Wednesday, December 31, 2014

CMV and the Expectant Mother - Q&A with Dr. Gail Demmler-Harrison

Recently I posted a question on Dr. Gail Demmler-Harrison's Texas Children's Hospital blog and I wanted to share both the question and answer on my personal blog for others to read. Mostly it mirrors my most recent post but in more technical terms! I invite you to read and learn!

Sandra says:

Dear Dr. Gail, I first want to thank you for taking the time to do this blog and respond to all of the questions you receive. It has provided immense support to myself and many families I am sure. Many of my friends are at an age where they are contemplating children. Regarding CMV testing, is there a better time for them to do it (pre/post conception). Also with so many medical professionals not having CMV on their radar, what is the specific test that my friends need to ask for? And finally, when the baby is born what should the mother ask for regarding testing the baby? I’d like to share your response with my friends. Many thanks to you and your blog!!!!!

  • Dr. Gail Demmler-Harrison, Infectious Diseases Dr. Gail Demmler-Harrison, Infectious Diseases says:

    Dear Sandra,
    Thank you for your post on my TCH CMV BLOG and for your kind words.
    The best time for a woman of childbearing age to know her CMV status is at the time of pregnancy planning, that is BEFORE pregnancy, so she can prepare and practice precautions before conception.
    Another time, which would be practical for many women, would be to request CMV testing at the first prenatal visit, as early in pregnancy as possible. However, if the first prenatal visit occurs at 6-8 weks gestation, valuable preventive measures may be missed during a very vulnerable time of pregnancy.
    A woman who is not immune to CMV is vulnerable to catching the virus for the first time during pregnancy, and transmission to the fetus may occur in up to 40% of these women who contract CMV for the first time during pregnancy.
    The CMV tests to request from the doctor may include
    CMV IgG antibody – this measures the body response to all CMV infections, and if positive, indicates a CMV infection has occurred, sometime during the life of the person, recent or past. If negative, then the individual is susceptible to catching CMV for the first time.
    CMV IgM antibody- this antibody measures the body response to a recent CMV infection; a positive test indicates a recent CMV infection; the individual woman’s response to CMV IgM production is variable and CMV IgM may last anywhere form 2 weeks to a year or more in some women.
    CMV IgG avidity index antibody- this special index antibody may be ordered in some cases where the CMV IgG and the CMV IgM antibody are both positive. The avidity index may be able to prodvide an estimate about whether or not the CMV infection occurred up to 3 to 4 months prior, but is not accurate beyond that time.
    If a woman knows she is both pregnant and CMV IgG antibody negative, studies have shown she is more likely to successfully practice the recommended precautions. For this reason, some CMV experts advocate women be tested for CMV. However, not all experts or obstetricians agree on this point, so it is up to the individual woman and her doctor to discuss these options, and decide what is best for her particular case and circumstances.
    All women who are pregnant should be informed about CMV and be aware about the common modes of transmission of CMV. They should be knoweldgeable about CMV precautions that are recommended to reduce their risk of contracting a CMV infection during pregnancy. These precautions are outlined in my TCH CMV BLOG and on the CDC website
    The CMV testing that is recommended in a newborn to determine whether or not the baby has congenital CMV infection include the following tests to directly detect CMV in the body fluids of the newborn:
    urine CMV viral culture or shell vial rapid CMV culture
    urine CMV PCR
    saliva CMV viral culture or shell vial rapid CMV culture
    saliva CMV PCR.
    A positive CMV test done in the first 21 days of life indicates a congenital CMV infection that is present from birth.
    A CMV IgG antibody is not recommended routinely to determine if a newborn is congenitally infected with CMV, because the mother will transfer her own CMV IgG antibody to her newborn, but the newborn may not be congenitally infected. Also, a CMV IgM antibody in the newborn is not very sensitive, and only about one third of congenitally infected newborns will have a positive CMV IgM antibody at birth. A CMV blood PCR may also be ordered in special cases to determine the level of CMV in the blood of a newborn.
    Also, newborn dried blood spot screening test (DBS) retrieval, with parental permission, from the State Laboratories who perform newborn screening may also be performed in special cases and tested by the CDC for evidence of CMV DNA in the newborn’s dried blood spot. This test is most often done to retrospectively determine if a newborn was congenitally infected with CMV. However, it is also being evaluated as a possible method to screen all newborns for congenital CMV.
    All newborns who exhibit signs or symptoms of congenital CMV should be tested for CMV. However, since not all newborns exhibit the same symptoms, some experts feel universal newborn screening for congenital CMV should be routine practice, so that all newborns wiht congenital CMV infection are detected and offered appropriate management of their condition. Research continues on the best approach to test and screen newborns for congenital CMV, and efforts for changes in public health policies that address the important contemproary issues surrounding congnnital CMV diagnosis and treatment and prevention are underway in many USA states and countries.
    I hope this information is helpful to you and your friends.
    Best wishes.
    Dr Gail Demmler Harrison

