parvovirus

Parvovirus B-19 in Parvovirus B-19 in PregnancyPregnancy

By La Lura White MDBy La Lura White MD

Maternal Fetal MedicineMaternal Fetal Medicine

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy

It is a typical, busy Friday afternoon at the clinic, It is a typical, busy Friday afternoon at the clinic, and Ms. Jones, a 25-year-old G2P1 at 17 weeks' and Ms. Jones, a 25-year-old G2P1 at 17 weeks' gestation, mentions that her 5-year-old gestation, mentions that her 5-year-old daughter's pediatrician thinks her little girl has daughter's pediatrician thinks her little girl has fifth disease. fifth disease.

Your patient asks you if this poses any concern Your patient asks you if this poses any concern for her or her fetus. What's your next step, and for her or her fetus. What's your next step, and how do you counsel her? how do you counsel her?

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy Fifth disease, or erythema infectiosum, is caused by Fifth disease, or erythema infectiosum, is caused by

parvovirus B19.parvovirus B19. Fifth disease was so named because it was the fifth Fifth disease was so named because it was the fifth

pink-red rash--following scarlet fever, measles, rubella, pink-red rash--following scarlet fever, measles, rubella, and roseola--to be described by physicians.and roseola--to be described by physicians.

The annual incidence of acute parvovirus in pregnancy The annual incidence of acute parvovirus in pregnancy has been estimated at 1 in 400 pregnancies.has been estimated at 1 in 400 pregnancies.

In approximately 30% of those cases, the infection is In approximately 30% of those cases, the infection is transmitted to the fetus.transmitted to the fetus.

Brown and colleagues first reported adverse perinatal Brown and colleagues first reported adverse perinatal outcomes associated with maternal parvovirus infection outcomes associated with maternal parvovirus infection in 1984.in 1984.


Parvovirus is a member of the family Parvoviridae.Parvovirus is a member of the family Parvoviridae.

The virus contains a single-stranded DNA.The virus contains a single-stranded DNA.

It can only infect humans.It can only infect humans.

50% of all adults have been infected sometime 50% of all adults have been infected sometime during childhood or adolescence.during childhood or adolescence.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy EpidemiologyEpidemiology

Congenital infection rates vary depending on the Congenital infection rates vary depending on the prevalence in the community.prevalence in the community.

Approximately 50 to 75% of adult women are immune.Approximately 50 to 75% of adult women are immune.

20% to 30% of susceptible adults in school settings will 20% to 30% of susceptible adults in school settings will become infected.become infected.

Day-care workers have a 20% to 50% risk of Day-care workers have a 20% to 50% risk of seroconversion.seroconversion.

The risk of infection among susceptible adults following The risk of infection among susceptible adults following household exposure to an infected person is household exposure to an infected person is approximately 50%.approximately 50%.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy Maternal infection with parvovirus B19 is estimated to occur in 0.25-Maternal infection with parvovirus B19 is estimated to occur in 0.25-

6% of the susceptible pregnancies.6% of the susceptible pregnancies.

Spontaneous abortion may occur as a result of maternal infection in Spontaneous abortion may occur as a result of maternal infection in the first trimester (risk, 10%).the first trimester (risk, 10%).

The risk for congenital infection from an infected mother is between The risk for congenital infection from an infected mother is between 10% to 20% , and is highest in the first and second trimesters.10% to 20% , and is highest in the first and second trimesters.

The fetus is at greatest risk during the 3 to 6 weeks after maternal The fetus is at greatest risk during the 3 to 6 weeks after maternal infection with parvovirus.infection with parvovirus.

The overall fetal loss rate associated with maternal infection ranges The overall fetal loss rate associated with maternal infection ranges from 2% to 10%.from 2% to 10%.

The average time from diagnosis to resolution is about 6 weeks. The average time from diagnosis to resolution is about 6 weeks.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy Transmission is greatest during viremia and before symptoms arise.Transmission is greatest during viremia and before symptoms arise.

Parvovirus B19 most commonly is transmitted among humans via Parvovirus B19 most commonly is transmitted among humans via respiratory secretions and hand-to-mouth contact.respiratory secretions and hand-to-mouth contact.

Blood products also have been linked to infection, with the greatest Blood products also have been linked to infection, with the greatest risk attributed to coagulation factor concentrate transfusion.risk attributed to coagulation factor concentrate transfusion.

