Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia (Dr Hui); Department of Perinatal Medicine, Mercy Hospital for Women, Heidelberg, Victoria, Australia (Dr Hui); Reproductive Epidemiology Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia (Dr Hui); Northern Health, Epping, Victoria, Australia (Dr Hui).
Child Population and Translational Health Research, Children's Hospital at Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia (Dr Shand); Department of Maternal-Fetal Medicine, Royal Hospital for Women, Randwick, New South Wales, Australia (Dr Shand); Department of Maternal-Fetal Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia (Dr Shand).
Am J Obstet Gynecol MFM. 2021 Jul;3(4):100355. doi: 10.1016/j.ajogmf.2021.100355. Epub 2021 Mar 22.
Congenital cytomegalovirus is caused by maternal primary or nonprimary infection during pregnancy and is a major preventable cause of neurodisability. The proposed strategies to reduce congenital cytomegalovirus include primary prevention with maternal hygiene measures and secondary prevention by serologic screening for detecting maternal primary infection. A recent randomized trial found that high-dose valaciclovir treatment resulted in a significant reduction in fetal infection after first-trimester maternal primary infection, leading to calls to start routine serologic screening in pregnancy. Previously, observational studies have found a reduction in fetal infection with after maternal primary cytomegalovirus infection when hyperimmune globulin is administered twice weekly during the first trimester of pregnancy; however, this has not been replicated in randomized trials that have used different regimens. Furthermore, some evidence from a single intervention trial and observational studies do not provide us with the necessary data required for rolling out an appropriate screening program. All screening tests may be associated with harm; in the case of congenital cytomegalovirus, there is the well-recognized potential for increasing terminations of pregnancy without diagnostic confirmation of fetal infection or sequelae. Although valaciclovir and hyperimmune globulin treatments may significantly reduce fetal infection rates, they do not prevent severe cytomegalovirus-related fetal brain damage in all pregnancies. Therefore, it is not clear that the offer of a prenatal intervention will provide sufficient reassurance to screen-positive women. In addition, the effectiveness of a prenatal screening and treatment strategy is predicated on a high rate of maternal primary infection, which is limited to regions with low cytomegalovirus seroprevalence, such as Western Europe. In some countries, such as the United States, Finland, and Brazil, nonprimary maternal infections are responsible for most congenital cytomegalovirus health burdens, limiting the potential impact of pregnancy screening. In this invited clinical perspective, we reviewed the evidence and outlined the steps needed to be taken before determining whether the benefits of routine screening for cytomegalovirus in pregnancy outweigh the harms. Until we have the necessary evidence, we should follow the current advice of multiple national health authorities and focus on promoting primary prevention through maternal hygiene precautions.
先天性巨细胞病毒是由母体妊娠期间原发性或非原发性感染引起的，是导致神经发育障碍的主要可预防病因。减少先天性巨细胞病毒感染的策略包括通过母体卫生措施进行初级预防，以及通过血清学筛查检测母体原发性感染进行二级预防。最近的一项随机试验发现，在妊娠早期母体原发性感染后，高剂量伐昔洛韦治疗可显著降低胎儿感染率，这促使人们呼吁在妊娠期间常规进行血清学筛查。此前，观察性研究发现，在妊娠早期每周两次给予高免疫球蛋白治疗母体原发性巨细胞病毒感染后，胎儿感染率降低；然而，在使用不同方案的随机试验中并未得到复制。此外，来自单次干预试验和观察性研究的一些证据并未为我们提供开展适当筛查计划所需的必要数据。所有筛查试验都可能存在危害；对于先天性巨细胞病毒，在没有胎儿感染或后遗症的诊断确认的情况下，增加终止妊娠的可能性是众所周知的。虽然伐昔洛韦和高免疫球蛋白治疗可显著降低胎儿感染率，但并不能预防所有妊娠中严重的巨细胞病毒相关胎儿脑损伤。因此，提供产前干预是否能为筛查阳性的女性提供足够的保证尚不清楚。此外，产前筛查和治疗策略的有效性取决于母体原发性感染率高，而这仅限于巨细胞病毒血清流行率低的地区，如西欧。在一些国家，如美国、芬兰和巴西，非原发性母体感染是导致大多数先天性巨细胞病毒健康负担的原因，限制了妊娠筛查的潜在影响。在这篇特邀临床观点文章中，我们回顾了证据，并概述了在确定常规筛查妊娠巨细胞病毒是否利大于弊之前需要采取的步骤。在我们获得必要的证据之前，我们应该遵循多个国家卫生当局的现行建议，重点通过母体卫生预防措施促进初级预防。
