Laboratory testing for cytomegalovirus among pregnant women in the United States: a retrospective study using administrative claims data
© Leung et al.; licensee BioMed Central Ltd. 2012
Received: 20 June 2012
Accepted: 23 November 2012
Published: 3 December 2012
Routine cytomegalovirus (CMV) screening during pregnancy is not recommended in the United States and the extent to which it is performed is unknown. Using a medical claims database, we computed rates of CMV-specific testing among pregnant women.
We used medical claims from the 2009 Truven Health MarketScan® Commercial databases. We computed CMV-specific testing rates using CPT codes.
We identified 77,773 pregnant women, of whom 1,668 (2%) had a claim for CMV-specific testing. CMV-specific testing was significantly associated with older age, Northeast or urban residence, and a diagnostic code for mononucleosis. We identified 44 women with a diagnostic code for mononucleosis, of whom 14% had CMV-specific testing.
Few pregnant women had CMV-specific testing, suggesting that screening for CMV infection during pregnancy is not commonly performed. In the absence of national surveillance for CMV infections during pregnancy, healthcare claims are a potential source for monitoring practices of CMV-specific testing.
KeywordsCMV Cytomegalovirus MarketScan Pregnant women Screening Laboratory testing
Cytomegalovirus (CMV) is the most common congenital viral infection in the United States and a leading cause of congenital hearing loss and neurological disability . CMV can be transmitted to the fetus when a CMV seronegative woman develops a primary CMV infection during pregnancy, or from latent virus reactivation from maternal CMV infection acquired prior to pregnancy or re-infection with a new CMV strain during pregnancy. The risk of CMV transmission to the fetus is higher among pregnant women with primary infection compared to those who were IgG positive prior to pregnancy, IgG positive at their first pregnancy visit, or IgM positive with high IgG avidity and therefore presumed to have non-primary infection (30-40% compared to 0.2-2%) . Although vertical transmission is more likely to occur as a result of maternal infections in the third trimester, the rate of permanent sequelae from CMV is lower among infants infected during the third trimester than among infants born to mothers with primary CMV infection in the first trimester [3, 4]. In the United States, approximately 42-50% of women 20–49 years of age are CMV seronegative , and it is estimated that 27,000 primary CMV infections occur among pregnant women each year .
Most CMV infections in immunocompetent persons are asymptomatic or present with non-specific symptoms [7, 8], with only a minority of persons experiencing mononucleosis . Diagnosis of CMV infection among otherwise healthy adults generally relies on serologic testing; proposed algorithms have included documentation of seroconversion or detection of CMV-specific IgM antibody in association with low IgG avidity . However confirmation of CMV seroconversion during pregnancy has practical challenges . Demonstrating seroconversion requires multiple blood draws over time as CMV IgM testing alone is not adequately specific for diagnosing primary infection. It does not allow for reliable determination of the timing of infection, and in the case of a pregnant woman, does not provide information on whether CMV infection occurred before or after the start of pregnancy. IgG avidity may provide information on a window of time during which primary infection may have occurred; however, most commercial laboratories in the United States do not currently offer CMV IgG avidity testing . When primary maternal CMV infection is diagnosed or suspected, additional diagnostic testing, including PCR or viral culture of either amniotic fluid or fetal blood and fetal ultrasound or magnetic resonance imaging, may allow for determination of whether fetal infection has occurred.
There is currently no recommendation for routine CMV screening during pregnancy by any professional association or national public health authority [11, 12] and provider and public awareness of congenital CMV infection is low [13–16]. An uncontrolled study suggested that CMV hyperimmune globulin administered during pregnancy may help reduce the risk of congenital CMV infection  and additional data from controlled clinical studies may inform future treatment options [18–20]. The extent to which prenatal screening or diagnostic testing for CMV is occurring in the United States is unknown and there is currently little information on national practices around CMV testing during pregnancy. Identifying testing practices will provide useful information to monitor future screening and prevention programs. We used a large healthcare claims database to explore current practices and rates of CMV testing among pregnant women in the United States.