Spread transplacentally to the fetus during active maternal infection Spread transplacentally to the fetus during active maternal infection (33% transmission rate) can occur any time during pregnancy.(33% transmission rate) can occur any time during pregnancy.

Seasonal variation has been noted as well, with higher rates of Seasonal variation has been noted as well, with higher rates of infection during the late winter, spring, and early summer than at infection during the late winter, spring, and early summer than at other times of the year. other times of the year.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy There essentially are 2 phases of parvovirus There essentially are 2 phases of parvovirus

infection. infection.

Viral replication in the bone marrow, viremia, and Viral replication in the bone marrow, viremia, and viral shedding in the throat characterize the first viral shedding in the throat characterize the first phase.phase.

Occurs 5 to 10 days after exposure, is when the Occurs 5 to 10 days after exposure, is when the infection is most contagious.infection is most contagious.

Individuals often are unaware that they have Individuals often are unaware that they have parvovirus during this period, which increases the parvovirus during this period, which increases the risk of exposure to others.risk of exposure to others.


Most children with parvovirus infection feel well. Some Most children with parvovirus infection feel well. Some develop mild, cold-like signs and symptoms early in the develop mild, cold-like signs and symptoms early in the illness:illness:

Sore throat Sore throat Slight fever Slight fever Upset stomach Upset stomach Headache Headache Fatigue Fatigue Itching Itching

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy The hallmark of the second The hallmark of the second

phase is the appearance of a phase is the appearance of a rash and associated rash and associated arthralgias.arthralgias.

The rash, which usually is The rash, which usually is maculopapular or maculopapular or papulovesicular, typically papulovesicular, typically waxes and wanes over a waxes and wanes over a period of several days or period of several days or weeks, reappearing after weeks, reappearing after exercise, warm baths, or sun exercise, warm baths, or sun exposure.exposure.

Eventually it may extend to Eventually it may extend to the arms, trunk, thighs and the arms, trunk, thighs and buttocks, areas where the buttocks, areas where the rash has a pink, lacy, slightly rash has a pink, lacy, slightly raised appearance.raised appearance.

Seen most frequently among Seen most frequently among preschool and school-age preschool and school-age children in the United Stateschildren in the United States


In the absence of a rash, nonspecific flu-like symptoms and In the absence of a rash, nonspecific flu-like symptoms and symmetrical joint pain.symmetrical joint pain.

An adult who has not previously been infected with parvovirus An adult who has not previously been infected with parvovirus B19 can be infected and become ill, and develop a rash, or joint B19 can be infected and become ill, and develop a rash, or joint pain or swelling, or both. The joint symptoms usually resolve in pain or swelling, or both. The joint symptoms usually resolve in a week or two, but they may last several months. a week or two, but they may last several months.

33% of infected individuals are asymptomatic.33% of infected individuals are asymptomatic.

Individuals are no longer infectious once they enter the second Individuals are no longer infectious once they enter the second phase because by that time their immune system has begun phase because by that time their immune system has begun producing antigen-antibody complexes. producing antigen-antibody complexes.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy Pathogenesis: Pathogenesis: The primary site of Parvovirus B19 infections is within The primary site of Parvovirus B19 infections is within

erythroid precursor cells and it has an affinity for the late erythroid precursor cells and it has an affinity for the late normoblast stage and the cardiac myocytes and also normoblast stage and the cardiac myocytes and also causes a decrease in the number of platelets.causes a decrease in the number of platelets.

Following Parvovirus B19 infection, erythrocytes will lyse Following Parvovirus B19 infection, erythrocytes will lyse arresting erythropoiesis.arresting erythropoiesis.

Lymphocyte, granulocyte and platelet counts may also Lymphocyte, granulocyte and platelet counts may also

fall during infection. fall during infection.


The B19V incubation period is usually 4-14 days.The B19V incubation period is usually 4-14 days.

Hydrops fetalis has been reported with maternal B19 Hydrops fetalis has been reported with maternal B19 infection and appears to be due primarily to fetal anemia infection and appears to be due primarily to fetal anemia and resulting cardiac failure induced by the anemia and and resulting cardiac failure induced by the anemia and the fetal myocarditis.the fetal myocarditis.

