current knowledge on both the obstetrical and pediatric areas, while also highlighting controversial aspects and future perspectives. There is a need to enhance awareness among the general population and pregnant women through specific information programs. Further research is needed to better define the classification of individuals at birth and to have a deeper understanding of the long-term outcomes for so defined children. Finally, the availability of valaciclovir medication throughout pregnancy, where appropriate, has prompted the assessment of a universal serological antenatal screening. It is recommended to establish a dedicated unit for better evaluation and management of both mothers and children.
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Affiliation(s)
- S. Salomè
- Division of Neonatology, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - F. R. Corrado
- Division of Neonatology, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - L. L. Mazzarelli
- Division of Obstetrician and Gynecologist, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - G. M. Maruotti
- Division of Obstetrician and Gynecologist, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - L. Capasso
- Division of Neonatology, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - D. Blazquez-Gamero
- Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (Imas12), Translational Research Network in Pediatric Infectious Diseases (RITIP), Universidad Complutense, Madrid, Spain
| | - F. Raimondi
- Division of Neonatology, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
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Rybak-Krzyszkowska M, Górecka J, Huras H, Massalska-Wolska M, Staśkiewicz M, Gach A, Kondracka A, Staniczek J, Górczewski W, Borowski D, Jaczyńska R, Grzesiak M, Krzeszowski W. Cytomegalovirus Infection in Pregnancy Prevention and Treatment Options: A Systematic Review and Meta-Analysis. Viruses 2023; 15:2142. [PMID: 38005820 PMCID: PMC10675417 DOI: 10.3390/v15112142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/06/2023] [Accepted: 10/19/2023] [Indexed: 11/26/2023] Open
Abstract
OBJECTIVES Cytomegalovirus (CMV) infection is a significant health concern affecting numerous expectant mothers across the globe. CMV is the leading cause of health problems and developmental delays among infected infants. Notably, this study examines CMV infection in pregnancy, its management, prevention mechanisms, and treatment options. METHODS Specifically, information from the Cochrane Library, PUBMED, Wiley Online, Science Direct, and Taylor Francis databases were reviewed along with additional records identified through the register, the Google Scholar search engine. Based on the search, 21 articles were identified for systematic review. RESULTS A total of six randomized controlled trials (RCTs) were utilized for a meta-analytic review. As heterogeneity was substantial, the random effects model was used for meta-analysis. Utilizing the random-effects model, the restricted maximum likelihood (REML) approach, the estimate of effect size (d = -0.479, 95% CI = -0.977 to 0.019, p = 0.060) suggests the results are not statistically significant, so it cannot be inferred that the prevention methods used were effective, despite an inverse relationship between treatment and number of infected cases. The findings indicated that several techniques are used to prevent, diagnose, and manage CMV infection during pregnancy, including proper hygiene, ultrasound examination (US), magnetic resonance imaging (MRI), amniocentesis, viremia, hyperimmunoglobulin (HIG), and valacyclovir (VACV). CONCLUSIONS The current review has significant implications for addressing CMV infection in pregnancy. Specifically, it provides valuable findings on contemporary management interventions to prevent and treat CMV infection among expectant mothers. Therefore, it allows relevant stakeholders to address these critical health concerns and understand the effectiveness of the proposed prevention and treatment options.
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Affiliation(s)
- Magda Rybak-Krzyszkowska
- Department of Obstetrics, Perinatology University Hospital, 30-551 Kraków, Poland; (J.G.); (M.S.)
- Hi-Gen Centrum Medyczne, 30-552 Kraków, Poland
| | - Joanna Górecka
- Department of Obstetrics, Perinatology University Hospital, 30-551 Kraków, Poland; (J.G.); (M.S.)
| | - Hubert Huras
- Department of Obstetrics and Perinatology, Jagiellonian University Medical College, 30-551 Kraków, Poland;
| | - Magdalena Massalska-Wolska
- Clinical Department of Gynecological Endocrinology and Gynecology, University Hospital, 30-551 Kraków, Poland;
| | - Magdalena Staśkiewicz
- Department of Obstetrics, Perinatology University Hospital, 30-551 Kraków, Poland; (J.G.); (M.S.)
| | - Agnieszka Gach
- Department of Genetics, Polish Mother’s Memorial Hospital-Research Institute, 93-338 Łódź, Poland;
| | - Adrianna Kondracka
- Department of Obstetrics and Pathology of Pregnancy, Medical University of Lublin, 20-081 Lublin, Poland;
| | - Jakub Staniczek
- Department of Gynecology, Obstetrics and Gynecological Oncology, Medical University of Silesia, 40-055 Katowice, Poland;
| | - Wojciech Górczewski
- Obstetrics and Gynecology Ward, Independent Public Health Care Facility “Bl. Marta Wiecka County Hospital”, 32-700 Bochnia, Poland;
| | - Dariusz Borowski
- Clinic of Obstetrics and Gynecology, Provincial Combined Hospital in Kielce, 25-736 Kielce, Poland;
| | - Renata Jaczyńska
- Department of Obstetrics, Perinatology and Gynecology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Mariusz Grzesiak
- Department of Perinatology, Obstetrics and Gynecology, Polish Mother’s Memorial Hospital-Research Institute, 93-338 Łódź, Poland; (M.G.); (W.K.)
