Assessing the risk factors for cytomegalovirus and prediction the relationship between abortion and virus in Kirkuk City Hospitals

Background: Cytomegalovirus belongs to the Herpesviridae family of subfamily Betahrpesvirnae. CMV is one of the major causes of perinatal and congenital viral infection. Also can cause spontaneous abortion in pregnant women in the first trimester of gestation. Objective: To identify the relationship between CMV and women’s demographic variables of age, parity, occupation, residence and socioeconomic status etc. To determine the prevalence rate of CMV in aborted women in the 1st trimester. To assess the relationship between abortion and CMV. To determine anti CMV IgM and IgG in women after abortion. To find out the consequences of risk factorsof CMV on fetus and maternal. Methodology: A descriptive correlational design was used in this study. Data were collected from three maternity hospitals in Kirkuk city. A convenience sample of (100) aborted women in the first trimester of gestation were selected in this study, who were admitted in maternity hospitals. A questionnaire designed about assess the risk factors for cytomegalovirus and prediction the relationship between abortion and virus. Assessment tool was constructed by the researcher after extensive review of previous studies and relevant literature. The study instrument consists of two main parts; part one was Demographic data for. And the part two include (Test result and Risk factors for cytomegalovirus on pregnant women). The data were described statistically and analyzed through the use of descriptive and inferential statistical analysis procedures Results: The prevalence rate of CMV IgG seropositivity was reported (37%), while the prevalence rate of CMV


Introduction
Cytomegalovirus (CMV) belongs to the Herpesviridae family of subfamily Betahrpesvirnae. It is also called Human Herpes Viruses type 5 (HHV-5) according to (ICD) International Classification of Diseases. Cytomegalovirus can maintain hidden inside the body for a long time. Cytomegalovirus energizing is associated with hormonal changes and immunosuppression (Andrievskaya et al., 2015). Human Cytomegalovirus (HCMV) causes the first typical infection of the Betaherpesvirinae subfamily (Yeroh et al., 2015). CMV similar to all of the other herpes viruses founds hiding inside the human host. Primary HCMVI results in a latent or persistent contagious that can be found within endothelial cells, different tissues, and (PBMCs) peripheral blood mononuclear cells. The majority of babies would have a subclinical infection (O'Connor & Murphy, 2012). Reactivation of hidden cytomegalovirus outcomes in at least negative results as initial infections. Placenta infection with the movement of trans-placenta of cytomegalovirus across the interface of materno-fetal and is a pre-requisite to infection the fetus. While CMV infection also can be limited to the placenta and there is rising guide that indirect impacts cytomegalovirus infection of placenta contributes to negative pregnancy result (Hamilton et al., 2012). At first cytomegalovirus infection occurs in the seronegative defenseless host and the frequent exposure reasons reactivation of inactive (contamination or re-infection) in a seropositive in immune host Seropositive of recurrence cytomegalovirus was higher among people with lower socioeconomic status (Almusaw, 2018). The CMV may result from primary or recurrence cytomegalovirus illness.
While the recurrence cytomegalovirus is the most common cause for an extreme disease which increases with age and higher in the developed countries among lower financial strata (Hamid et al.,2014;Schoenfisch et al., 2011). The involuntary loss of pregnancy from conception to twenty-four weeks of pregnancy is called a miscarriage. Cytomegalovirus is caused by spontaneous abortion in more than 70% of abortion fettles (Jihad et al., 2015). The clinical manifestations range of cytomegalovirus from asymptomatic about (90%) of cases to more severe fetal damage and in uncommon cases, CMV causes death due to abortion. CMV can be lifethreatening of all persons suffering from immunecompromised such as organ transplant recipients, newborn infants, and Human Immune Virus-infected persons (Zhou et al., 2015). CMV can be done in several methods: directly from ascending CMVI or by direct contact the newborn baby during labor with the infected mucus of cervical and by infected tissue of a placenta. Transmission of contagion is possible after delivery through breastfeeding of the baby or by contacting the secretions of the mother's body containing cytomegalovirus. The infections of CMV are not high. CMV predisposition in households and its spread among young children in the centers of daycare. The susceptibility rate of cytomegalovirus during childbearing age is well established. Among pregnant women between 40-80 % will be cytomegalovirus susceptible at the beginning of childbearing age. The susceptibility rate of CMV differs by racial or ethnic, age groups, and socioeconomic status (Gao et al., 2018;Revello et al., 2015). Intracellular continuous contributes to the virus to the long hiding of infection. The location of the intracellular protects the CMV from the act of determining antibodies. The changes in the humoral immunity combination with childbearing age depending on the repetition of CMVI and gestational age (Andrievskaya et al., 2015). The congenital of CMVI appear as a non-primary infection, primary infection with CMV a new strain, or reactivation of a hidden infection (Gaur et al., 2020). The infection of fetal and risk of associated harms is higher after the initial infection. The fetal contiguous risk is greatest with maternal initial CMVI and much less with frequent infection as the CMV stays hidden after primary infection in the host cell. CMV perhaps shed in the fluids of the body in any person infected with this virus CMV can be found in breast milk, saliva, tears, and semen (Abdul Wahab et al., 2012). During childbearing age at any time, nonprimary or primary contagious of maternal (including reinfection or reactivation with a various cytomegalovirus strain) CMV can cross the placenta and cause infecting the fetal that leading to congenital cytomegalovirus infection. In the USA, approximately 1 quarter of congenital CMVIs was ascribable to primary contiguous of maternal and 3 quarter were ascribable to nonprimary contiguous of maternal (Wang et al., 2011). Also, the initial infection shows to be more probable to reason symptoms at birth and long-term inability than non-primary infection of maternal. Berger et al. reported 2 cases of an acute initial CMVI with no symptoms of the disease that was found in the child and mother and a frequent CMVI that perform to encephalitis cytomegalovirus necrotizing in the fetus (Berger et al.,2011). During primary maternal cytomegalovirus occurs increment in placental volume because enlarges in placental vasculature to compensate the fetus. The beneficial effect of antibodies perhaps mediated through the enhanced function of the placenta and improved nutrition and supplies oxygen to the fetus. Thus, it has been lately hyperimmunoglobulin therapy observed for CMVI is help to reduce the size and fetal ultrasound abnormality and inflammation of the placenta (Akunaeziri, 2018).

