Acute infection with parvovirus B19 in early pregnancy

Abstract

A 23-year-old primigravida was referred to our institute at 12 + 4 weeks' gestation with increased nuchal translucency (NT) thickness. Family history and the pregnancy to date were normal. On ultrasound examination using a Voluson E8 (GE Medical Systems, Zipf, Austria) equipped with a 3.5-5-MHz transabdominal probe, the crown-rump length was 71.3 mm and NT measured 2.5 mm. Echocardiography revealed both tricuspid valve and mitral valve insufficiency. A positive A-wave was observed in the ductus venosus on Doppler imaging. Neither pleural effusion nor ascites was found. Suspecting fetal anemia, we arranged for a serological examination of maternal blood which showed acute parvovirus infection (parvovirus B19 immunoglobulin (IgG) positive; IgG, 20 IU/mL; parvovirus B19 IgM positive; IgM index, 9.6).At 12 + 6 weeks' gestation there were signs of significant deterioration in the fetal condition with reversed flow in the ductus venosus during atrial contraction, the development of fetal hydrops and persistent atrioventricular (AV) valve insufficiency. At 13 + 0 weeks' gestation the fetus received an intracardiac transfusion of 1.5 mL irradiated red blood cell concentrate with increased hematocrit (blood group O rhesus negative) plus 0.5 mL of a platelet concentrate given through a 22-G needle.Three days after transfusion, positive flow in the A-wave of the ductus venosus was noted and the AV valve insufficiency showed signs of improvement. Generalized hydrops was no longer evident. The NT had increased to 4.4 mm. A second transfusion of 2 mL red blood cell concentrate and 1 mL platelet concentrate was given through the umbilical vein at the placental insertion. Blood sampling for red blood cell count proved impossible as the vein collapsed on aspiration.At 13 + 5 weeks' gestation, signs of deterioration (reversal of flow in the ductus venosus and an increase in NT to 5.6 mm) suggested a progression of fetal anemia. We therefore gave 2.5 mL red blood cells intravenously. Improvement was evident in both AV valves and in the ductus venosus waveform.There was renewed deterioration of flow in the ductus venosus at 14 + 4 weeks' gestation and fetal middle cerebral artery velocity was high at 35.0 cm/s 1 . Repeat transfusion was performed intravascularly with 2.5 mL red blood cell concentrate. NT thickness remained at 5.6 mm, and only the tricuspid valve still showed signs of insufficiency.At 15 + 6 weeks' gestation fetal middle cerebral artery velocity had increased to 39.5 cm/s. A fifth intravascular transfusion of 2.9 mL red blood cell concentrate was performed and the subsequent hemoglobin level was 12.0 g/dL.Follow-up ultrasound examinations showed normal fetal development. A small echogenic focus in the myocardium of the right ventricle that had been noted at the time of the first intracardiac transfusion persisted until birth. A small pericardial effusion documented after the first blood transfusion resolved completely by 17 weeks' gestation. Fetal magnetic resonance imaging at 28 + 5 weeks' gestation showed no evide...

Practice Bulletin No. 151

“…The annual cost of treating the permanent disabilities and complications caused by CMV infections in the United States is estimated to be more than $1.86 billion (17). Cytomegalovirus infection resulting from exposure to infected cervical secretions or breast milk is typically asymptomatic and is not associated with severe neonatal sequelae (18,19). Cytomegalovirus infection resulting from exposure to infected cervical secretions or breast milk is typically asymptomatic and is not associated with severe neonatal sequelae (18,19).…”

Early Signs of Cardiac Failure: A Clue for Parvovirus Infection Screening in the First Trimester?

“…There are only a few cases of parvovirus infection with reversed a-wave in the DV [7,12] , and our case was the earliest in pregnancy. NT measurement and DV Doppler findings are helpful indicators of the presence of severe fetal anemia [12] and fetal cardiac dysfunction [13,14] . In fetal anemia, increased fetal cardiac output is believed to be due to a decrease in blood viscosity, which in turn leads to increased venous return and cardiac preload.…”

Parvovirus B19 infection in human pregnancy

“…Following acute infection with hPV B19 in the first trimester of pregnancy, nuchal translucency measurements and ductus venosus Doppler velocimetry findings are helpful indicators of the presence of severe fetal anaemia. 180 After confirmation of maternal hPV B19 infection in the first 20 weeks of gestation, fetal surveillance should be initiated no later than 4 weeks after the onset of illness or estimate of seroconversion. If the ultrasound findings are suggestive of hydrops fetalis, the mother should be referred to a tertiary referral centre.…”

“…142 In those fetuses considered to be at high risk of disease, weekly Doppler examination of the middle cerebral artery peak systolic velocity and ductus venosus velocity should be performed, which are measures of the increased cardiac output and decreased plasma viscosity associated with fetal anaemia. [179][180][181][182][183][184][185][186] The early ultrasound signs of cardiac failure are cardiomegaly and ascites, 53,126,187 which may be a manifestation of hepatitis and hypoalbuminaemia as much as cardiac failure from anaemia. 53 The risk of fetal death persists for some months after maternal infection and may occur without hydrops or maternal symptoms.…”