- Department of Gynecology and Obstetrics, Medical University of Łódź, 93-338 Łódź, Poland
| | - Waldemar Krzeszowski
- Department of Perinatology, Obstetrics and Gynecology, Polish Mother’s Memorial Hospital-Research Institute, 93-338 Łódź, Poland; (M.G.); (W.K.)
- Salve Medica, 91-210 Lodz, Poland
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3
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Egloff C, Sibiude J, Vauloup-Fellous C, Benachi A, Bouthry E, Biquard F, Hawkins-Villarreal A, Houhou-Fidouh N, Mandelbrot L, Vivanti AJ, Picone O. New data on efficacy of valacyclovir in secondary prevention of maternal-fetal transmission of cytomegalovirus. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:59-66. [PMID: 35900718 DOI: 10.1002/uog.26039] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/21/2022] [Accepted: 07/18/2022] [Indexed: 05/27/2023]
Abstract
OBJECTIVE Congenital cytomegalovirus (CMV) infection is the leading cause of non-genetic hearing and neurological deficits. The aim of our study was to evaluate the efficacy and safety of valacyclovir (VCV) treatment in preventing CMV transmission to the fetus after maternal primary infection. METHODS This was a retrospective, multicenter study evaluating the rate of maternal-fetal CMV transmission in pregnancies with maternal primary CMV infection treated with VCV at a dosage of 8 g per day (VCV group) compared with a control group of untreated women. Each case underwent virological testing to confirm maternal primary infection and to provide accurate dating of onset of infection. The primary outcome was the presence of congenital CMV infection at birth diagnosed based on polymerase chain reaction analysis of saliva, urine and/or blood samples. The efficacy of VCV treatment was assessed using logistic regression analysis adjusted for a propensity score. RESULTS In total, 143 patients were included in the final analysis, of whom 59 were in the VCV group and 84 were in the untreated control group. On propensity-score-adjusted analysis, VCV treatment was significantly associated with an overall reduction in the rate of maternal-fetal CMV transmission (odds ratio, 0.40 (95% CI, 0.18-0.90); P = 0.029). The rate of maternal-fetal CMV transmission, determined at birth, in the VCV vs control group was 7% (1/14) vs 10% (1/10) after periconceptional maternal primary infection (P = 1.00), 22% (8/36) vs 41% (19/46) after first-trimester maternal primary infection (P = 0.068) and 25% (2/8) vs 52% (14/27) after second-trimester maternal primary infection (P = 0.244). When analyzing the efficacy of VCV treatment according to maternal viremia at treatment initiation, there was a trend towards greater efficacy when patients were viremia-positive (21% vs 43%; P = 0.072) compared with when they were viremia-negative (22% vs 17%; P = 0.659). Maternal side effects associated with VCV were mild and non-specific in most cases. CONCLUSION Our findings indicate that VCV treatment of pregnant women with primary CMV infection reduces the risk of maternal-fetal transmission of CMV and may be effective in cases with primary infection in the first and second trimesters. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C Egloff
- Service de Gynécologie-Obstétrique, Hôpital Louis-Mourier, AP-HP, Colombes, France
- University of Paris, Paris, France
- IAME, INSERM, Paris, France
| | - J Sibiude
- Service de Gynécologie-Obstétrique, Hôpital Louis-Mourier, AP-HP, Colombes, France
- University of Paris, Paris, France
- IAME, INSERM, Paris, France
- FHU PREMA, Paris, France
- Research Group on Infections during Pregnancy (GRIG), Velizy, France
| | - C Vauloup-Fellous
- Research Group on Infections during Pregnancy (GRIG), Velizy, France
- Virology Department, Hôpital Paul-Brousse, INSERM U1993, Université Paris Saclay, AP-HP, Villejuif, France
| | - A Benachi
- Research Group on Infections during Pregnancy (GRIG), Velizy, France
- Department of Obstetrics and Gynecology, DMU Santé des Femmes et des Nouveau-nés, Hôpital Antoine Béclère, Paris Saclay University, AP-HP, Clamart, France
| | - E Bouthry
- Research Group on Infections during Pregnancy (GRIG), Velizy, France
- Department of Biology of Infectious Agents, Angers University Hospital, Angers, France
| | - F Biquard
- Department of Obstetrics and Gynaecology, Angers University Hospital, Angers, France
| | - A Hawkins-Villarreal
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Fetal Medicine Service, Obstetrics Department, Santo Tomás Hospital, University of Panama, Panama City, Panama (on behalf of the Iberoamerican Research Network in Obstetrics, Gynecology and Translational Medicine)
| | - N Houhou-Fidouh
- Virology Department, Hôpital Bichat Claude-Bernard, Université de Paris, AP-HP, Paris, France
| | - L Mandelbrot
- Service de Gynécologie-Obstétrique, Hôpital Louis-Mourier, AP-HP, Colombes, France
- University of Paris, Paris, France
- IAME, INSERM, Paris, France
- FHU PREMA, Paris, France
- Research Group on Infections during Pregnancy (GRIG), Velizy, France
| | - A J Vivanti
- Research Group on Infections during Pregnancy (GRIG), Velizy, France
- Department of Obstetrics and Gynecology, DMU Santé des Femmes et des Nouveau-nés, Hôpital Antoine Béclère, Paris Saclay University, AP-HP, Clamart, France
| | - O Picone
- Service de Gynécologie-Obstétrique, Hôpital Louis-Mourier, AP-HP, Colombes, France
- University of Paris, Paris, France
- IAME, INSERM, Paris, France
- FHU PREMA, Paris, France
- Research Group on Infections during Pregnancy (GRIG), Velizy, France
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Abstract