Parvovirus B19 causes up to 27% cases of non-immune Parvovirus B19 causes up to 27% cases of non-immune hydrops in anatomically normal fetuses.hydrops in anatomically normal fetuses.

Parvovirus causes fetal anemia by hindering Parvovirus causes fetal anemia by hindering erythropoiesis in a manner similar to that seen in anemic erythropoiesis in a manner similar to that seen in anemic adults.adults.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy Infected pregnant women may exhibit a transient Infected pregnant women may exhibit a transient

and mild anemia because of the predilection of and mild anemia because of the predilection of the virus for destroying erythroid precursor cell the virus for destroying erythroid precursor cell lines.lines.

This slight decrease in hemoglobin is observed This slight decrease in hemoglobin is observed within a few days of infection.within a few days of infection.

Individuals with sickle cell disease, other Individuals with sickle cell disease, other hemoglobinopathies, immunocompromised hemoglobinopathies, immunocompromised individuals,(transplant patients, HIV positive) or individuals,(transplant patients, HIV positive) or are at risk for transient aplastic crisis and may are at risk for transient aplastic crisis and may require hospitalization.require hospitalization.

Parvovirus B-19 in PregnancyParvovirus B-19 in PregnancyDiagnosisDiagnosis

Pregnant women who have symptoms of parvovirus Pregnant women who have symptoms of parvovirus infection or who are asymptomatic but who know they infection or who are asymptomatic but who know they have been exposed to the infection should undergo have been exposed to the infection should undergo diagnostic serology.diagnostic serology.

The enzyme-linked immunosorbent assay (ELISA) and The enzyme-linked immunosorbent assay (ELISA) and Western blot analysis appear is a reliable methods for Western blot analysis appear is a reliable methods for detecting IgG and IgM antibodies in maternal serum.detecting IgG and IgM antibodies in maternal serum.

Both antibodies are produced in response to the Both antibodies are produced in response to the parvovirus infection.parvovirus infection.

The sensitivity and specificity of IgM for confirming the The sensitivity and specificity of IgM for confirming the presence of acute infection are 100% and 89%, presence of acute infection are 100% and 89%, respectively.respectively.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy Acute infection is diagnosed when a gravida is IgM Acute infection is diagnosed when a gravida is IgM

positive.positive.

IgM antibodies usually are present by the third day after IgM antibodies usually are present by the third day after development of the rash and may persist for 1 to several development of the rash and may persist for 1 to several months after exposure.months after exposure.

Titers usually begin to decline by 30 to 60 days after Titers usually begin to decline by 30 to 60 days after infection.infection.

IgG antibodies appear 7 days after infection, and the IgG antibodies appear 7 days after infection, and the patient then remains IgG positive throughout life.patient then remains IgG positive throughout life.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy Women who are IgG negative should undergo repeat Women who are IgG negative should undergo repeat

testing in 3 to 4 weeks with paired samples.testing in 3 to 4 weeks with paired samples.

This provides both the physician and the pathologist with This provides both the physician and the pathologist with a baseline for comparison.a baseline for comparison.

If IgG and IgM remain negative, the fetus is not at riskIf IgG and IgM remain negative, the fetus is not at risk If seroconversion is documented in the second sample, If seroconversion is documented in the second sample,

however, fetal surveillance is indicated.however, fetal surveillance is indicated.

Perform Polymerase Chain Reaction (PCR) to detect Perform Polymerase Chain Reaction (PCR) to detect Parvovirus B-19 DNA in maternal sera.Parvovirus B-19 DNA in maternal sera.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy Monitoring and treating the infected fetusMonitoring and treating the infected fetus

Women with documented seroconversion should undergo an initial Women with documented seroconversion should undergo an initial targeted fetal ultrasound to identify or rule out congenital anomalies.targeted fetal ultrasound to identify or rule out congenital anomalies.

Should perform weekly ultrasounds for 8 to 10 weeks after maternal Should perform weekly ultrasounds for 8 to 10 weeks after maternal infection.infection.

If the physician finds hydrops at sonography--the presence of which If the physician finds hydrops at sonography--the presence of which indicates that the fetus has parvovirus-induced anemia--indicates that the fetus has parvovirus-induced anemia--cordocentesis (for B19-specific IgM).cordocentesis (for B19-specific IgM).

