After extensive counseling as to the diagnosis of fetal CMV and their options, including pregnancy termination, the couple chose to continue the pregnancy. After consultation with an infectious disease specialist, CMV immune globulin (200 U/kg, for a total Cisplatin cost dose of 10 g intravenous [IV]) was recommended starting at 25 weeks of gestation with subsequent doses of 5 g IV planned at monthly intervals. Fetal magnetic resonance imaging (MRI) at 25 weeks of gestation showed no evidence of intracranial calcifications or abnormalities. Figure 1 Representative perinatal ultrasound image showing fetal echogenic bowel. Fetal echogenic bowel refers to increased echogenicity or brightness of the fetal bowel noted on second trimester ultrasound examination. The diagnosis of echogenic bowel should …
At 30 weeks of gestation, following 2 doses of CMV immune globulin, the fetal heart-rate tracing was noted to have absent variability and repetitive late decelerations (category III). A biophysical profile was 2/10 (2 points for amniotic fluid volume only) and umbilical artery Doppler velocimetry showed reversed end-diastolic flow. A viable female infant was delivered by emergent cesarean weighing 920 g with Apgar scores of 2, 7, and 10 at 1, 5, and 10 minutes, respectively. Cord blood analysis showed an arterial pH of 7.16 and base excess of ?12.5 and venous of pH 7.29 and base excess of ?8.9. The neonate was intubated and admitted to neonatal intensive care. Chest radiography showed ground glass opacities consistent with congenital CMV pneumonia.
Hematologic abnormalities included thrombocytopenia, coagulopathy, elevated transaminase levels, and hyperbilirubinemia. CMV antigenemia was present in the infant��s blood, and CMV DNA was identified in urine and cerebrospinal fluid. Placental pathology showed diffuse fibrin deposition and villous edema. Specific immunostaining of the placenta was positive for CMV (Figure 2). Figure 2 Representative histologic images of a placenta with cytomegalovirus (CMV) infection. (A) Placental histology shows moderate villous edema, intervillous fibrin deposition, amnion hyperplasia, and grade I inflammation. (B) Specific immunostaining confirms … The infant was treated with IV gancyclovir (6 mg/kg twice daily) with subsequent resolution of laboratory and imaging abnormalities over a 10-day period.
Ultrasound examination of the head and abdomen showed no evidence of calcifications, ventriculomegaly, or hepatosplenomegaly prior to treatment. Ophthalmologic examination showed no evidence of retinitis. However, the infant failed multiple newborn hearing screens and appeared to have Cilengitide profound bilateral deafness. Antiviral therapy was continued for 6 weeks. The infant was discharged home in stable condition on day of life 55. Discussion CMV infection is very common in the United States, with 50% to 80% of reproductive-age women showing serological evidence of previous infection.