Fetal Brain Injury Associated with Parvovirus B19 Congenital Infection Requiring Intrauterine Transfusion.

BACKGROUND: Infection with parvovirus B19 (B19V) during pregnancy may cause severe fetal anemia, hydrops, and fe tal death. Furthermore, neurodevelopmental impairment among survivors may occur despite appropriate prenatal management, including intrauterine transfusion (IUT). OBJECTIVES: Our primary objective was to describe cerebral lesions on MRI in fetuses with severe anemia requiring IUT for B19V infection. Our secondary objective was to search for clinical and biological characteristics associated with the occurrence of such lesions. STUDY DESIGN: We performed a retrospective review of data on fetuses infected with B19V and requiring at least one IUT between 2005 and 2016. Fetuses with abnormal cerebral MRI results in the 3rd trimester were compared to those with normal MRI results. RESULTS: Of 34 transfused fetuses, 26 children were born at full term. Five intrauterine fetal deaths, 1 neonatal death, and 2 terminations of pregnancy occurred. Cerebral anomalies were observed in 7/27 fetuses on MRI, including cerebellar hemorrhage or a small cerebellum. Only viral load in fetal blood appeared to be associated with brain lesions (11.5 log10 copies/mL [10.5-12.5] in case of abnormal MRI results vs. 9.5 log10 copies/mL [7.8-10.0]; p = 0.05). CONCLUSIONS: Among the fetuses transfused for B19V infection, 26% presented with prenatal abnormal cerebral imaging results. In our study, viral load in fetal blood appeared to be the only factor associated with fetal brain lesions.

History of parvovirus B19 infection is associated with silent cerebral infarcts.

BACKGROUND: The relationship between silent cerebral infarcts (SCIs) and history of parvovirus B19 (B19V) has not been systematically evaluated. As an ancillary study from the Silent Cerebral Infarct Trial (SIT) (NCT00072761), we tested the hypothesis that a history of B19V infection is associated with an increased prevalence of SCIs in children with sickle cell anemia. PROCEDURE: We used a retrospective cross-sectional cohort study design; each participant underwent a brain magnetic resonance imaging (MRI) scan and medical record review for prior B19V infection (n = 958). RESULTS: SCI was present in 30% (287 of 958) of participants and 17% (165 of 958) had a history of B19V infection. Based on prior evidence that low baseline hemoglobin (Hgb) levels are associated with increased odds of SCI, Hgb levels were divided into tertiles (<7.6 g/dl, ≥7.6-≤8.5 g/dl, ≥8.6 g/dl) and multivariable analysis was used to determine the relationship between the joint effect of prior B19V infection, Hgb levels, and SCI. Prior B19V infection and the lowest Hgb tertile were associated with increased risk of SCI (odds ratio [OR] 2.12; 95% CI, 1.17-3.84; P = 0.013); no prior B19V infection and the highest Hgb tertile were associated with a decreased risk (OR 0.56; 95% CI, 0.38-0.84; P = 0.004). CONCLUSIONS: Efforts to decrease the incidence of B19V infection, such as the development of a B19V vaccine, may decrease SCI prevalence.

Polymicrogyria in a fetus with human parvovirus B19 infection: a case with radiologic-pathologic correlation.

We report the prenatal magnetic resonance imaging (MRI) appearance of polymicrogyria with pathologic correlation in a fetus with congenital parvovirus B19 infection. Prenatal ultrasound revealed non-immune hydrops, but detected no fetal brain abnormalities. A subsequent fetal MRI scan performed at 23 weeks' gestation demonstrated bilateral polymicrogyria, which was confirmed at autopsy. To our knowledge, prenatal diagnosis of polymicrogyria in association with congenital parvovirus B19 infection has not been previously described. This case provides further evidence for brain abnormalities resulting from congenital parvovirus B19 infection, and suggests that fetal neuroimaging with MRI would be of value in suspected cases of congenital parvovirus infection.

Parvovirus B19 in pregnancy: prenatal diagnosis and management of fetal complications.

PURPOSE OF REVIEW: Parvovirus B19 infection is often considered a mild and self-limiting disease of minor clinical importance. This review aims to raise awareness of recently discovered potentially devastating consequences of this infection in pregnancy, and provides updated guidelines on diagnosis and management. RECENT FINDINGS: In contrast to previous beliefs, parvovirus B19 infection during any stage of pregnancy may not only cause fetal death, but may also result in severe and irreversible neurological sequelae in survivors. Improved diagnostic techniques allow more reliable and earlier diagnosis of fetal disease. SUMMARY: Clinicians need to be aware of the risk of adverse outcome of parvovirus B19 infection in pregnancy, and sometimes the long interval between exposure and fetal symptoms. Accurate diagnosis using PCR and weekly ultrasound checks ups with Doppler measurement of middle cerebral artery flow velocity up to 20 weeks postexposure may improve detection of fetal disease. More timely treatment likely results in improved outcome.