Percutaneous umbilical blood sampling [PUBS]) is indicated to Percutaneous umbilical blood sampling [PUBS]) is indicated to

assess fetal blood in preparation for intrauterine red blood cell assess fetal blood in preparation for intrauterine red blood cell transfusion to treat the anemia.transfusion to treat the anemia.

Send fetal blood for IgG testing or for PCR (sensitivity, 100%) after Send fetal blood for IgG testing or for PCR (sensitivity, 100%) after 22 weeks, as IgG antibodies do not appear in the fetal circulation 22 weeks, as IgG antibodies do not appear in the fetal circulation until this gestational age.until this gestational age.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy At the time of fetal blood sampling, which carries a At the time of fetal blood sampling, which carries a

complication rate of approximately 1%, blood is sent to complication rate of approximately 1%, blood is sent to the lab to determine mean corpuscular volume (MCV), the lab to determine mean corpuscular volume (MCV), hematocrit, leukocyte count, and platelet count.hematocrit, leukocyte count, and platelet count.

Thrombocytopenia may accompany fetal anemia, and Thrombocytopenia may accompany fetal anemia, and fetal hemorrhage from the cordocentesis site has been fetal hemorrhage from the cordocentesis site has been reported.reported.

Karyotype may be obtained from fetal blood or Karyotype may be obtained from fetal blood or amniocytes if there is a high risk of aneuploidy.amniocytes if there is a high risk of aneuploidy.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy Middle cerebral artery time-Middle cerebral artery time-

averaged mean velocity for the averaged mean velocity for the detection of anemia as the detection of anemia as the cause of fetal hydrops.cause of fetal hydrops.

The mean (z score) of middle The mean (z score) of middle cerebral artery time-averaged cerebral artery time-averaged mean velocity for fetuses with mean velocity for fetuses with normal hemoglobin was 1.1 +/- normal hemoglobin was 1.1 +/- 0.81 and for the fetuses with 0.81 and for the fetuses with anemia was 4.71 +/- 2.16 (P anemia was 4.71 +/- 2.16 (P <.001).<.001).

The sensitivity for the The sensitivity for the increased middle cerebral increased middle cerebral artery time-averaged mean artery time-averaged mean velocity to predict fetal anemia velocity to predict fetal anemia was 91%, and the specificity was 91%, and the specificity was 100%. was 100%.

Flow velocity waveform in the fetal middle cerebral artery in a severely anemic fetus at 22 weeks (left) and in a normal fetus (right). In fetal anemia, blood velocity is increased


Reversed flow in the ductus Reversed flow in the ductus venosus Doppler have been venosus Doppler have been reported that could be explained by reported that could be explained by both end-stage heart failure and both end-stage heart failure and regurgitation secondary to tricuspid regurgitation secondary to tricuspid insufficiency.insufficiency.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy Intrauterine red blood cell transfusion is Intrauterine red blood cell transfusion is

indicated if fetal anemia is confirmed.indicated if fetal anemia is confirmed.

When aggressive management with serial When aggressive management with serial transfusions is employed, fetal survival may transfusions is employed, fetal survival may be as high as 60% to 80% compared to only be as high as 60% to 80% compared to only a 15% to 30% survival rate without such a 15% to 30% survival rate without such intervention.intervention.

Overall perinatal survival associated with Overall perinatal survival associated with nonimmune hydrops ranges from 50% to nonimmune hydrops ranges from 50% to 98%. 98%.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy Ultrasound-guided PUBS is performed and an immediate Ultrasound-guided PUBS is performed and an immediate

fetal Hct performed.fetal Hct performed.

If the Hct is less than 25%, then irradiated, CMV-free, Oneg If the Hct is less than 25%, then irradiated, CMV-free, Oneg packed red blood cells are transfused via the spinal needle packed red blood cells are transfused via the spinal needle or catheter into the fetal umbilical vein.or catheter into the fetal umbilical vein.

Combined intravascular/intraperitoneal transfusion can be Combined intravascular/intraperitoneal transfusion can be utilized, which allows a more gradual increase in fetal Hct utilized, which allows a more gradual increase in fetal Hct than intravascular transfusion alone.than intravascular transfusion alone.

