What is the management approach for fetal growth restriction in pregnant individuals with confirmed Cytomegalovirus (CMV) infection?

Management of Fetal Growth Restriction in Pregnant Women with CMV Infection

In pregnant individuals with confirmed CMV infection and fetal growth restriction (FGR), management should include PCR testing for CMV via amniocentesis, serial umbilical artery Doppler assessments, and timing delivery based on Doppler findings and severity of growth restriction.

Diagnostic Approach

Initial Evaluation

• Perform a detailed obstetrical ultrasound examination (CPT code 76811) to assess for:
  • Fetal growth parameters
  • Presence of other CMV-associated anomalies:
    • Ventriculomegaly
    • Hyperechogenic bowel
    • Pericardial effusion
    • Ascites
    • Enlarged cisterna magna 1

Genetic and Infectious Workup

• Offer prenatal diagnostic testing with amniocentesis for:
  • Chromosomal microarray analysis (CMA) 2
  • PCR for CMV in the amniotic fluid 2, 3
    • Should be performed at least 7-8 weeks after presumed maternal infection
    • Should be done after 21 weeks of gestation 4
  • Quantitative determination of CMV DNA in amniotic fluid may help predict fetal outcome 4

Monitoring Protocol

Ultrasound Surveillance

• Serial ultrasound examinations every 2-4 weeks to monitor:
  • Fetal growth trajectory
  • Development of additional anomalies 4
  • Amniotic fluid volume

Doppler Assessment

• Serial umbilical artery Doppler assessment to evaluate for deterioration 2
  • Weekly Doppler evaluation for decreased end-diastolic velocity or severe FGR (EFW <3rd percentile) 2
  • Doppler assessment 2-3 times per week when absent end-diastolic velocity (AEDV) is detected 2, 5
  • Daily monitoring when reversed end-diastolic velocity (REDV) is present 2

Fetal Well-being Assessment

• Weekly cardiotocography (CTG) testing after viability for FGR without AEDV/REDV 2
• Increase frequency of CTG when FGR is complicated by AEDV/REDV 2
• Consider biophysical profile (BPP) testing twice weekly in severe cases 5

Delivery Timing Algorithm

Based on Doppler Findings

1. Normal end-diastolic flow with mild FGR (EFW 3rd-10th percentile)

   • Deliver at 38-39 weeks of gestation 2

2. Decreased end-diastolic flow or severe FGR (EFW <3rd percentile)

   • Deliver at 37 weeks of gestation 2, 5

3. Absent end-diastolic velocity (AEDV)

   • Deliver at 33-34 weeks of gestation 2, 5
   • Hospitalize and administer antenatal corticosteroids prior to delivery 5

4. Reversed end-diastolic velocity (REDV)

   • Deliver at 30-32 weeks of gestation 2
   • Immediate hospitalization, administration of antenatal corticosteroids, and heightened surveillance with CTG at least 1-2 times per day 2, 5

Peridelivery Management

Antenatal Interventions

• Administer antenatal corticosteroids if delivery is anticipated before 36 6/7 weeks 2, 5
  • Be aware that steroids may transiently improve Doppler findings but can increase metabolic demands 5

Neuroprotection

• Administer magnesium sulfate for fetal and neonatal neuroprotection for pregnancies <32 weeks of gestation 2, 5

Mode of Delivery

• Consider cesarean delivery for pregnancies with FGR complicated by AEDV/REDV based on the clinical scenario 2, 5

Neonatal Considerations

Testing and Follow-up

• Test all babies born to women with confirmed CMV infection with urine or saliva sample within the first 21 days of life 3
• Follow up all infants with CMV infection at birth for at least 2 years to check hearing and brain development 3, 1
• Be vigilant for sensorineural hearing loss, which is common in congenital CMV infection 3, 1

Treatment

• Consider antiviral treatment (valganciclovir or ganciclovir) for symptomatic newborns with congenital CMV infection 3

Pitfalls and Caveats

• Absence of sonographic findings does not guarantee a normal outcome in CMV-infected fetuses 4
• Past CMV infection does not confer immunity to the mother or protect the fetus from reinfection 6
• Primary CMV infection in early pregnancy carries the highest risk of severe fetal effects 6
• The risk of transmission increases with gestational age, but severity of fetal effects is greater when infection occurs before 20 weeks 6