Objectives of Study
-To identify the relationship between CMV and women's demographic variables of age, parity, occupation, residence and socioeconomic status etc.
-To determine the prevalence rate of CMV in aborted women in the 1 st trimester.
-To assess the relationship between abortion and CMV -To determine anti CMV IgM and IgG in women after abortion -To find out the consequences of risk factors of CMV on fetus and maternal.

Study design and setting
A design of this study was descriptive correlational study conducted for aborted women whom pregnant loss.

RESULTS
This chapter presents the findings of the data analysis systematically in tables and these correspond with the objectives of the study as follows:

Knowledge Items about the Risk Factors Sample Responses No
Yes Not sure

Residency:
The majority of subject reported that they live in urban areas (64%), these result is consistent approximately with Alghalibi et al., (2016) who stated of their study sample that they live in urban areas was (71,1%).

Level of Education:
Concerning the level of education; were preliminarily graduated and college graduated (22%) are more than other levels. This finding is higher than that obtained by Ali, (2020) who reported that the level of education Primary school level was (12.5 %). Aljumaili et al., (2014)  House Property: About (43%) to whom have own house at house property this result is inconsistent with Demmler (1991) who stated in his study the high rate of house property was rent house.

Consanguinity:
Consanguineous degree made about two thirds (60%) of the study sample, while the 2nd degree of consanguinity is a greater percentage (42%) more than 1st degree. This result is higher than that reported by Karatas et al., (2008) was18% Consanguineous. Regarding the Regularity of the Menstrual Cycle, regular cycle period was (59%) are more than irregular.

Distribution of the Reproductive Data Characteristics of the Study Sample
These studies were inconsistent with Mostad et al., (2000) who reported in his study irregular menstrual cycle.

 Age at Married
A higher percentage of the sample (74%) was their age of marriage at 16-26 years, Mean + S.D. (1.76 + .452), according to the study of Iraqi CSO (2011) recommended that the mean age for marriage was 22 years old.

