Guideline Summary NGC-7745

Guideline T itle
Cytomegalovirus infection in pregnancy.
Bibliographic Source(s)
Y inon Y , Farine D, Y udin MH, Gagnon R, Hudon L, Basso M, Bos H, Delisle MF, Menticoglou S, Mundle W , Ouellet A,
Pressey T, Roggensack A, Boucher M, Castillo E, Gruslin A, Money DM, Murphy K, Ogilvie G, Paquet C, Van Eyk N, van
Schalkwyk J. Cytomegalovirus infection in pregnancy. J Obstet Gynaecol Can. 2010 Apr;32(4):348-54. [38 references]
PubMed
Guideline Status
This is the current release of the guideline.

Scope
Disease/Condition(s)
Cytomegalovirus infection in pregnancy
Guideline Category
Diagnosis
Evaluation
Management
Prevention
Risk Assessment
Screening
Treatment
Clinical Specialty
Infectious Diseases
Obstetrics and Gynecology
Pediatrics
Intended Users
Advanced Practice Nurses
Physician Assistants
Physicians
Guideline Objective(s)
To review the principles of prenatal diagnosis of congenital cytomegalovirus (CMV) infection and to describe the outcomes
of the affected pregnancies
T arget Population
Pregnant women
Interventions and Practices Considered
Diagnosis/Evaluation
1. Serologic testing in women with suspected cytomegalovirus (CMV)
2. Amniocentesis
3. Ultrasound (US) examinations
Management/T reatment
1. Serial US examinations
2. Quantitative polymerase chain reaction (PCR) for viral deoxyribonucleic acid (DNA) in amniotic fluid
3. Fetal magnetic resonance imaging (MRI) (considered but not recommended)

4.

Intravenous treatment with CMV-hyperimmune globulin

5. Ganciclovir treatment
Prevention
1.

Good personal hygiene

2.

Routine serologic screening for pregnant women (considered but not recommended)

3.
4.

Patient education to seronegative women

Serologic monitoring of health care and child care workers

5.

Serologic monitoring of pregnant women who have a young child in day care

Major Outcomes Considered

Effective management of fetal infection during pregnancy
Neonatal signs of cytomegalovirus infection (CMV)
Long-term sequelae of CMV:
Sensorineural hearing loss
Mental retardation
Delay in psychomotor development
Visual impairment

Methodology
Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Searches of Unpublished Data
Description of Methods Used to Collect/Select the Evidence
Medline was searched for articles published in English from 1966 to 2009, using appropriate controlled vocabulary
(congenital CMV infection) and key words (intrauterine growth restriction, microcephaly). Results were restricted to
systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. Searches were
updated on a regular basis and incorporated into the guideline. Grey (unpublished) literature was identified through
searching the websites of health technology assessment and health technology assessment-related agencies, clinical
practice guideline collections, clinical trial registries, and national and international medical specialty societies.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
W eighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Quality of Evidence Assessment*
I: Evidence obtained from at least one properly randomized controlled trial
II-1: Evidence obtained from well-designed controlled trials without randomization.
II-2: Evidence obtained from well-designed cohort (prospective or retrospective) or case-control studies, preferably from
more than one centre or research group
II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results from
uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this
category
III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
*Adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care.

Methods Used to Analyze the Evidence

Systematic Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Classification of Recommendations

A. There is good evidence to recommend the clinical preventive action

B. There is fair evidence to recommend the clinical preventive action
C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical
preventive action; however, other factors may influence decision-making
D. There is fair evidence to recommend against the clinical preventive action
E. There is good evidence to recommend against the clinical preventive action
L. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence
decision-making
Adapted from the Classification of Recommendations criteria described in the Canadian Task Force on Preventive Health Care.

Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation
This guideline has been reviewed by the Maternal Fetal Medicine Committee and approved by Executive and Council of the
Society of Obstetricians and Gynaecologists of Canada.

Recommendations
Major Recommendations
The quality of evidence (I-III) and classification of recommendations (A-E, L) are defined at the end of the "Major
Recommendations."
1. Diagnosis of primary maternal cytomegalovirus (CMV) infection in pregnancy should be based on de-novo
appearance of virus-specific IgG in the serum of a pregnant woman who was previously seronegative, or on detection
of specific IgM antibody associated with low IgG avidity. (II-2A)
2. In case of primary maternal infection, parents should be informed about a 30% to 40% risk for intrauterine
transmission and fetal infection, and a risk of 20% to 25% for development of sequelae postnatally if the fetus is
infected. (II-2A)
3. The prenatal diagnosis of fetal CMV infection should be based on amniocentesis, which should be done at least 7
weeks after presumed time of maternal infection and after 21 weeks of gestation. This interval is important because
it takes 5 to 7 weeks following fetal infection and subsequent replication of the virus in the kidney for a detectable
quantity of the virus to be secreted to the amniotic fluid. (II-2A)
4. The diagnosis of secondary infection should be based on a significant rise of IgG antibody titre with or without
the presence of IgM and high IgG avidity. In cases of proven secondary infection, amniocentesis may be considered,
but the riskbenefit ratio is different because of the low transmission rate. (III-C)
5. Following a diagnosis of fetal CMV infection, serial ultrasound examinations should be performed every 2 to 4
weeks to detect sonographic abnormalities, which may aid in determining the prognosis of the fetus, although it is
important to be aware that the absence of sonographic findings does not guarantee a normal outcome. (II-2B)
6. Quantitative determination of CMV deoxyribonucleic acid (DNA) in the amniotic fluid may assist in predicting the
fetal outcome. (II-3B)
7. Routine screening of pregnant women for CMV by serology testing is currently not recommended. (III-B)
8. Serologic testing for CMV may be considered for women who develop influenza-like illness during pregnancy or
following detection of sonographic findings suggestive of CMV infection. (III-B)
9. Seronegative health care and child care workers may be offered serologic monitoring during pregnancy. Monitoring
may also be considered for seronegative pregnant women who have a young child in day care. (III-B)
Definitions:
Quality of Evidence Assessment*
I: Evidence obtained from at least one properly randomized controlled trial
II-1: Evidence obtained from well-designed controlled trials without randomization
II-2: Evidence obtained from well-designed cohort (prospective or retrospective) or casecontrol studies, preferably from
more than one centre or research group
II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results from
uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this
category
III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
Classification of Recommendations
A. There is good evidence to recommend the clinical preventive action
B. There is fair evidence to recommend the clinical preventive action
C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical
preventive action; however, other factors may influence decision-making
D. There is fair evidence to recommend against the clinical preventive action
E. There is good evidence to recommend against the clinical preventive action
L. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence
decision-making

*Adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care.
Adapted from the Classification of Recommendations criteria described in the Canadian Task Force on Preventive Health Care.

Clinical Algorithm(s)
An algorithm for prenatal diagnosis of congenital cytomegalovirus (CMV) is provided in the original guideline document.

Evidence Supporting the Recommendations

T ype of Evidence Supporting the Recommendations
The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").
Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational
studies.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
Effective management of fetal infection following maternal cytomegalovirus (CMV) infection in pregnancy
Potential Harms
It has been repeatedly reported that prenatal diagnosis procedures performed too close to the onset of maternal infection
carry a substantial risk of false negative results.

Qualifying Statements
Qualifying Statements
This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The
information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local
institutions can dictate amendments to these opinions. They should be well documented if modified at the local level.

Implementation of the Guideline

Description of Implementation Strategy
An implementation strategy was not provided.
Implementation T ools
Clinical Algorithm
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Y inon Y , Farine D, Y udin MH, Gagnon R, Hudon L, Basso M, Bos H, Delisle MF, Menticoglou S, Mundle W , Ouellet A,
Pressey T, Roggensack A, Boucher M, Castillo E, Gruslin A, Money DM, Murphy K, Ogilvie G, Paquet C, Van Eyk N, van
Schalkwyk J. Cytomegalovirus infection in pregnancy. J Obstet Gynaecol Can. 2010 Apr;32(4):348-54. [38 references]
PubMed
Adaptation
Not applicable: The guideline was not adapted from another source.
Date Released
2010 Apr
Guideline Developer(s)
Society of Obstetricians and Gynaecologists of Canada - Medical Specialty Society
Source(s) of Funding
Society of Obstetricians and Gynaecologists of Canada

Guideline Committee
Maternal Fetal Medicine Committee and Infectious Diseases Committee
Composition of Group T hat Authored the Guideline
Principal Authors: Y oav Y inon, MD, Toronto ON; Dan Farine, MD, Toronto ON; Mark H. Y udin, MD, Toronto ON
Maternal Fetal Medicine Committee: Robert Gagnon, MD (Chair), Montreal QC; Lynda Hudon, MD (Co-Chair), Montreal QC;
Melanie Basso, RN, Vancouver BC; Hayley Bos, MD, London ON; Marie-France Delisle, MD, Vancouver BC; Dan Farine, MD,
Toronto ON; Savas Menticoglou, MD, W innipeg MB; W illiam Mundle, MD, W indsor ON; Annie Ouellet, MD, Sherbrooke QC;
Tracy Pressey, MD, Vancouver BC; Anne Roggensack, MD, Calgary AB
I nfectious Diseases Committee: Mark H. Y udin, MD (Chair), Toronto ON; Marc Boucher, MD, Montreal QC; Eliana Castillo,
MD, Vancouver BC; Andre Gruslin, MD, Ottawa ON; Deborah M. Money, MD, Vancouver BC; Kellie Murphy, MD, Toronto ON;
Gina Ogilvie, MD, Vancouver BC; Caroline Paquet, RM, Trois-Rivires QC; Nancy Van Eyk, MD, Halifax NS; Julie van
Schalkwyk, MD, Vancouver BC
Financial Disclosures/Conflicts of Interest
Disclosure statements have been received from all members of the committees.
Guideline Status
This is the current release of the guideline.
Guideline Availability
Electronic copies: Available in Portable Document Format (PDF) from the Society of Obstetricians and Gynaecologists of
Canada W eb site .
Print copies: Available from the Society of Obstetricians and Gynaecologists of Canada, La socit des obsttriciens et
gyncologues du Canada (SOGC) 780 promenade Echo Drive Ottawa, ON K1S 5R7 (Canada); Phone: 1-800-561-2416
Availability of Companion Documents
None available
Patient Resources
None available
NGC Status
This NGC summary was completed by ECRI Institute on October 7, 2010. The information was verified by the guideline
developer on November 15, 2010.
Copyright Statement
This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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