Over a century of research has focused on improving our understanding of congenital cytomegalovirus (cCMV), yet it remains the most common congenital infection in the United States, affecting 3 to 6 per 1000 live born infants each year. Pregnancies affected by cCMV are at a heightened risk of spontaneous abortion and intrauterine fetal demise. Neonates born with cCMV are also at substantial risk for long-term neurodevelopmental sequelae and disability, including sensorineural hearing loss, even those born without clinically apparent disease. Considerable progress has been made in recent years in study of the epidemiology and transmission of cCMV, developing better diagnostic strategies, implementing newborn screening programs, improving therapeutics, and launching vaccine trials. In this article, we review recent developments in the understanding of the virology and immunobiology of cytomegalovirus. We further discuss how this knowledge informs our understanding of the pathophysiology of cCMV and directs strategies aimed at improving outcomes and quality of life for congenitally infected children. We also provide an update on the epidemiology of cCMV in the United States, evolving scientific understanding of maternal-fetal transmission, enhanced screening approaches, and recognition of neonatal and long-term sequelae. Finally, we review the current landscape of pediatric cCMV research and provide recommendations for novel and high-priority areas for future investigation.
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Affiliation(s)
- Megan H Pesch
- Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
| | - Mark R Schleiss
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
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5
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Boucoiran I, Yudin M, Poliquin V, Caddy S, Gantt S, Castillo E. Guideline No. 420: Cytomegalovirus Infection in Pregnancy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:893-908. [PMID: 34089905 DOI: 10.1016/j.jogc.2021.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To provide an update on current recommendations for cytomegalovirus (CMV) infection during pregnancy. The objectives of this guideline are: TARGET POPULATION: Patients of child-bearing age, pregnant patients, and patients planning a pregnancy. BENEFITS, HARMS, AND COSTS The patient partners urged us to make awareness of preventive strategies a high priority, despite concern that discussing CMV with patients could cause unnecessary anxiety. CMV educational interventions have shown benefits from increased awareness of cCMV prevalence and preventive strategies among providers, patients, and families. EVIDENCE We searched MEDLINE, EMBASE, and CENTRAL databases for CMV in pregnancy. The search terms were developed using MeSH terms and keywords (Appendix). The results were filtered for articles published between January 2010 and October 2020 and systematic reviews, meta-analyses, clinical trials, and observational studies. The main inclusion criteria were pregnant patients and infants, as the target population, and CMV infection, as the diagnosis of interest. Recommendations are graded according to the U.S. Preventive Services Task Force grade of recommendations and level of certainty. VALIDATION METHODS We collaborated with patient partners, including members of CMV Canada (cmvcanada.com). In formulating our recommendations, we included patients' voices to add a unique and valuable perspective, thus ensuring that our recommendations are relevant to the patient-provider partnership. INTENDED AUDIENCE All perinatal health care providers. RECOMMENDATIONS (GRADE AND LEVEL OF CERTAINTY IN PARENTHESES).
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6
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Directive clinique no 420 : Infection à cytomégalovirus pendant la grossesse. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:909-925. [PMID: 34089903 DOI: 10.1016/j.jogc.2021.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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7
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Lambelet V, Vouga M, Pomar L, Favre G, Gerbier E, Panchaud A, Baud D. SARS-CoV-2 in the context of past coronaviruses epidemics: Consideration for prenatal care. Prenat Diagn 2020; 40:1641-1654. [PMID: 32453451 PMCID: PMC7283830 DOI: 10.1002/pd.5759] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 05/22/2020] [Accepted: 05/23/2020] [Indexed: 12/18/2022]
Abstract
Since December 2019, the novel SARS-CoV-2 outbreak has resulted in millions of cases and more than 200 000 deaths worldwide. The clinical course among nonpregnant women has been described, but data about potential risks for women and their fetus remain scarce. The SARS and MERS epidemics were responsible for miscarriages, adverse fetal and neonatal outcomes, and maternal deaths. For COVID-19 infection, only nine cases of maternal death have been reported as of 22 April 2020, and pregnant women seem to develop the same clinical presentation as the general population. However, severe maternal cases, as well as prematurity, fetal distress, and stillbirth among newborns have been reported. The SARS-CoV-2 pandemic greatly impacts prenatal management and surveillance and raise the need for clear unanimous guidelines. In this narrative review, we describe the current knowledge about coronaviruses (SARS, MERS, and SARS-CoV-2) risks and consequences on pregnancies, and we summarize available current candidate therapeutic options for pregnant women. Finally, we compare current guidance proposed by The Royal College of Obstetricians and Gynaecologists, The American College of Obstetricians and Gynecologists, and the World Health Organization to give an overview of prenatal management which should be utilized until future data appear.
