The Case for Routine Screening of Cytomegalovirus before Pregnancy: Counseling with Wisdom in the Face of Uncertainty

This issue of the Israel Medical Association Journal contains the debate between two prominent and experienced infectious disease consultants (Drs. Rahav and Schlesinger) and an additional review with opinions by an outstanding teratologist (Prof. Ornoy) on the controversial issue of routine testing for congenitally acquired cytomegalovirus infection. No country has officially embraced such a policy; in fact, the Health Ministry recommended several years ago that no routine testing be performed for CMV during pregnancy, unless clinically indicated. Nonetheless, many Israeli gynecologists routinely determine immunoglobulin G and M levels in pregnant women, the results of which are often difficult to interpret. These, in turn, lead to referral to infectious disease consultants and teratologists, second (and third) opinions, great anxiety for the involved couples (and some for the consulting physicians too), and painful interventions, ranging from amniocentesis to interruption of pregnancy, of which a certain percentage by definition must be unnecessary. The authors of the pro-routine and against-routine testing have made excellent arguments for their respective positions, while the reviewing teratologist has refrained from making definite recom mendations on the issue. This quandary reflects the complexity of the issue: the inherent psychological and social sensitivity of pregnancy, the fear of a couple having a congenitally deformed child, and the doctor’s fear of malpractice litigation. Although much data are available, the answers to many issues remain undetermined, all elegantly presented by the three authors. Practicing medicine more often than not involves living and deciding in the face of uncertainty. The case of congenital CMV is therefore not unusual, although it catches the physician and the pregnant couple at a most sensitive juncture. As guidelines are currently lacking, a strong argument should be made for