The Truven Health MarketScan® Commercial Databases (Truven Health MarketScan Databases, Truven Health Analytics, Ann Arbor, MI) are derived from insurance claims for almost 40 million employees and their beneficiaries in the United States . We used outpatient and inpatient claims data from the 2009 MarketScan Commercial Claims and Encounters databases, including information on demographics, health plan membership, International Classification of Diseases-9th revision, Clinical Modification (ICD-9-CM) codes, and Current Procedural Terminology (CPT) codes. This study was reviewed by the human subjects research coordinator at the CDC and, as an analysis of secondary data without personal identifiers, was determined not to require institutional review board review.
We defined pregnant women as women aged 15–44 years enrolled for 365 days in 2009 with their first delivery code Appendix identified during October-December 2009 in order to ensure that enrollees’ medical claims for the entire pregnancy were captured. The delivery date was approximated using the date of the first claim with a delivery code. We assumed that pregnancies lasted for no longer than 42 weeks and defined pregnancy-associated claims as those occurring in the 42 weeks before the first claim with a delivery code. We classified claims which occurred during 0–13 weeks to be within the 1st trimester, those within weeks 14–26 to be in the 2nd trimester, and those within weeks 27–42 to be in the 3rd trimester. A prenatal visit was defined as a medical claim with a code consistent with prenatal care Appendix. Prenatal care was defined as ≥2 prenatal visits in the 1st trimester or ≥1 global billing codes for prenatal care (CPT 59400, 59425, 59426, 59510, 59610) anytime during the pregnancy. We defined CMV-specific testing as a claim for CMV IgG, IgM, direct fluorescent testing (DFA), enzyme immunoassay (EIA), or polymerase chain reaction (PCR) Appendix. Potential cases of CMV infection or disease were defined as pregnant women with an ICD-9-CM code for CMV disease (078.5); cases of infectious mononucleosis were defined as pregnant women with an ICD-9-CM code for mononucleosis (075). Since mononucleosis is a potential symptom and possible indication of maternal CMV infection , we examined rates of pregnant women with a diagnostic code for mononucleosis. Although infectious mononucleosis is a clinical syndrome commonly associated with primary Epstein-Barr virus infection during or after second decade of life , adults with primary CMV infection may also develop mononucleosis-like syndromes . Evidence of laboratory confirmation of CMV infection was not included in the CMV case definition because laboratory testing results were not available in the MarketScan database. We defined urban residence based on an enrollee’s Metropolitan Statistical Area (MSA) status.
We computed frequencies of pregnant women with a code for CMV disease and CMV-specific testing to evaluate whether a pregnant woman had a diagnostic code for CMV disease based on clinical assessment alone, or also in combination with laboratory testing. We performed Pearson Chi Square or Fisher’s exact test to examine whether there was an association between CMV-specific testing and age, region, residence in an urban area, and diagnosis of infectious mononucleosis. Variables with a p-value <0.05 were considered significant. The data were analyzed using SAS (version 9.2; SAS Institute Inc, Cary, NC).
To better understand the possible sensitivity of the 2009 MarketScan Commercial databases for detecting claims for CMV-specific laboratory testing, we calculated frequencies of pregnant women with ≥1 codes for other laboratory tests that are recommended by the American College of Obstetricians and Gynecologists to be routinely performed during pregnancy . These sub-groups included pregnant women who had claims for rubella, anemia, urine, glucose, syphilis, hepatitis B, chlamydia, and HIV testing Appendix. Among these women, we also calculated the frequency of pregnant women with a code for CMV-specific testing.