Ultrasound diagnosis, management and prognosis in a consecutive series of 27 cases of fetal hydrops following maternal parvovirus B19 infection.

INTRODUCTION: Fetal hydrops caused by anemia from parvovirus B19 infection (FH-B19) is rare. Doppler measurement of the middle cerebral artery peak systolic velocity (PSV-MCA) improves its prenatal diagnosis, but its frequency and prognosis are still poorly known. Despite improved survival due to in utero transfusions, the possibility of late neurological sequelae makes prognosis uncertain. OBJECTIVES: To assess the frequency, management and prognosis of a consecutive series of FH-B19 observed over a 15-year period. METHODS: Retrospective study of 27 cases of FH-B19, that is, 3/100,000 births, 24 of them discovered during routine second-trimester ultrasound. All but 1 case (96.2%) had at least four of the six ultrasound signs that Saltzman et al. [Obstet Gynecol 1989;74:106-111] suggested as indicators of anemia. Of the fetuses tested, 80% had a PSV-MCA >1.5 MoM, also indicative of anemia. Of the 19 fetuses treated by exchange transfusions, 11 were liveborn compared with 2 of the 6 not so treated (57.8 vs. 33.3%, NS). The survival rate was higher during the second half of the study period (23.1 vs. 71.4%, p < 0.02) for less severe anemia (p < 0.03) and for repeated transfusions (p = 0.03). In our series, 1 case of prenatal cerebral atrophy was identified on screening. All 13 liveborn children appeared healthy at the age of 1 year. CONCLUSION: In cases of fetal hydrops, Saltzman et al.'s ultrasound criteria and PSV-MCA measurement made it possible to determine the likelihood that anemia is the cause of the hydrops and to measure its intensity. Use of these techniques allowed us to choose the most appropriate treatment (transfusion or not, depending on the degree of anemia), and survival improved notably in our series.

Early signs of cardiac failure: a clue for parvovirus infection screening in the first trimester?

Parvovirus B19 is a small single-stranded DNA virus and a potent inhibitor of erythropoiesis due to its cytotoxicity to erythroid progenitor cells. Although adult disease is generally mild, fetal parvovirus B19 infection can cause spontaneous abortion in early pregnancy and aplastic anemia, nonimmune hydrops fetalis and in utero fetal demise. The prevalence of parvovirus B19 maternal infection during pregnancy is about 1-2%. The vertical transmission occurs in 10-35%, being highest in the first and second trimesters. The risk of adverse fetal outcome is 10%. In contrast to the second or third trimester, in pregnancies affected by increased nuchal translucency (NT) in the late first trimester, the prevalence of maternal infection was not higher than in the general population. We report a case of first-trimester parvovirus B19 infection with increased NT and reversed a-wave in the ductus venosus (DV) at 11 weeks, with fetal demise 2 weeks later.

Erythema infectiosum (Fifth disease) and pregnancy.

QUESTION: One of my patients is currently 14 weeks pregnant. She is a teacher in grade 1, and there is an epidemic of Fifth disease in the school where she teaches. Can this disease affect her pregnancy and how should I care for her? ANSWER: Erythema infectiosum (Fifth disease) is usually a benign disease for children and mothers, but might have serious consequences for a fetus due to hemolytic anemia, although the risk is very low. You should evaluate the mother's immune status. If she is already immune (IgG positive), the risks are nil. If she is not immune (although the risk of the fetus's being affected is very low), fetal surveillance by repeated ultrasonographic examination and immune status reevaluation has been recommended. If a fetus is found to be affected, intrauterine evaluation and treatment are available at tertiary care centres.

Human B19 parvovirus infection in an obstetric population. A prospective study determining fetal outcome.

In a prospective study of 1,967 pregnant women who were routinely screened for recent human B19 parvovirus infection, 64 (3.3%) were identified as being IgM positive. No adverse effects were documented by ultrasound in any of the fetuses. The outcome of pregnancy was favorable in 95.1% of these women, with no evidence of hydrops fetalis or any congenital abnormalities. Two neonates (3.4%) were small for gestational age, and there was one abortion. Samples of blood obtained from 20 neonates born to women with evidence of recent infection were B19 parvovirus IgM negative. Recent infection with human B19 parvovirus in pregnancy constitutes a low risk for the development of adverse fetal effects; hence, routine antenatal screening is not warranted.