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Affiliation(s)
- Valentine Lambelet
- Materno‐Fetal and Obstetrics Research Unit, Department of Woman‐Mother‐ChildLausanne University HospitalLausanneSwitzerland
| | - Manon Vouga
- Materno‐Fetal and Obstetrics Research Unit, Department of Woman‐Mother‐ChildLausanne University HospitalLausanneSwitzerland
| | - Léo Pomar
- Materno‐Fetal and Obstetrics Research Unit, Department of Woman‐Mother‐ChildLausanne University HospitalLausanneSwitzerland
| | - Guillaume Favre
- Materno‐Fetal and Obstetrics Research Unit, Department of Woman‐Mother‐ChildLausanne University HospitalLausanneSwitzerland
| | - Eva Gerbier
- Materno‐Fetal and Obstetrics Research Unit, Department of Woman‐Mother‐ChildLausanne University HospitalLausanneSwitzerland
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, Lausanne University Hospital and University of LausanneUniversity of GenevaGenevaSwitzerland
- Service of PharmacyLausanne University HospitalLausanneSwitzerland
| | - Alice Panchaud
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, Lausanne University Hospital and University of LausanneUniversity of GenevaGenevaSwitzerland
- Service of PharmacyLausanne University HospitalLausanneSwitzerland
- Institute of Primary Health Care (BIHAM)University of BernBernSwitzerland
| | - David Baud
- Materno‐Fetal and Obstetrics Research Unit, Department of Woman‐Mother‐ChildLausanne University HospitalLausanneSwitzerland
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El-Qushayri AE, Ghozy S, Abbas AS, Dibas M, Dahy A, Mahmoud AR, Afifi AM, El-Khazragy N. Hyperimmunoglobulin therapy for the prevention and treatment of congenital cytomegalovirus: a systematic review and meta-analysis. Expert Rev Anti Infect Ther 2020; 19:661-669. [PMID: 33148067 DOI: 10.1080/14787210.2021.1846521] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Objective: To examine the safety and efficacy of hyeprimmunoglobulin therapy on vertical transmission of congenital cytomegalovirus (CCMV).Method: We searched nine databases for studies investigating the effect of Hyperimmunoglobulin among pregnant women with CMV.Results: Of total eight studies, the pooled prevalence of CCMV was 36.5% (95% confidence intervals (CI): 26-49%). There was no evidence that hyperimmunoglobulin is effective against CCMV [odds ratio (OR) (95% (CI)) = 0.53 (0.20-1.42)]. However, analyzing only studies of pregnant women with confirmed primary infection, a significant reduction in the congenital CCMV rates was observed [OR (95% CI) = 0.33 (0.18-0.59)]. Based on the purpose, CCMV prevention was successful with a reduction of the CCMV rates [OR (95% CI) = 0.33 (0.16-0.68)[, while treatment was not]OR (95% CI) = 0.80 (0.04-15.01)]. The most common adverse pregnancy outcome was prematurity, followed by intrauterine growth retardation (IUGR) and termination of pregnancy (TOP), with no significant impact of antenatal hyperimmunoglobulin usage.Conclusion: Our results showed a promising efficacy of hyperimmunoglobulin therapy among pregnant women with confirmed primary infection, which fades away on including secondary infection. This effectiveness was limited to the prevention, not the treatment, of CCMV. More randomized controlled trials are needed to provide concrete evidence.