Characteristics of pregnant women a and pregnant women a with a diagnostic code for CMV, MarketScan 2009
Pregnant womenawith an ICD-9-CM diagnostic code for CMV disease
Age Group (years)
Diagnostic Code for Infectious Mononucleosis c
Type of CMV testing and timing of CMV testing among pregnant women a and among pregnant women a with a diagnostic code for CMV, MarketScan 2009
Pregnant womenawith CMV-specific testingb
Pregnant womenawith an ICD-9-CM diagnostic code for CMV disease and CMV-specific testingb
Type of CMV-specific Test b
CMV PCR ONLY
CMV DFA ONLY
CMV Serology ONLY (CMV IgG, IgM, and EIA)
CMV PCR AND CMV Serology
CMV PCR AND Non-Specific Culture or PCR
CMV PCR, CMV Serology, AND Non-specific Culture or PCR
CMV DFA, CMV Serology, AND Non-Specific Culture or PCR
CMV Serology AND Non-specific Culture or PCR
Gestational Age when CMV-Specific Testing Conducted c
Association between CMV-specific testing a by selected factors, pregnant women b , MarketScan 2009
Age Group (years)
Diagnostic Code for Infectious Mononucleosis d
Rates of routinely recommended laboratory tests for pregnant women a , and rates of CMV-specific testing among pregnant women a with claims for routinely recommended laboratory tests, MarketScan, 2009
Routinely recommended laboratory tests for pregnant womena
Pregnant womenawith CMV-specific testingb
Hepatitis B testing
We identified 12 (0.02%) pregnant women with an ICD-9-CM code for CMV disease among the 77,773 pregnant women. Four (33%) were aged 20–29 years and 8 (67%) were aged 30–39 years [Table 1]. Ten (80%) had a code for CMV-specific testing performed during pregnancy, with half tested in the 1st trimester [Table 2]. None of the pregnant women with an ICD-9-CM code for CMV had a diagnostic code for mononucleosis.
This is the first study to examine rates of prenatal CMV testing in the United States using national healthcare claims data. We found that the rate of claims for CMV testing among privately-insured pregnant women in 2009 was low (2%), which suggests that screening for CMV infection during pregnancy is not commonly performed. This finding is consistent with self-reported data from physicians in which only 1-2% reported routinely screening their pregnant patients for CMV infection [13, 25]. Among those who reported ever testing for CMV during pregnancy, testing usually occurred in response to detection of a fetal abnormality or patient request for testing . We did not expect to find evidence of widespread prenatal screening for CMV infection in the United States as there are no recommendations for it at this time from professional associations such as the American College of Obstetricians and Gynecologists [11, 24]. In some European countries and in Israel, prenatal testing for CMV is more widely performed, even in the absence of recommendations for routine screening [26, 27]. We found higher rates of testing among patients in our study population with a diagnosis of mononucleosis, a symptom potentially attributable to CMV infection, but the rate of testing for CMV was only 14% even in this high-risk group. Although CMV infection is often asymptomatic, CMV infection should be considered as part of the differential diagnosis in pregnant women who present with mononucleosis-like symptoms [13, 22]. Understanding current obstetric CMV testing practices is important for identifying baseline testing practices, and, in the future, for monitoring implementation of screening and prevention programs as recommendations evolve.
Routine prenatal screening for CMV remains controversial and has not been endorsed by any professional organization or public health authority worldwide [11, 12, 27]. Data on the effectiveness of treatments for primary CMV infection in pregnancy are limited [4, 20], although results from initial studies of treatment with CMV-specific hyperimmune globulin were promising . In a study performed in Italy, they found that only 1 out of 31 pregnant women (3%) with primary CMV infection who received hyperimmune globulin gave birth to an infant with CMV disease, compared to 7 out of 14 pregnant women (50%) with primary CMV infection who did not receive hyperimmune globulin . However, this was not a randomized controlled study and the efficacy of treatment with hyperimmune globulin could not be properly assessed. Data from randomized clinical trials in Europe and the United States could provide evidence needed for treatment of primary CMV infection with hyperimmune globulin [18–20]. Given the limited experience with CMV IgG avidity testing in clinical settings in the United States, algorithms for CMV counseling and screening, and effective treatment options, would need to be evaluated before routine prenatal screening for primary CMV infection could be recommended.
