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Objective: The objective of the study was to assess the effectiveness of ultrasound in the antenatal prediction of symptomatic congenital cytomegalovirus (CMV) infection. Study Design: The sonograms of 650 fetuses from mothers with primary CMV infection were correlated to fetal or neonatal outcome. Infection status was disclosed by viral urine isolation at birth or CMV tissue inclusions at autopsy. Classification of symptomatic disease was based on postnatal clinical or laboratory findings or macroscopic evidence of tissue damage at autopsy. Results: Ultrasound abnormalities were found in 51 of 600 mothers with primary infection (8.5%) and 23 of 154 congenitally infected fetuses (14.9%). Symptomatic congenital infection resulted in 1 of 23 and 68 of 131 cases with or without abnormal sonographic findings, respectively. Positive predictive values of ultrasound vs symptomatic congenital infection was 35.3% relating to all fetuses or infants from mothers with primary infection and 78.3% relating to fetuses or infants with congenital infection. Conclusion: When fetal infection status is unknown, ultrasound abnormalities predict symptomatic congenital infection in only a third of cases. [Copyright &y& Elsevier]