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Abstract

We thank Picone and Mandelbrot for their interesting comments. In Belgium, 3 prenatal ultrasound scans are refunded by the Federal Institute for Health Insurance (1st, 2nd, and 3rd trimester ultrasound examinations). As mentioned in our article, pregnant patients with primary cytomegalovirus infections were invited for targeted additional ultrasound scans to be performed every 4 weeks until delivery. Dates of the ultrasound scans and gestational ages for every included patient were registered (data not shown) as well as fetal and placental findings. We share the same opinion about correlations between autopsy findings and clinical postnatal cytomegalovirus impairments. Histopathologic observations should be interpretated with caution to avoid overestimation of adverse outcomes. On the other hand, underestimation of adverse outcomes should not be neglicted. A few patients in this study declined autopsy or were lost for follow-up. For several cases of pregnancy terminations, neuropathological examinations failed because of fetal brain tissue autolyse. Underestimation of adverse outcomes or missed falsely negative ultrasound assessments are therefore not excluded and could have led to overrated negative predictive values for fetal ultrasound. This study was initiated 20 years ago, the knowledge about cytomegalovirus infection, its natural history during pregnancy, and available tools for prenatal risk stratification were limited, compared with actual management options. In 1996, patients with first-trimester primary cytomegalovirus infection and proven fetal infection based on amniotic fluid analysis were considered to be at high risk for severe neurologic postnatal impairments. Therefore, management options that included pregnancy termination, even for cases with negative fetal ultrasound results, were discussed with patients. Important progress has been made. Risk for fetal neurologic impairments can be stratified with the use of noninvasive techniques like magnetic resonance imaging analysis with improved sensitivity and sensibility when compared with fetal ultrasound scanning.1Cannie M.M. Devlieger R. Leyder M. et al.Congenital cytomegalovirus infection: contribution and best timing of prenatal MR imaging.Eur Radiol. 2016; 26: 3760-3769Crossref PubMed Scopus (56) Google Scholar This was implemented in our clinical practice with fewer indications for terminations. Nevertheless, discussions about prognosis and cytomegalovirus-related postnatal sequelae remain difficult. Counseling should include a broader clinical approach with a more extended screening for adverse outcomes. Ophthalmologic cytomegalovirus complications are clearly underestimated2Tear Fahnehjelm K. Olsson M. Fahnehjelm C. Lewensohn-Fuchs I. Karltorp E. Chorioretinal scars and visual deprivation are common in children with cochlear implants after congenital cytomegalovirus infection.Acta Paediatr. 2015; 104: 693-700Crossref PubMed Scopus (4) Google Scholar as is long-term progressive hearing deterioration that has been noted in 18–62% of all children with sensorineural hearing loss at birth.3Foulon I. Naessens A. Faron G. Foulon W. Jansen A.C. Gordts F. Hearing thresholds in children with a congenital CMV infection: a prospective study.Int J Pediatr Otorhinolaryngol. 2012; 76: 712-717Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar Both could lead to cytomegalovirus-related neurodevelopmental impairments without adequate identification and management. Primary maternal cytomegalovirus infections: accuracy of fetal ultrasound to predict sequelae in offspringAmerican Journal of Obstetrics & GynecologyVol. 216Issue 3PreviewWe thank Leyder et al1 for their contribution that addresses the important and challenging issue of predicting outcome when cytomegalovirus infection is diagnosed prenatally. Their group in Brussels has a long-standing experience in this field. The study confirms findings by us2 and others that the time of maternal infection is a prognostic factor, because all cases with a poor outcome had an infection before 15 weeks of gestation (2 cases with unknown timing). The other major factor to be associated with poor outcome is the presence of ultrasound abnormalities. Full-Text PDF