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Affiliation(s)
| | - Sherief Ghozy
- Faculty of Medicine, Mansoura University, Mansoura, Egypt.,El Sheikh Zayed Specialized Hospital, Giza, Egypt
| | | | - Mahmoud Dibas
- Sulaiman Al Rajhi University, College of Medicine, Qassim, Saudi Arabia
| | | | | | - Ahmed M Afifi
- Department of Internal Medicine and Division of Digestive Diseases, College of Medicine, University of Kentucky, USA.,Department of Clinical Pathology-Hematology and Ain Shams Medical Research Institute (MASRI), Faculty of Medicine, Ain Shams University, Ain Shams, Egypt
| | - Nashwa El-Khazragy
- Department of Clinical Pathology-Hematology and Ain Shams Medical Research Institute (MASRI), Faculty of Medicine, Ain Shams University, Ain Shams, Egypt
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9
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Leruez‐Ville M, Ville Y. Is it time for routine prenatal serological screening for congenital cytomegalovirus? Prenat Diagn 2020; 40:1671-1680. [DOI: 10.1002/pd.5757] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 04/27/2020] [Accepted: 05/23/2020] [Indexed: 01/12/2023]
Affiliation(s)
- Marianne Leruez‐Ville
- AP‐HP, Hôpital Necker Enfants‐Malade, Laboratoire de Virologie Centre National de Reference des herpes virus‐ Laboratoire associé infection congénitale à cytomégalovirus Paris France
- EA 7328, Paris Descartes Université Université de Paris Paris France
| | - Yves Ville
- EA 7328, Paris Descartes Université Université de Paris Paris France
- AP‐HP Hospital Necker Enfants‐Malade, Maternité Paris France
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10
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Bartlett AW, Hamilton ST, Shand AW, Rawlinson WD. Fetal therapies for cytomegalovirus: What we tell prospective parents. Prenat Diagn 2020; 40:1681-1692. [PMID: 32271956 DOI: 10.1002/pd.5692] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 03/23/2020] [Accepted: 03/27/2020] [Indexed: 12/17/2022]
Abstract
Congenital CMV is the most common congenital infection in the developed world. Infection results in congenital disease ranging from asymptomatic infection to severe neurodevelopmental impairment, and occasionally fetal or neonatal death. Fetal infection can occur through maternal-fetal transmission during primary maternal infection or maternal reactivation or re-infection. Awareness among maternal health care providers and parents is low. The prevention of maternal CMV infection currently relies on hygiene measures, with no effective CMV vaccine or prophylactic therapies. No licensed treatment options are available to prevent maternal-fetal transmission or fetal disease. Hyperimmunoglobulin and valaciclovir have been investigated for prevention of maternal-fetal transmission or fetal treatment, with some evidence supporting consideration of maternal administration of hyperimmunoglobulin or valaciclovir therapy in certain circumstances. This article outlines the clinical evidence regarding proven preventative behavioral measures and experimental hyperimmunoglobulin and valaciclovir therapies, that is structured around common questions asked by pregnant women about CMV infection. It is aimed to help maternity health care providers counsel prospective parents about congenital CMV disease and the preventative and therapeutic strategies currently available.
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Affiliation(s)
- Adam W Bartlett
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, NSW, Australia.,School of Women's and Children's Health, UNSW Sydney, NSW, Australia
| | - Stuart T Hamilton
- School of Women's and Children's Health, UNSW Sydney, NSW, Australia.,Virology Research Laboratory, Serology and Virology Division (SAViD), NSW Health Pathology, Prince of Wales Hospital, Sydney, Randwick, NSW, Australia
| | - Antonia W Shand
- Child Population and Translational Health Research, Children's Hospital at Westmead Clinical School, The University of Sydney, Sydney, Australia.,Department of Maternal Fetal Medicine, Royal Hospital for Women, Randwick, NSW, Australia
| | - William D Rawlinson
- School of Women's and Children's Health, UNSW Sydney, NSW, Australia.,Virology Research Laboratory, Serology and Virology Division (SAViD), NSW Health Pathology, Prince of Wales Hospital, Sydney, Randwick, NSW, Australia.,School of Biotechnology and Biomolecular Sciences, UNSW Sydney, NSW, Australia.,School of Medical Sciences, UNSW Sydney, NSW, Australia
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11
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De Santis M, Apicella M, De Luca C, D'Oria L, Valentini P, Sanguinetti M, Lanzone A, Scambia G, Santangelo R, Masini L. Valacyclovir in primary maternal CMV infection for prevention of vertical transmission: A case-series. J Clin Virol 2020; 127:104351. [PMID: 32325395 DOI: 10.1016/j.jcv.2020.104351] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/24/2020] [Accepted: 04/01/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND No treatment is currently approved for cytomegalovirus infection in pregnancy. Valacyclovir has been studied in symptomatic cytomegalovirus infected fetuses and seems to reduce the risk of serious sequelae. OBJECTIVES We used off-label valacyclovir on pregnant women with primary cytomegalovirus infection to reduce the risk of fetal infection. STUDY DESIGN We treated 12 pregnant women with 8 g/day valacyclovir after diagnosis of cytomegalovirus infection until amniocentesis. We continued treatment until delivery in case of fetal infection. We periodically performed serology and virology tests on the women from referral until delivery and monitored them for adverse effects while on treatment. All women underwent late amniocentesis. We followed up infants for 5-28 months. RESULTS At the time of amniocentesis, we observed a transmission rate of 17 %, and at birth we observed a transmission rate of 42 %. Two women with negative amniocentesis and infected newborns had viremia reactivation after valacyclovir discontinuation. We observed no symptomatic infections at birth and one isolated sensory-neural hearing loss at follow-up. CONCLUSIONS This is the first series of antiviral treatment in women with a diagnosis of cytomegalovirus infection before amniocentesis. Valacyclovir may control cytomegalovirus infection while it is administered and reduce transmission at amniocentesis. Late transmission after treatment discontinuation is a risk. We advocate the need for a controlled trial of valacyclovir therapy starting from diagnosis of maternal infection until delivery, regardless of prenatal diagnosis of infection.