Another prenatal approach for prevention of congenital CMV is counseling of women to avoid exposures to CMV during pregnancy for all pregnant women, regardless of their CMV serostatus. The American College of Obstetricians and Gynecologists recommends counseling pregnant patients about thorough hand-washing when around young children to reduce CMV transmission . Some data suggest that pregnant women are more likely to adopt and maintain practices to reduce household exposure to CMV if they are aware of their CMV seronegative status . Routine determination of CMV serostatus before or early in pregnancy may enhance patient education efforts directed at reducing exposure to CMV during pregnancy to prevent maternal infection and subsequent vertical transmission. Data from a large prospective study in France reported that seroconversion rates in pregnant women told of their CMV seronegative status and counseled to adopt behavioral measures to reduce CMV exposure were 0.2%, significantly lower than estimated pre-intervention seroconversion rates in the study and expected rates for this population [28, 29]. However, adherence to recommended preventative measures was not monitored and the study did not use a randomized design because the investigators deemed it unethical. Results of a survey of obstetricians and gynecologists in 2007 found fewer than half reported counseling their patients about preventing CMV infection . Fuller implementation of recommendations for routine counseling and the addition of screening for CMV serostatus during pregnancy as part of risk reduction counseling in the United States would require provider education. In addition, careful consideration of the timing and reporting of such testing, as well as wider availability of CMV IgG avidity testing and standardization of commercial assays  would be required such that pregnant women identified as seropositive could be managed with additional diagnostic testing as appropriate.
There are a number of limitations to this study based on medical claims reported for insurance reimbursement purposes. We did not have access to laboratory results and it is not possible to link MarketScan claims data with medical records to validate our ascertainment of CMV testing. There is no CPT code for CMV IgG avidity testing and therefore we were unable to determine rates of IgG avidity testing. Claims data may underestimate laboratory tests that were performed if the provider failed to bill for the testing or it was not reimbursed by the enrollee’s insurance plan. Rates of CMV testing may be further underestimated in claims data if providers bill for CMV testing as part of a bundled claim for comprehensive prenatal care services under global billing rather than with a CMV-specific code. It seems unlikely however that CMV testing rates among pregnant women are much higher than those we report as we did not find substantially higher testing rates even among pregnant women for whom claims for other routine laboratory tests recommended during pregnancy were captured in the MarketScan Commercial database. It is unclear why rates of prenatal care for this privately insured population were lower than expected, especially for some routinely recommended tests such as anemia, hepatitis B, and rubella testing. Administrative claims data may not fully capture all prenatal care services, and this may be partially due to global billing. The MarketScan population is not representative of the national population since the data represents a large convenient sample primarily of individuals with private employer insurance, which accounts for 56% of the US population in 2009 . People with employer-sponsored insurance are less likely to be low-income or non-white than are uninsured or publicly-insured people . Separate MarketScan databases exist with healthcare claims data for the Medicaid population and it would be useful to examine CMV testing rates in the population with publicly-financed health insurance.
This study serves as a baseline for understanding clinical awareness of and prenatal testing practices for CMV in the United States. Based on assignment of an ICD-9-CM code for CMV disease, we estimate the rate of CMV diagnosis during pregnancy in this population to be 0.02%. While 1-7% of susceptible pregnant women are estimated to develop CMV infection during pregnancy in the United States [6, 29], there are limited data on the proportion of these infections that are symptomatic, lead to a medical visit, or result in diagnosis. Future studies may want to examine pregnant women with ultrasound results showing fetal abnormalities and the rates of maternal and fetal CMV testing among this group. The problem of maternal CMV infection during pregnancy and subsequent vertical transmission that results in neurologic impairments and hearing loss among children remains silent, despite its substantial public health burden . There is currently no national surveillance for CMV infection or disease among pregnant women or infants and children. Healthcare claims and other administrative databases can be used to monitor uptake of medical services [33, 34]. Use of these types of data are advantageous since the information is computerized and are available for large patient populations. As options for CMV prevention, diagnosis and treatment during pregnancy expand, there will be a growing need to monitor prenatal testing practices.