Fetuses with severe degrees of anemia may require Fetuses with severe degrees of anemia may require transfusion in stages in order to avoid cardiac transfusion in stages in order to avoid cardiac decompensation and bradycardia.decompensation and bradycardia.

Published formulas assist in estimating the volume of blood Published formulas assist in estimating the volume of blood to be transfused.to be transfused.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy Rodis and colleagues surveyed members of the Society for Rodis and colleagues surveyed members of the Society for

Maternal-Fetal Medicine in Maternal-Fetal Medicine in 19971997 regarding their management of regarding their management of parvovirus infection and its sequelae in pregnancy.parvovirus infection and its sequelae in pregnancy.

539 cases of parvovirus-induced nonimmune hydrops reported.539 cases of parvovirus-induced nonimmune hydrops reported. Of the perinatologists surveyed, 89% utilized ultrasonography for Of the perinatologists surveyed, 89% utilized ultrasonography for

the initial management of parvovirus infection in pregnancy.the initial management of parvovirus infection in pregnancy.

7.5% utilized amniocentesis to send fluid for polymerase chain 7.5% utilized amniocentesis to send fluid for polymerase chain reaction (PCR) testing.reaction (PCR) testing.

2% utilized fetal blood sampling.2% utilized fetal blood sampling.

Outcomes of these 539 cases revealed that nonimmune hydrops Outcomes of these 539 cases revealed that nonimmune hydrops secondary to parvovirus infection resolved spontaneously in 34% secondary to parvovirus infection resolved spontaneously in 34% of the cases.of the cases.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy Another 29% resolved following intrauterine Another 29% resolved following intrauterine

transfusion.transfusion.

In 6%, fetal demise occurred following transfusion.In 6%, fetal demise occurred following transfusion.

All cases of fetal death after transfusion occurred All cases of fetal death after transfusion occurred within 48 hours of the procedure, suggesting that within 48 hours of the procedure, suggesting that either the fetus was simply too moribund to tolerate either the fetus was simply too moribund to tolerate the transfusion or that demise was secondary to the transfusion or that demise was secondary to procedure-related complications.procedure-related complications.

The incidence of fetal death when anemia and The incidence of fetal death when anemia and

hydrops were managed expectantly, i.e., without hydrops were managed expectantly, i.e., without intrauterine transfusion, was 30%. intrauterine transfusion, was 30%.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy Since several case reports have documented spontaneous Since several case reports have documented spontaneous

resolution of non-immune hydrops in fetuses with confirmed resolution of non-immune hydrops in fetuses with confirmed congenital Parvovirus B-19 infection.congenital Parvovirus B-19 infection.

Therefore, medical therapy for the fetus is not always necessary Therefore, medical therapy for the fetus is not always necessary for fetal survival.for fetal survival.

The principal intervention for treatment of fetal non-immune The principal intervention for treatment of fetal non-immune hydrops from congenital Parvovirus B-19 infection has been hydrops from congenital Parvovirus B-19 infection has been intrauterine fetal transfusion.intrauterine fetal transfusion.

If PUBS confirms significant fetal anemia, then fetal transfusion If PUBS confirms significant fetal anemia, then fetal transfusion can accelerate the natural resolution of non-immune hydrops in can accelerate the natural resolution of non-immune hydrops in these fetuses.these fetuses.

A proposal for IgG therapy has recently been made in the British A proposal for IgG therapy has recently been made in the British literature.literature.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy DiagnosisDiagnosis During the first trimester fetuses with parvovirus B19 During the first trimester fetuses with parvovirus B19

infection can present with increased nuchal translucency infection can present with increased nuchal translucency and congenital anomalies (Ventriculomegaly, Mild and congenital anomalies (Ventriculomegaly, Mild hydrocephaly, microcephaly)hydrocephaly, microcephaly)

In second and third trimesters fetal infection by parvovirus In second and third trimesters fetal infection by parvovirus B19 can be suspected by the use of ultrasound with the B19 can be suspected by the use of ultrasound with the presence of:presence of:

Fetal hydropsFetal hydrops AscitesAscites Pleural or pericardial effusionPleural or pericardial effusion Skin thickeningSkin thickening Cardiomegaly (increased cardiac biventricular outer Cardiomegaly (increased cardiac biventricular outer

diameter) diameter)