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Affiliation(s)
- Marco De Santis
- Fondazione Policlinico Universitario A. Gemelli IRCCS, dipartimento scienze della salute della donna e del bambino e di sanità pubblica, Rome, Italy; Telefono Rosso - Teratology Information Service, Centro Studi per la Tutela della Salute della Madre e del Concepito, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Massimo Apicella
- Fondazione Policlinico Universitario A. Gemelli IRCCS, dipartimento scienze della salute della donna e del bambino e di sanità pubblica, Rome, Italy; Telefono Rosso - Teratology Information Service, Centro Studi per la Tutela della Salute della Madre e del Concepito, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Carmen De Luca
- Fondazione Policlinico Universitario A. Gemelli IRCCS, dipartimento scienze della salute della donna e del bambino e di sanità pubblica, Rome, Italy; Telefono Rosso - Teratology Information Service, Centro Studi per la Tutela della Salute della Madre e del Concepito, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luisa D'Oria
- Fondazione Policlinico Universitario A. Gemelli IRCCS, dipartimento scienze della salute della donna e del bambino e di sanità pubblica, Rome, Italy; Telefono Rosso - Teratology Information Service, Centro Studi per la Tutela della Salute della Madre e del Concepito, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Piero Valentini
- Fondazione Policlinico Universitario A. Gemelli IRCCS, dipartimento scienze della salute della donna e del bambino e di sanità pubblica, Rome, Italy
| | - Maurizio Sanguinetti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, dipartimento scienze di laboratorio e infettivologiche, Rome, Italy
| | - Antonio Lanzone
- Fondazione Policlinico Universitario A. Gemelli IRCCS, dipartimento scienze della salute della donna e del bambino e di sanità pubblica, Rome, Italy; Telefono Rosso - Teratology Information Service, Centro Studi per la Tutela della Salute della Madre e del Concepito, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Scambia
- Fondazione Policlinico Universitario A. Gemelli IRCCS, dipartimento scienze della salute della donna e del bambino e di sanità pubblica, Rome, Italy
| | - Rosaria Santangelo
- Fondazione Policlinico Universitario A. Gemelli IRCCS, dipartimento scienze di laboratorio e infettivologiche, Rome, Italy
| | - Lucia Masini
- Fondazione Policlinico Universitario A. Gemelli IRCCS, dipartimento scienze della salute della donna e del bambino e di sanità pubblica, Rome, Italy; Telefono Rosso - Teratology Information Service, Centro Studi per la Tutela della Salute della Madre e del Concepito, Università Cattolica del Sacro Cuore, Rome, Italy
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12
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Minsart AF, Rypens F, Smiljkovic M, Kakkar F, Renaud C, Lamarre V, Boucher M, Boucoiran I. Prenatal findings, neonatal symptoms and neurodevelopmental outcome of congenital cytomegalovirus infection in a university hospital in Montreal, Quebec. J Perinat Med 2020; 48:234-241. [PMID: 32031981 DOI: 10.1515/jpm-2019-0331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 12/29/2019] [Indexed: 11/15/2022]
Abstract
Background Outcome of congenital cytomegalovirus (cCMV) infection in the absence of routine CMV screening and third-trimester scan in North America is scarcely documented. The aim of this study was to assess the severe outcomes related to cCMV according to the indication for screening. Methods This was a retrospective study of 84 mother-child pairs followed for cCMV between 2003 and 2017 at CHU Sainte-Justine in Montreal, Canada. Prenatal ultrasound, neonatal symptoms, neuroimaging and severe outcomes (cerebral palsy, severe cognitive impairment, bilateral hearing loss or neonatal death) were reviewed. Results Among 38 cases with abnormal prenatal ultrasound, 41.9% of live-born infants developed severe outcomes. Sixteen (42.1%) were detected in the third trimester. Among 16 cases diagnosed prenatally because of maternal history, all had normal prenatal ultrasound, and none developed severe outcomes. Among cases diagnosed postnatally because of neonatal symptoms, 25% developed severe outcomes. All infants who developed severe outcomes had moderate/severe neonatal symptoms. Conclusion Outcome of cCMV infection varies according to the reason for screening and timing of diagnosis. Any prenatal ultrasound anomaly might indicate a risk of severe outcome, and warrants a detailed ultrasound scan. However, late detection, or postnatal diagnosis, represented more than half of the cases, and awareness of this will help ensuring optimal management.