 Age at 1st pregnancy
The Mean + S.D. of the sample their age at 1st pregnancy is (1.52 + .559). About half of the sample (51%) of their age at 1st pregnancy is between (16-22) years, according to the study of Iraqi CSO (2011) reported that only (14.3%) was starting their reproductive life at (15-19) years old.

 Interval between last pregnancy & this Pregnancy
According to the period of interval between last pregnancy and present pregnancy, who have less than one year are (38%) more than others, according to the study of Iraqi CSO (2011) reported that 25% of women need for family planning for regulating the intervals between pregnancies for two years and more.

 Follow-up pregnancy in Health Center
The sample that not attending the health center is (73%) more than those attending, so the percentage is the same in the type of follow-up to the health center (no follow-up) and only (27%) follow-up pregnancy in the health center. These studies were consistent with Willame et al., (2015) who reported only (10.5%) follow-up pregnancy in the health center.

 Follow-up pregnancy in External Specialist Clinic
The sample that attending the external specialist clinic is (60%) more than who attending and the percentage is (34%) of them have irregular follow-up based on the type of follow-up to an external specialist clinic, these studies consist with Willame et al., (2015) who reported (78.6%) follow-up pregnancy in external specialist clinic.

 Current Abortion
Regarding the current abortion in weeks, more than a third sample size (36%) are between (10-15) weeks. These studies are consistent with Bonalumi et al., (2011) who reported the higher prevalence of current abortion in weeks from (12-16) weeks.

 Causes of Abortion
Approximately (71%) of these study samples are diagnosed. A higher percentage (38%) of these causes is CMV and (28%) are unknown causes. This result is less than the result that reported with Hussan (2013) was (56%) of aborted women with unknown causes of abortion and reported CMV IgM (21%), (29 IgG) causes of abortion.

 Last Age of Pregnancy in Weeks
According to the last age of the pregnancy, less than 20 weeks made near half of the sample (41%). weeks. This study is less than reported with Pass & Arav-Boger (2018) who reported the higher prevalence of the last age of a pregnancy from (20-21) weeks. the same number (1-2) makes (48%) according to the number of para, these study consistent with Lee et al., (2020) who reported the number of para (1) makes (47.7%) and reported (39.0%) in his study when the number of para. (2).

 Number of Abortions
While regarding the number of abortions, (67%) of the sample who have one abortion, these studies higher than reported by Umeh et al., (2015) who reported the number of abortions when (one) abortion makes (54%).

 Number of Stillbirths
According to the number of stillbirths, higher percentage (88%) is who have no stillbirth, these study consistent with Alvarado-Esquivel et al., (2018) Who reported (89.3%) have no stillbirth.

Type of Previous Deliveries
The type of previous deliveries, NVD made (58%) of sample is higher than other types, these studies consistent with Marin et al., (2016) who reported (56 %) NVD.

Distribution the Women's Knowledge Responses Regarding to All Items about the Risk Factors. Table (4-3):
In the table of the women's knowledge  responses regarding all items about the risk factors discussion the women smoking cigarettes less than 20 cigarettes per day is only 1%, and more than 20 cigarettes per day are also 1%. These results supported by Hussain & Sullivan (2017)  . It was concluded that socio-economic status of the tested women has no significant effects on the rates of anti-CMV IgG and IgM seropositive results.

Recommendations
There is need to increase public awareness about cytomegalovirus and their effect on maternal and fetal as well as it correlation with history abortion and congenital cytomegalovirus infection. Encourage the women to attained regular antenatal visit to conduct Routine screening of CMV IgM and CMV IgG. And any women with a history of abortion must be investigated before and after pregnancy. Educational program about risk factor and consequences of cytomegalovirus and Educational program about practice good personal hygiene to reduce the risk of congenital CMV infection and transmission, especially hand washing after hand ling diapers or oral secretions shout be conducting on nurses in maternity ward to give care to cases with cytomegalovirus.
Adoption of psychological support program to pregnant women or aborted women with cytomegalovirus. Women were more frequently aware of CMV if they were followed by an obstetrician than by a midwife or a general practitioner. Although most women were followed by an obstetrician, theinformation rate remained low. It is crucial to improve CMV information to pregnant women from the 1st trimester in order to prevent the risks for the fetus/newborn.