A plea to expectant families!

Three years ago today our “healthy” baby was discharged from the hospital at 3 days old. The year ahead would lead to diagnostic hell for our family as we would soon watch our daughter’s health deteriorate.
Our perfectly hearing baby went on to have a profound loss in one ear.
The small head due to her prematurity was in fact microcephaly due to a brain malformation called Polymicrogyria.
The little shivers and twitches…the staring spells; those were actually seizures and happened hundreds of times each day. Later on, the only “cure” for our daughter would be to disconnect half her brain.
The reason our daughter didn’t use her left hand? She had a form of cerebral palsy called left hemiparesis.
What was the “why” behind all of these mysterious diagnoses?
 It ended up being a simple “cold” like illness I had while pregnant.  Something never mentioned or even hinted at after all my trips to doctors, emergency rooms, and failed rounds of antibiotics (I was told I had bronchitis). It’s a virus that around 80% of the population has had in their lives, and is very common among toddlers in preschool settings.  It leaves a healthy person unscathed, but for a developing fetus it can be catastrophic.  The virus is called Cytomegalovirus and 1/150 neonates are positive for the virus, with devastating consequences and even death in 1/5 of those babies.  And - by the way - testing for Cytomegalovirus IS NOT part of the standard newborn screening program. We retrospectively diagnosed our daughter by retrieving her newborn bloodspot and sending it to the CDC for testing.
The reason for this post is that YOU can ask your OBGYN for a simple blood test during your first prenatal visit to see if you have had a prior CMV (Cytomegalovirus) infection. If you have had a prior infection it greatly reduces the risk of dire consequences if you contract it again in pregnancy. If you are negative for a prior CMV infection it will put you on alert to take simple precautions during your pregnancy, such as not sharing cups and utensils with toddlers and kissing them on the forehead and not lips.
If you are found to have a primary CMV infection during pregnancy there are interventions that can take place. You can be referred to an infectious disease specialist and could potentially receive immunoglobulin treatment while your baby is still in utero.
If you haven’t been tested in pregnancy it’s not too late! At birth you can request for a simple saliva swab or urine sample to be taken from your baby and tested for CMV.  If positive it will alert you to follow up with more intensive hearing screens, and to take other seemingly “insignificant” findings more seriously. For example, the medical professionals brushed off our daughter’s smaller head size – but had we known she was also CMV + it would have alerted us to get her in faster for an MRI of the head.
Finally, if a baby is diagnosed with CMV at birth – with careful consideration and under the care of a pediatric infectious disease specialist - the infant can be placed on a course of oral antivirals. Our own daughter started antivirals but only after ONE YEAR had gone by and at that time she had completely lost hearing in one ear – after passing the newborn hearing screen.
I ask that you learn from our family and take these actions into consideration. CMV (Cytomegalovirus) is common and there are measures you can take to protect your unborn child. I don’t want our experience to be repeated again!

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