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Affiliation(s)
- Anne-Frédérique Minsart
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Université de Montréal - Sainte-Justine University Hospital, Montreal, Canada
| | - Françoise Rypens
- Department of Radiology, Université de Montréal - Sainte-Justine University Hospital, Montreal, Quebec, Canada
| | - Mina Smiljkovic
- Division of Infectious Diseases, Department of Pediatrics, Université de Montréal - Sainte-Justine University Hospital, Montreal, Quebec, Canada
| | - Fatima Kakkar
- Division of Infectious Diseases, Department of Pediatrics, Université de Montréal - Sainte-Justine University Hospital, Montreal, Quebec, Canada
| | - Christian Renaud
- Division of Infectious Diseases, Department of Pediatrics, Université de Montréal - Sainte-Justine University Hospital, Montreal, Quebec, Canada
| | - Valérie Lamarre
- Division of Infectious Diseases, Department of Pediatrics, Université de Montréal - Sainte-Justine University Hospital, Montreal, Quebec, Canada
| | - Marc Boucher
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Université de Montréal - Sainte-Justine University Hospital, Montreal, Canada
| | - Isabelle Boucoiran
- Women and Children Infectious Diseases Center, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, H3T 1C5, QC, Canada.,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and of Social and Preventive Medicine, Université de Montréal, Montreal, QC, Canada
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13
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Kyriakopoulou A, Serghiou S, Dimopoulou D, Arista I, Psaltopoulou T, Dinopoulos A, Papaevangelou V. Antenatal imaging and clinical outcome in congenital CMV infection: A field-wide systematic review and meta-analysis. J Infect 2020; 80:407-418. [PMID: 32097687 DOI: 10.1016/j.jinf.2020.02.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/08/2020] [Accepted: 02/12/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Postnatal outcome in fetuses with congenital cytomegalovirus infection (cCMV) varies from asymptomatic infection to severe neurodevelopmental impairment. Αntenatal biomarkers of long-term clinical outcome, have yet to be established. Α systematic review and meta-analysis was performed to examine whether prenatal cerebral ultrasonography (US) and magnetic resonance imaging (MRI) findings in cCMV fetuses may predict clinical outcome. METHODS PubMed and the Web of Science were systematically searched to identify studies reporting on any prenatal US and/or MRI imaging of fetuses with cCMV as well as their postnatal clinical outcome. All reported associations between imaging and postnatal clinical outcome were systematically extracted. Where appropriate, the reported associations were quantitatively synthesized within Bayesian random-effects meta-analyses. RESULTS A total of 1336 studies were screened to identify 26 eligible observational studies. Overall, 4181 fetuses were studied, of which 1518 had been diagnosed with cCMV. All studies performed fetal US while in 14 (54%) MRI was also performed. Studies substantially varied in timing of fetal imaging, reporting of abnormalities, definition of poor outcome and statistical analysis. Among studies reporting on statistical significance, 6/6 for US and 3/4 for MRI identified significant associations between imaging findings and outcome. In our meta-analyses, within isolated abnormalities, only microcephaly had greater than 95% probability of being associated with poor outcome (OR 26.7; 95% CI, 1.44-1464.5; I2, 19%). Effect sizes for US were higher than those for MRI findings. CONCLUSIONS Although studies displayed significant heterogeneity in both methodology and analytical decisions, it became evident that when both prenatal cerebral US and MRI are normal the negative predictive value of poor outcome is high. This is important for clinicians when consulting pregnant women. Need to standardize practices and definitions become evident. FUNDING There was no source of funding.
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Affiliation(s)
- Aikaterini Kyriakopoulou
- Third Department of Paediatrics, Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens 115 27, Greece.
| | - Stylianos Serghiou
- Department of Epidemiology and Population Health, Stanford School of Medicine, Stanford University, Stanford, CA, United States; Meta-Research Innovation Center at Stanford, Stanford University, Stanford, CA, United States
| | - Dimitra Dimopoulou
- Third Department of Paediatrics, Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens 115 27, Greece
| | - Ioli Arista
- Health Economist, Independent Researcher, Athens, Greece
| | - Theodora Psaltopoulou
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens 115 27, Greece
| | - Argyrios Dinopoulos
- Third Department of Paediatrics, Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens 115 27, Greece
| | - Vassiliki Papaevangelou
- Third Department of Paediatrics, Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens 115 27, Greece
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14
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Abstract
Congenital infections are infections transmitted from mother to child during pregnancy (transplacentally) or delivery (peripartum). They have the potential to adversely affect fetal development and long-term neurodevelopmental outcome through inflammatory, destructive, developmental, or teratogenic lesions of the brain. Because the fetal/neonatal brain has a limited capacity to respond to injury, early inflammatory changes may be difficult to visualize and only manifest as neurocognitive disability later in life. Teratogenic effects, which may include aberrations of neuronal proliferation and migration, are more easily visible on imaging, but may be equally difficult to use to predict long-term neurocognitive outcomes. This chapter reviews the general pathophysiology of congenital infection and describes the epidemiology, the antenatal and postnatal diagnosis, and the treatment of congenital infections as well as the long-term neurodevelopmental outcomes.
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Affiliation(s)
- Isabelle Boucoiran
- Mother and Child Infection Center, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, QC, Canada; Departments of Obstetrics and Gynecology and Social and Preventive Medicine, University of Montreal, Montreal, QC, Canada.