List of international classification of diseases, 9th revision, clinical modification (ICD-9-CM) and current procedural terminology (CPT) codes
CMV Laboratory Testing
CMV Antibody Testing
CMV Direct fluorescent antibody (DFA) Testing
CMV enzyme immunoassay
CMV Infectious agent detection by nucleic acid (DNA or RNA)
CPT 87252, 87254
Non-specific virus isolation by culture
CPT 83890–1, 83898, 83900–2, 83904–9, 83912, 87800-1
Non-specific molecular diagnostics or infectious agent detection (DNA or RNA)
Premature rupture of membranes or delayed delivery after spontaneous, unspecified, or artificial rupture of membranes
Other indications for care or intervention related to labor and delivery, not elsewhere classified
Complications of labor and delivery
Complications of Puerperium (period right after delivery)
Postpartum care and examination, immediately after delivery
Outcome of delivery
ICD-9-CM 69.02, 69.52
Dilation and curettage or aspiration curettage of uterus, following delivery or abortion
CPT 01958, 01960–2, 01967-9
Anesthesia for delivery
Insertion cervical dilator
Episiotomy or vaginal repair
CPT 59510, 59514
CPT 59610, 59612, 59618, 59620
Delivery after previous cesarean delivery
Complications of pregnancy
Supervision high-risk pregnancy
Pregnancy examination or test, positive result
Other intrauterine operations on fetus and amnion
Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery
Unlisted fetal invasive procedure, including ultrasound guidance
Ultrasound guidance for fetal transfusion or cordocentesis
Ultrasound guidance for chorionic villus sampling
Ultrasound guidance for amniocentesis
Amniotic fluid scan (spectrophotometric)
CPT 83030, 83033
Human placental lactogen
Fetal lung maturity assessment
Pregnancy-associated plasma protein-A
Human chorionic gonadotropin
Hemoglobin or rbcs, fetal, for fetomaternal hemorrhage
Tissue culture of amniotic fluid or chorionic villus cells
Chromosome analysis using amniotic fluid or chorionic villus cells
In situ chromosome analysis for amniotic fluid cells
CPT 59400, 59425, 59426, 59510, 59610
Global billing code for routine prenatal obstetric care
CMV Diagnosis and CMV-Related Symptoms
Routinely Recommended Laboratory Tests
CPT 82947–8, 82950–2, 83036-7
CPT 81007, 81020, 87086, 87088, 87070–1, 87073, P7001
CPT 86592–3, 80055, 86781
CPT 3513F, 80074, 86704, 86706, 87340, 87341
Hepatitis B Test
CPT 3511F, 86631, 86632, 87110, 87270, 87320, 87485, 87486, 87487, 87490, 87491, 87492, 87810; ICD-9 V739
CPT 86689, 86701, 86702, 86703, 87390, 87391, 87534, 87535, 87536, 87537, 87538, 87539, G0432, G0433, G0435
CPT 85013–4, 85018
Anemia: Blood count with hematocrit, Blood count with hemoglobin
International Classification of Diseases, 9th revision, Clinical Modification
Current Procedural Terminology
Polymerase chain reaction
Direct fluorescent antibody
We would like to thank Andreea Creanga and Carrie Shapiro-Mendoza for their technical assistance and input on designing the study.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention, US Department of Health and Human Services.
There were no sources of financial support.
- Dollard SC, Grosse SD, Ross DS: New estimates of the prevalence of neurological and sensory sequelae and mortality associated with congenital cytomegalovirus infection. Rev Med Virol. 2007, 17 (5): 355-363. 10.1002/rmv.544.View ArticlePubMedGoogle Scholar
- Kenneson A, Cannon MJ: Review and meta-analysis of the epidemiology of congenital cytomegalovirus (CMV) infection. Rev Med Virol. 2007, 17 (4): 253-276. 10.1002/rmv.535.View ArticlePubMedGoogle Scholar
