(pregnant)

INVESTIGATION OF

RUBELLAIN

PREGNANT WOMEN OF

UNKNOWN RUBELLA IMMUNITYSTATUS

11/27/2007 2S.R.Tabatabaei MD,MPH - PIRC

Rubella is the first virus demonstrated as a teratogen.

Humans are the only natural host of rubella virus(EXCLUSIVELY)

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What happened when a pregnant woman exposed to RUELLA?

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When a pregnant woman is exposed to rubella

What should we do?

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Gregg was the first to describe the 3 characteristic manifestations of CRS: -heart disease-cataracts -deafness

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Why? Maternal Infection Maternal viremia Intrauterine Transmission CRS

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The most important determinant of fetal infection & fetal defects is:

GESTATIONAL AGE

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When will a pregnant mother get VIREMIA ?

Maternal immunization : - vaccine-related - Previous InfectionRe-infection: 2%, especially <12 wk, CRS(rare)Lit. Review: 30Re- infection in adults and children

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What happened for mother when she exposed to RUELLA?

Immunity(+) “ (-): -nothing -Infection -subclinical, symptomatic

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The incubation period :14–21 days The prodromal phase :mild catarrhal symptoms 2/3 of infections: subclinical The most characteristic sign is retroauricular, posterior cervical,

and postoccipital lymphadenopathy (No other disease causes the tender enlargement of these nodes)

An enanthem appears in 20% of patients just before the onset of the skin rash. It consists of discrete rose-colored spots on the soft palate (Forchheimer spots)

Lymphadenopathy is evident at least 24 hr before the rash appears and may remain for 1 wk or more.

RASH: It begins on the face and spreads quickly. Its evolution is

so rapid that the rash may be fading on the face by the time it appears on the trunk. During the second day the rash may assume a pinpoint appearance, especially over the trunk, resembling that of scarlet fever. Mild itching may occur. The eruption usually clears by the third day. Desquamation is minimal.

Rubella without a rash has been described. 11/27/2007S.R.Tabatabaei MD,MPH - PIRC 12

maculopapular rash

lymphadenopathy

fever

arthropathy (up to 60% of cases)

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Maternal rubella during pregnancy can result in:

-miscarriage,

-fetal death, -congenital rubella syndrome -Late sequels years later -placental infection ± persistent fetal

infection -no infection(counseling?)

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The most important thing is: GESTATIONAL AGE Fetal Inf. (Miller & colleagues)

90% <11 wk G.A67% 13-1425% 23-2653% Third trimester 100%(last month of

pregnancy) Congenital defect:90% if maternal infection < 11wk (<8wk,first month)33% 11-12 wk11% 13-1424% 15-16Uncommn >16

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Why this happen?

The placenta is a relatively effective barrier to fetal infection from 12-28wk

but it is not so effective in the first & third

trimesters Particularly in the last month of

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Cellular & tissue damage in the infected fetus:

-Tissue necrosis due to vascular insufficiency

-Reduced cellular multiplication time -Chromosomal breaks -Production of a protein inhibitor causing

mitotic arrests in certain cell types

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The most distnctive feature of congenital rubella is:

CHRONICITY ONCE THE FETUS IS INFECTED EARLY IN

GESTATION

The virus persists in fetal tissue until well beyond delivery

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CRS is not a static disease ¾ of infected infants show NO

apparent involvement at birth but experience consequences years later Sonography (NL?) conselling

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Recommendation:

all rashes in pregnancy be investigated

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1-A blood specimen should be obtained as soon as possible for specific IgG and IgM antibody

2-A single positive IgG test indicates rubella immunity3-A significant rise in IgG Ab (paired sera) or positive IgM

Ab test indicates recent infection4-Negative IgG and negative IgM on first testing should

be retested (the first specimen should be reanalyzed along with the second specimen )

5-Positive IgG titers and negative IgM to determine if they acquired immunity before pregnancy or infection during pregnancy

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Rubella in Pregnant Women

Note that in reinfection, IgM is usually absent or only present transiently at a low level

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1- IG 2- VACCINE 3- Termination of pregnancy 4- NOTHING

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No recommendation for routine use in pregnant women

0.55 mg/kg IG (IM): 1- ↓ viral shedding 2- ↓ Rate of the viremiaPoints: 1-The absence of clinical signs in a woman who has

received IM-IG does not guarantee that fetal infection has been prevented

2-Adminstration of IG eliminates the value of IgG-Ab testing to detect maternal infection but IgM-Ab can be used.

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Immunizatoin of non-pregnant women within 3 days of exposure

Because if the exposure did no result In infection, immunization will protect them in the future.

Pregnancy within 28 days (3 months) of immunization

The MMR vaccine must be offered to IgG negative women postpartum

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BUT in pregnant women:

A small % of offspring in such acses had signs of infection, but no defects.

Rubella vaccine during pregnancy

≠ termination

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Shed small amount of virus from the pharynx (7-28 days after immunization)

NO evidence of transmission of the vaccine virus

NO Risk for mother

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The only effective way to prevent CRS is to terminate the pregnancy

But it is not an easy decision Why?

Evaluation of mother/baby

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Since 1968, a highly effective live attenuated vaccine has been available with 95% efficacy

Universal vaccination is now offered to all infants as part of the MMR regimen

Some countries continue to selectively vaccinate schoolgirls before they reach childbearing age.

Both universal and selective vaccination policies will work provided that the coverage is high enough.

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Antenatal screening:

All pregnant women attending antenatal clinics are tested  for immune  status  against rubella.

Non-immune  women  are  offered rubella vaccination in the immediate post partum period.

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Vaccination of women In

child-bearing age

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در باردار خانم با برخورد نحوه الگوریتمروبال با مواجهه

نظر * از بررسی و نمونه گرفتن IgMو IgGبالفاصلهاختصاصی

های * تست برای شده فریز نمونه یک گذاشتن کناربعدی احتمالی

+

-

recentinfection

مصون بیشتر احتمالاست

+

مجدد هفته 2-3نمونهو بعد

با آن همزمان چکاول نمونه

مجدد از 6نمونه بعد هفتهمواجهه

نمونه با همزمان چک واول

Inf نداده رخاست

-

IgG IgM

+ -

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