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy Hypertrophic myocardiopathyHypertrophic myocardiopathy Hyperechoic bowelHyperechoic bowel HepatomegalyHepatomegaly Abdominal wall edemaAbdominal wall edema Bilateral hydrocelesBilateral hydroceles

Intracranial calcificationsIntracranial calcifications Intrauterine growth restrictionIntrauterine growth restriction StillbirthStillbirth Decreased movement in severe casesDecreased movement in severe cases Placentomegaly Placentomegaly Amniotic fluid volume disorders Amniotic fluid volume disorders


HydrothoraxHydrothorax


AscitesAscites


Scalp edemaScalp edema


Pericardial effusionPericardial effusion


Ascites, enlarged liver, cardiomegalyAscites, enlarged liver, cardiomegaly


Edema of face and Edema of face and abdominal distension.abdominal distension.

The thoracic cavity is The thoracic cavity is

filled by the pericardial filled by the pericardial sac distended by effusion sac distended by effusion and cardiomegaly.and cardiomegaly.

There is massive There is massive hepatomegaly. hepatomegaly.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy In the event of in utero fetal demise, order In the event of in utero fetal demise, order

maternal serology for parvovirus B19.maternal serology for parvovirus B19. If the maternal serology is positive, the physician If the maternal serology is positive, the physician

should send placental tissue for PCR analysis.should send placental tissue for PCR analysis.

Although autolysis often makes it very difficult Although autolysis often makes it very difficult for the pathologist to identify signs of myocarditis for the pathologist to identify signs of myocarditis at fetal autopsy, viral particles can be visualized at fetal autopsy, viral particles can be visualized by electron microscopy in tissue.by electron microscopy in tissue.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy Because Parvovirus B-19 is a DNA virus, chronic Because Parvovirus B-19 is a DNA virus, chronic

recurrent pediatric infection in infants with recurrent pediatric infection in infants with congenital Parvovirus infection has been reported.congenital Parvovirus infection has been reported.

Therefore, confirmed cases of congenital Therefore, confirmed cases of congenital Parvovirus infection should be reported to the Parvovirus infection should be reported to the child's pediatrician following deliver to allow for child's pediatrician following deliver to allow for pediatric monitoring of potential chronic infection.pediatric monitoring of potential chronic infection.

There are isolated case reports of congenital There are isolated case reports of congenital deformities among infants with congenital deformities among infants with congenital Parvovirus infection, but the pattern of Parvovirus infection, but the pattern of abnormalities does not suggest a syndrome.abnormalities does not suggest a syndrome.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy TREATMENT:TREATMENT:

No maternal treatment often too late when No maternal treatment often too late when recognized for prophylaxis and no medical recognized for prophylaxis and no medical management that prevents parvovirus B19 management that prevents parvovirus B19 infection.infection.

Treatment for fetuses with suspected congenital Treatment for fetuses with suspected congenital Parvovirus B-19 infection includes:Parvovirus B-19 infection includes:

Watchful waiting (conservative management) Watchful waiting (conservative management) High-dose IgG therapy High-dose IgG therapy Intrauterine fetal transfusion Intrauterine fetal transfusion


Parvovirus exposure:Parvovirus exposure:

Serology for Ig G and Ig M.Serology for Ig G and Ig M. If negative, repeat 3-4 weeks paired If negative, repeat 3-4 weeks paired

serum.serum. If still negative, no fetal risk.If still negative, no fetal risk. If positive, fetus at risk.If positive, fetus at risk.


Fetal surveillance, weekly US, MCA Fetal surveillance, weekly US, MCA Doppler.Doppler.

Assessment for 8-10 weeks.Assessment for 8-10 weeks.

Hydrops yes: cordocentesis, fetal Hydrops yes: cordocentesis, fetal transfusion.transfusion.

Hydrops no: further evaluation.Hydrops no: further evaluation.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy PreventionPrevention There are no known measures to treat or control There are no known measures to treat or control

parvovirus B19 infection.parvovirus B19 infection.

No reliable vaccine or treatment for mother:No reliable vaccine or treatment for mother:

Frequent hand washing is recommended as a practical Frequent hand washing is recommended as a practical and probably effective method to reduce the spread of and probably effective method to reduce the spread of parvovirus.parvovirus.