- Enders G, Daiminger A, Bader U, Exler S, Enders M: Intrauterine transmission and clinical outcome of 248 pregnancies with primary cytomegalovirus infection in relation to gestational age. J Clin Virol. 2011, 52 (3): 244-246. 10.1016/j.jcv.2011.07.005.View ArticlePubMedGoogle Scholar
- Yinon Y, Farine D, Yudin MH: Screening, diagnosis, and management of cytomegalovirus infection in pregnancy. Obstet Gynecol Surv. 2010, 65 (11): 736-743. 10.1097/OGX.0b013e31821102b4.View ArticlePubMedGoogle Scholar
- Bate SL, Dollard SC, Cannon MJ: Cytomegalovirus seroprevalence in the United States: the national health and nutrition examination surveys, 1988–2004. Clin Infect Dis. 2010, 50 (11): 1439-1447. 10.1086/652438.View ArticlePubMedGoogle Scholar
- Colugnati FA, Staras SA, Dollard SC, Cannon MJ: Incidence of cytomegalovirus infection among the general population and pregnant women in the United States. BMC Infect Dis. 2007, 7: 71-10.1186/1471-2334-7-71.View ArticlePubMedPubMed CentralGoogle Scholar
- Nigro G, Adler SP: Cytomegalovirus infections during pregnancy. Curr Opin Obstet Gynecol. 2011, 23 (2): 123-128. 10.1097/GCO.0b013e328342f1f6.View ArticlePubMedGoogle Scholar
- Stagno S, Britt W: Cytomegalovirus. Infectious Disease of the Fetus and Newborn Infant. Edited by: Remington JS, Kelin JO, Wilson CB, Baker CJ. 2006, Philadelphia, PA: Wb Saunders Co, 739-781.View ArticleGoogle Scholar
- Maine GT, Lazzarotto T, Landini MP: New developments in the diagnosis of maternal and congenital CMV infection. Expert Rev Mol Diagn. 2001, 1 (1): 19-29. 10.1586/1473718.104.22.168.View ArticlePubMedGoogle Scholar
- Dollard SC, Staras SA, Amin MM, Schmid DS, Cannon MJ: National prevalence estimates for cytomegalovirus IgM and IgG avidity and association between high IgM antibody titer and low IgG avidity. Clin Vaccine Immunol. 2011, 18 (11): 1895-1899. 10.1128/CVI.05228-11.View ArticlePubMedPubMed CentralGoogle Scholar
- ACOG: Perinatal viral and parasitic infections. ACOG practice bulletin. 2000, 20: 1-13.Google Scholar
- Yinon Y, Farine D, Yudin MH, Gagnon R, Hudon L, Basso M, Bos H, Delisle MF, Menticoglou S, Mundle W, et al: Cytomegalovirus infection in pregnancy. J Obstet Gynaecol Can. 2010, 32 (4): 348-354.View ArticlePubMedGoogle Scholar
- Center for Disease Control and Prevention (CDC): Knowledge and practices of obstetricians and gynecologists regarding cytomegalovirus infection during pregnancy--United States, 2007. MMWR Morb Mortal Wkly Rep. 2008, 57 (3): 65-68.Google Scholar
- Jeon J, Victor M, Adler SP, Arwady A, Demmler G, Fowler K, Goldfarb J, Keyserling H, Massoudi M, Richards K, et al: Knowledge and awareness of congenital cytomegalovirus among women. Infect Dis Obstet Gynecol. 2006, 2006: 80383-View ArticlePubMedPubMed CentralGoogle Scholar
- Korver AMH, de Vries JJC, de Jong JW, Dekker FW, Vossen ACTM, Oudesluys-Murphy AM: Awareness of congenital cytomegalovirus among doctors in the Netherlands. J Clin Virol. 2009, 46 (Suppl 4): S11-S15.View ArticlePubMedGoogle Scholar
- Ross DS, Victor M, Sumartojo E, Cannon MJ: Women's knowledge of congenital cytomegalovirus: results from the 2005 HealthStyles TM survey. Journal of Womens Health. 2008, 17 (5): 849-858. 10.1089/jwh.2007.0523.View ArticleGoogle Scholar
- Nigro G, Adler SP, La Torre R, Best AM, Congenital Cytomegalovirus Collaborating Group: Passive immunization during pregnancy for congenital cytomegalovirus infection. N Engl J Med. 2005, 353 (13): 1350-1362. 10.1056/NEJMoa043337.View ArticlePubMedGoogle Scholar
- Revello MG, IRCCS Policlinico S Matteo: Efficacy Study of Human Cytomegalovirus (HCMV) Hyperimmune Globulin to Prevent Congenital HCMV Infection (CHIP). http://clinicaltrials.gov/ct2/show/record/NCT00881517,
