Seroprevalence of human cytomegalovirus among pregnant women who had undergone abortion(s) attending El-Damazin Hospital for Obstetrics and Gynecology, Sudan: A

Human cytomegalovirus (HCMV) is a major cause of Background: congenital infections. It is more widespread in developing countries and communities with low socioeconomic status. The infection can cause pregnancy loss or spontaneous abortion. Tests are available for the detection of HCMV IgG and IgM antibodies. Many pregnant women in Blue Nile State, Sudan, have suffered from recurrent pregnancy loss, and currently there is no available data concerning the prevalence of HCMV in Blue Nile state. This study aimed to determine HCMV antibodies (IgG and IgM) among pregnant women, who had undergone abortion(s), attending El-Damazin Hospital for Obstetrics and Gynecology. This was a descriptive, cross-sectional hospital-based study. Methods: 270 pregnant women, who had undergone abortion(s) and who attended El-Damazin Hospital for Obstetrics and Gynecology, were included in the study from September to December 2018. Personal and clinical data were collected directly from each participant into a predesigned questionnaire. Serum samples were separated and stored at -20 ̊C until used. Samples were analyzed for HCMV IgG and IgM using enzyme-linked immune-sorbent assay (ELISA). Participants were categorized into three age groups: 15-25 years Results: (33.7%; 91/270); 26-40 years (62.2%; 168/270); and >41 years (4.1%; 11/270). The majority of the participants had IgG antibodies to HCMV (74.8%; 202/270), while only 13.3% (36/270) had IgM antibodies to HCMV. Most abortion cases were documented in the first trimester (85.6%; 231/270) and this had a significant relationship with IgG level (P=0.003). Low socioeconomic status was recorded in 84.8% (229/270) of participants and showed significant correlation with IgG level (P=0.025), whereas 1 2 3

and showed significant correlation with IgG level (P=0.025), whereas illiteracy was reported in 41.9% (113/270) of participants and did not have a significant relationship.
Seroprevalence of HCMV in this study population was Conclusions: 74.8% for IgG antibodies. There was an association between HCMV IgG level and first trimester abortion and low socioeconomic status among the studied women. HCMV can produce maternal infection and exhibits a high tropism for cervical mucosa and is considered as the most implicated virus in recurrent spontaneous abortion (RSA) 8 . Many pregnant women in Blue Nile State, Sudan, have suffered from recurrent pregnancy loss, and currently there is no available data concerning the prevalence of HCMV in Blue Nile state; therefore, this study aimed to determine HCMV antibodies (IgG and IgM) among pregnant women, who had undergone abortion(s) in this state.

Study design
This was a descriptive cross-sectional hospital-based study aimed to detect the seroprevalence of CMV among pregnant women, who had undergone RSA, attending El-Damazin Hospital for Obstetrics and Gynecology in Blue Nile State, Sudan, between March 2017 and February 2019.
Permission to carry out the study was obtained from the College of Graduate Studies, Faculty of Medical Laboratory Sciences, University of Gezira and Ministry of Health, Blue Nile State, Sudan. All women examined were informed about the purpose of the study before collection of the specimens and written consent for participation was taken.

Participants and variables
A total of 270 blood samples, taken for the purpose of this study, were collected under aseptic conditions from the participants and sera were separated in sterile containers and stored at -20°C until tested. The inclusion criterion were all pregnant women attending El-Damazin Hospital for Obstetrics and Gynecology, Sudan to undergo an abortion.
Sample size was calculated using the following formula 9 : For CMV IgM the cut-off value was obtained by multiplying the optical density (OD) of the calibrator by factor (F) printed on label of calibrator. CMV IgM index for each sample obtained by dividing OD of sample over the cut-off.

Data analysis
Data analysis was done using Statistical Package for Social Sciences (SPSS version 24; IBM SPSS). Pearson Chi-squared test was used to test for statistical significance (P value), which was taken as significant when p < 0.05.

Results
A total of 270 women were enrolled in the study. The majority of the women were aged between 26 and 40 years. Low socioeconomic status was recorded in 84.8% (229/270) of participants, and illiteracy and women obtaining primary education was observed in 80% of participants. Most women were observed to be in the first trimester of pregnancy (85.5%; 231/270) (  Figure 1).
HCMV IgG detection was significantly correlated to socioeconomic status and gestation stage, but was not correlated to age group and education level (Table 2).

Discussion
CMV is globally distributed, with 40-100% of the global population positive for CMV antibodies 10,11 , particularly among low economic individuals 12 . In Sudan, there are only a few published data (Western and Central Sudan, and Khartoum) concerning epidemiology of HCMV among pregnant women. In our study area, which it located in the South of Sudan, there are no findings about the seroprevalence of HCMV in pregnant women who have had abortions.
The relationship between seroprevalence of HCMV and socioeconomic and education level among the present study population is significant, which may explain poor health status and susceptibility to certain diseases. Numerous studies have evaluated socioeconomic and education level for seroprevalence of HCMV, and most of these studies confirm the strong association between the socioeconomic disparities and high seropositivity [13][14][15][16][17] HCMV IgG level in this study was significantly correlated to abortion in the 1 st trimester gestation, which has also been shown by other studies 1,18 . HCMV infection is considered a significant public health problem because it can cause disease in those with weakened immune systems, which has been confirmed by a study in Sudan in which a high frequency (98.3%)of seroprevalence of HCMV among pregnant women was reported 19 .
In the present study, the sero-prevalence of HCMV among the participants was 74.8% for IgG and 13.3% for IgM; these findings are in total agreement with another study in Sudan among pregnant women 7 , but is in contrast to other study in Iran in which the frequency for HCMV IgG and IgM was 14.28% and 28.25%, respectively 20  This project contains the following extended data: -Questionnaire in English.
Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).