Excluding persons with fifth disease from work, child Excluding persons with fifth disease from work, child care centers, schools, or other settings is not likely to care centers, schools, or other settings is not likely to prevent the spread of parvovirus B19, since ill persons prevent the spread of parvovirus B19, since ill persons are contagious before they develop the characteristic are contagious before they develop the characteristic rash.rash.


RecommendationsRecommendations

CDC does not recommend that pregnant women should CDC does not recommend that pregnant women should routinely be excluded from a workplace where a fifth routinely be excluded from a workplace where a fifth disease outbreak is occurring.disease outbreak is occurring.

Rather, CDC considers that the decision to stay away Rather, CDC considers that the decision to stay away from a workplace where there are cases of fifth disease from a workplace where there are cases of fifth disease is an personal decision for a woman to make, after is an personal decision for a woman to make, after discussions with her family, physician, and employer.discussions with her family, physician, and employer.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy Because of the high prevalence of parvovirus B19 IgG among Because of the high prevalence of parvovirus B19 IgG among

adults, most pregnant women are not at risk for parvovirus adults, most pregnant women are not at risk for parvovirus infection, even during an epidemic of erythema infectiosum. infection, even during an epidemic of erythema infectiosum.

If a pregnant woman has symptoms of erythema infectiosum, with If a pregnant woman has symptoms of erythema infectiosum, with or without arthropathy, parvovirus B19 infection should be or without arthropathy, parvovirus B19 infection should be suspected.suspected.

Information concerning the fetal outcomes of reported cases of Information concerning the fetal outcomes of reported cases of infection in pregnancy should be provided, however, the risk of infection in pregnancy should be provided, however, the risk of adverse effects on the fetus requires careful surveillance.adverse effects on the fetus requires careful surveillance.

Therapeutic abortion is not indicated, because the intrauterine Therapeutic abortion is not indicated, because the intrauterine infection is more embryocidal than teratogenic.infection is more embryocidal than teratogenic.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy Management guidelines for pregnant women with Management guidelines for pregnant women with

symptomatic infectionsymptomatic infection: :

Monitoring of maternal serum IgM and Ig G.Monitoring of maternal serum IgM and Ig G.

Monitoring of maternal serum for elevated levels of a-Monitoring of maternal serum for elevated levels of a-fetoprotein may indicate fetal aplastic crisis, preliminary fetoprotein may indicate fetal aplastic crisis, preliminary study has suggested that fetal loss is unlikely if the level study has suggested that fetal loss is unlikely if the level stays within normal limits.stays within normal limits.

If the levels are increased, then serial ultrasonography If the levels are increased, then serial ultrasonography may be useful to detect hydrops fetalis.may be useful to detect hydrops fetalis.

In cases of hydrops fetalis fetal blood samples may In cases of hydrops fetalis fetal blood samples may reveal the severity of the aplastic crisis; if severe, in-reveal the severity of the aplastic crisis; if severe, in-utero transfusions or early delivery and transfusions may utero transfusions or early delivery and transfusions may be beneficial.be beneficial.

Parvovirus B-19 in PregnancyParvovirus B-19 in Pregnancy During prenatal visitsDuring prenatal visits Should inquire about any viral syndromes to which the gravida has Should inquire about any viral syndromes to which the gravida has

been exposed or about any symptoms that may have been caused been exposed or about any symptoms that may have been caused by a virus.by a virus.

When a patient's medical history is suspicious for parvovirus When a patient's medical history is suspicious for parvovirus exposure or infection, the physician should obtain serology to make exposure or infection, the physician should obtain serology to make a definitive diagnosis.a definitive diagnosis.

Thorough counseling when the infection is first diagnosed facilitates Thorough counseling when the infection is first diagnosed facilitates informed decision-making and encourages patient compliance with informed decision-making and encourages patient compliance with the management protocol, which is key to achieving a successful the management protocol, which is key to achieving a successful pregnancy outcome.pregnancy outcome.

Patients are more likely to return for frequent screening, such as Patients are more likely to return for frequent screening, such as weekly ultrasounds, if they understand the reasoning behind the weekly ultrasounds, if they understand the reasoning behind the screening and the actions to be taken. screening and the actions to be taken.


High index of suspicionHigh index of suspicionLook for me!Look for me!

parvovirus

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