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD): A Randomized Trial to Prevent Congenital Cytomegalovirus (CMV). http://clinicaltrials.gov/ct2/show/NCT01376778,
- Lazzarotto T, Guerra B, Gabrielli L, Lanari M, Landini MP: Update on the prevention, diagnosis and management of cytomegalovirus infection during pregnancy. Clin Microbiol Infect. 2011, 17 (9): 1285-1293.View ArticlePubMedGoogle Scholar
- Thomson Reuters [Healthcare] Inc: MarketScan Databases User Guide and Database Dictionary. 2009, Ann Arbor, MI: Thomson Reuters [Healthcare] IncGoogle Scholar
- Luzuriaga K, Sullivan JL: Infectious mononucleosis. N Engl J Med. 2010, 362 (21): 1993-2000. 10.1056/NEJMcp1001116.View ArticlePubMedGoogle Scholar
- Rodriguez-Bano J, Muniain MA, Borobio MV, Corral JL, Ramirez E, Perea EJ, Perez-Cano R: Cytomegalovirus mononucleosis as a cause of prolonged fever and prominent weight loss in immunocompetent adults. Clin Microbiol Infect. 2004, 10 (5): 468-470. 10.1111/j.1469-0691.2004.00880.x.View ArticlePubMedGoogle Scholar
- Routine Tests in Pregnancy [Educational Pamphlet AP133]. http://www.acog.org/publications/patient_education/bp133.cfm,
- Cahill A, Odibo A, Macones G: 649: Screening and treating for prevention of congenital cytomegalovirus: what are we doing? [abstract]. Am J Obstet Gynecol. 2009, 201 (6): S236-View ArticleGoogle Scholar
- Revello MG, Fabbri E, Furione M, Zavattoni M, Lilleri D, Tassis B, Quarenghi A, Cena C, Arossa A, Montanari L, et al: Role of prenatal diagnosis and counseling in the management of 735 pregnancies complicated by primary human cytomegalovirus infection: a 20-year experience. J Clin Virol. 2011, 50 (4): 303-307. 10.1016/j.jcv.2010.12.012.View ArticlePubMedGoogle Scholar
- Schlesinger Y: Routine screening for CMV in pregnancy: opening the pandora box?. Israel Medical Association Journal. 2007, 9 (5): 395-397.PubMedGoogle Scholar
- Vauloup-Fellous C, Picone O, Cordier AG, Parent-du-Chatelet I, Senat MV, Frydman R, Grangeot-Keros L: Does hygiene counseling have an impact on the rate of CMV primary infection during pregnancy? Results of a 3-year prospective study in a French hospital. J Clin Virol. 2009, 46: S49-S53.View ArticlePubMedGoogle Scholar
- Hyde TB, Schmid DS, Cannon MJ: Cytomegalovirus seroconversion rates and risk factors: implications for congenital CMV. Rev Med Virol. 2010, 20 (5): 311-326. 10.1002/rmv.659.View ArticlePubMedGoogle Scholar
- Income, Poverty, and Health Insurance Coverage in the United States. 2009, http://www.census.gov/prod/2010pubs/p60-238.pdf,
- Buchmueller TC, Monheit AC: Employer-sponsored health insurance and the promise of health insurance reform. Inquiry. 2009, 46 (2): 187-202. 10.5034/inquiryjrnl_46.02.187.PubMedGoogle Scholar
- Cannon MJ: Congenital cytomegalovirus (CMV) epidemiology and awareness. J Clin Virol. 2009, 46: S6-S10.View ArticlePubMedGoogle Scholar
- Feig DS, Razzaq A, Sykora K, Hux JE, Anderson GM: Trends in deliveries, prenatal care, and obstetrical complications in women with pregestational diabetes: a population-based study in Ontario, Canada, 1996–2001. Diabetes Care. 2006, 29 (2): 232-235. 10.2337/diacare.29.02.06.dc05-1482.View ArticlePubMedGoogle Scholar
- Tao G, Patterson E, Lee LM, Sansom S, Teran S, Irwin KL: Estimating prenatal syphilis and HIV screening rates for commercially insured women. Am J Prev Med. 2005, 28 (2): 175-181. 10.1016/j.amepre.2004.09.001.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/12/334/prepub
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