S5903 CMV Infection During Pregnancy in a Recent Liver Transplant Recipient: A Case Report

Introduction: Cytomegalovirus (CMV) is one of the most common infectious complications in liver transplantation (LT) recipients, with the highest risk being within the first 3 months following transplantation. Prophylaxis to prevent CMV is often administered to patients in the 3–6-month post-LT period, especially in high-risk patients. Given the immunocompromised state and frequent medication adjustments, LT recipients are usually recommended to wait up to 1-year after LT before attempting a pregnancy. This case features a patient presenting with CMV viremia during the 1st trimester of pregnancy only 9 months following LT. Case Description/Methods: A 31-year-old woman with a previous medical history of alcohol-related liver disease initially presented to our center in April 2024 for emergent LT (CMV D+/R, EBV D+/R+). Following LT, the immunosuppressive regimen consisted of mycophenolate mofetil, tacrolimus, as well as TMP-SMX and valganciclovir (VGV) for prophylaxis. VGV was continued for 6 months following LT given the CMV+ donor liver. Two months following cessation of VGV, patient was found to be pregnant and subsequently presented to our center with elevated aspartate aminotransferase/alanine aminotransferase of 62/87 and Alk Phos of 51 and concern for CMV viremia at 13 weeks of pregnancy. Workup was notable for a CMV viral load of 3,410 and no acute abnormalities of the allograft observed on ultrasound. Obstetric ultrasound revealed a live intrauterine pregnancy, with no gross anatomic anomalies of the fetus. Following a risk/benefit discussion, the decision was made to continue with pregnancy and initiate treatment for CMV with intravenous ganciclovir to protect against liver graft failure and fetal complications. While initial viremia clearance was achieved in 1-month, subsequent rebound viremia and concern for under size fetus and bilateral ventriculomegaly resulted in CMV-IVIG and VGV treatment planned for the duration of the pregnancy. Discussion: CMV infection following LT remains a major cause contributing to morbidity and mortality in the LT recipient population, with infection occurring during pregnancy elevating the risks further. Given the immunocompromised state of the transplant population and use of teratogenic medications to help prevent liver rejection and acute infections, pregnancies need to be carefully planned so as to minimize harm to both fetus and mother. This case highlights a rare occurrence of CMV infection during pregnancy following LT and highlights the importance of thorough birth control counseling and monitoring in women of child-bearing age.