| | - Fatima Kakkar
- Mother and Child Infection Center, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, QC, Canada; Department of Pediatrics, University of Montreal, Montreal, QC, Canada
| | - Christian Renaud
- Mother and Child Infection Center, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, QC, Canada; Department of Microbiology and Immunology, University of Montreal, Montreal, QC, Canada
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15
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Ribeiro PAF, Souza MQ, Dias DS, Álvares ACM, Nogueira LM, Machado JM, Dos Santos JC, Godoi RR, Nobrega YKM, Campos-da-Paz M, de Freitas SM, Felipe MSS, Torres FAG, Galdino AS. A Custom-Designed Recombinant Multiepitope Protein for Human Cytomegalovirus Diagnosis. Recent Pat Biotechnol 2019; 13:316-328. [PMID: 31333134 DOI: 10.2174/1872208313666190716093911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 06/17/2019] [Accepted: 07/28/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND The Human Cytomegalovirus (HCMV) has infected more than 90% of the world population and its prevalence can be related to the individuals geographical and socialeconomic status. Serological tests based on ELISA are pivotal for HCMV diagnosis. Due to the lack of standardization in the production/purification of antigens from viral preparations, ELISA tests are based on several recombinant proteins or peptides. As an alternative, multiepitope proteins may be employed. OBJECTIVE In this work, we developed a recombinant multiepitope protein (rMEHCMV) for HCMV diagnosis based on conserved and immunodominant epitopes derived from tegument (pp150, pp65 and pp28), glycoprotein gB (pp38) and DNA polymerase subunit (pp52) of HCMV. METHODS The rMEHCMV gene was synthesized de novo and overexpressed in Escherichia coli cells. The recombinant protein was purified to homogeneity using a Ni-NTA column. Biophysical analysis of recombinant protein was performed by circular dichroism. A preliminary biological activity test was performed using 12 positive human sera samples by using an in-house IgG ELISA. The following patents database were consulted: Espacenet, Google Patents and the National Institute of Intellectual Property (INPI, Brazil). RESULTS The recombinant multiepitope protein was successfully expressed in E. coli. The structural data obtained by circular dichroism spectroscopy showed that rMEHCMV is structurally disordered. An in-house IgG ELISA test with rMEHCMV was successfully used to recognized IgG from human serum samples. CONCLUSION Together, our results show that rMEHCMV should be considered as a potential antigenic target for HCMV diagnosis.
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Affiliation(s)
- Patrícia A F Ribeiro
- Laboratorio de Biotecnologia de Microrganismos, Universidade Federal de Sao Joao Del-Rei, Divinopolis, MG, 35501-296, Brazil
| | - Marilen Q Souza
- Departamento de Biologia Celular, Universidade de Brasilia, Brasília, DF, 70910-900, Brazil
| | - Daniel S Dias
- Laboratorio de Biotecnologia de Microrganismos, Universidade Federal de Sao Joao Del-Rei, Divinopolis, MG, 35501-296, Brazil
| | - Alice C M Álvares
- Laboratorio de Biofisica, Universidade de Brasilia, Brasilia, DF, 70910-900, Brazil
| | - Laís M Nogueira
- Laboratorio de Biotecnologia de Microrganismos, Universidade Federal de Sao Joao Del-Rei, Divinopolis, MG, 35501-296, Brazil
| | - Juliana M Machado
- Laboratorio de Biotecnologia de Microrganismos, Universidade Federal de Sao Joao Del-Rei, Divinopolis, MG, 35501-296, Brazil
| | - José C Dos Santos
- Departamento de Biologia Celular, Universidade de Brasilia, Brasília, DF, 70910-900, Brazil
| | - Renato R Godoi
- Laboratorio de Biotecnologia de Microrganismos, Universidade Federal de Sao Joao Del-Rei, Divinopolis, MG, 35501-296, Brazil
| | - Yanna K M Nobrega
- Laboratorio de Doencas Imunogeneticas e Cronico-degenerativas, Universidade de Brasilia, Brasilia, DF, 70910-900, Brazil
| | - Mariana Campos-da-Paz
- Laboratorio de Nanobiotecnologia, Universidade Federal de Sao Joao Del-Rei, Divinopolis, MG, 35501-296, Brazil
| | - Sonia M de Freitas
- Laboratorio de Biofisica, Universidade de Brasilia, Brasilia, DF, 70910-900, Brazil
| | - Maria S S Felipe
- Departamento de Biologia Celular, Universidade de Brasilia, Brasília, DF, 70910-900, Brazil
| | - Fernando A G Torres
- Departamento de Biologia Celular, Universidade de Brasilia, Brasília, DF, 70910-900, Brazil
| | - Alexsandro S Galdino
- Laboratorio de Biotecnologia de Microrganismos, Universidade Federal de Sao Joao Del-Rei, Divinopolis, MG, 35501-296, Brazil
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16
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Abstract
Viral infections are common complications of pregnancy. Although some infections have maternal sequelae, many viral infections can be perinatally transmitted to cause congenital or chronic infection in fetuses or infants. Treatments of such infections are geared toward reducing maternal symptoms and complications and toward preventing maternal-to-child transmission of viruses. This article reviews the treatment of herpes simplex virus, cytomegalovirus, hepatitis B and C viruses, and human immunodeficiency virus during pregnancy.
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Affiliation(s)
- Sarah C Rogan
- Maternal and Fetal Medicine Division, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, 300 Halket Street, Pittsburgh, PA 15213, USA
| | - Richard H Beigi
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Magee-Womens Hospital, 300 Halket Street, Pittsburgh, PA 15213, USA.
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