Dr. Wulan M. Soemardji, SpOG Rubella in pregnancy Dr. Wulan M. Soemardji, SpOG

CONGENITAL RUBELLA • Rubella is a teratogenic virus • Congenital rubella syndrome (CRS) occur during the US rubella epidemic of 1964 • The fetus is at risk of CRS only during primary infection • Possibilities fetal infection occurs during first 4 weeks after conception 61%, 5-8 w: 26%; 9-12 w: 8%; after 12 w: <5%

CONGENITAL RUBELLA syndrome • The most common abnormalities associated with 1st trim infection are: hearing loss in 60%-75%; eye defect: 50-90%%; heart disease: 40-85%; psychomotor retardation: 25-40% • Other abnormalities are: IUGR, hepatosplenomegaly • Less frequent: thrombocytopeni, meningoencephalities

EPIDEMIOLOGY • Also called German measles, caused by rubella virus • Minor infections in the absence of pregnancy • During pregnancy directly responsible for inestimable wastage, as well as for severe congenital malformation

Transmission from direct contact with the nasopharyngeal secretion of an infected person • The most contagious periode is the few days before the onset of a maculopapuler rash • The incubation period range 14 – 21 days

MATERNAL INFECTION • Symptomatic in 50%-70% • Mild, maculopapular rash for 3 days • Low fever, headache, loss of appetide, and sore throat • Generalized lymphadenopathy (especially postauricular, occipital) • Transient arthritis

FETAL INFECTION • At least 50% infected fetuses when primarymaternal infection occurs in the 1st trim, when the greatest risk of congenital anomalies exiests • Multiple organ system involvement • Permanent congenital defect: cataracts,microphthalmia, glaucoma, PDA, pulmonaryartery stenosis, atrioventricular septal defect,deafness, microcephaly, encephalopathy, mentalretardition and motor impairement

One third of infant asymptomatic at birth may develop late manifestation, including diabetes mellitus, thyroid disorders, and precocious puberty • Mortality • Spontaneous abortion 4-9%, stillbirth 2-3% • Overall mortality of infant with congenital rubella syndrome is 5-35%

CONGENITAL RUBELLA SYNDROME • Eye lesions: catarract, gloucoma, microphthalmia • Heart disease: patent ductus arteriosus, septal defect, pulmonary artery stenosis • Sensorineural deafness • Central nervous system defects: meningoencephalitis • Fetal growth restriction

Throbocytopenia and anemia • Hepatitis, hepatosplenomegaly, jaundice • Chronic diffuse interstitial pneumonitis • Osseous changes • Chromosomal abnormalitis

DIAGNOSIS • Serology, because viral isolation technically difficult, result of tissue culture take up 6 weeks • Antibody detection methods hemagglutination inhibition, RIA latex agglutination • Fourfold or greater increase in titer or seroconversion indicates acute infection

Monitoring Serologi pada infeksi Rubella IgG+/ IgM- IgG-/IgM+ IgG+/IgM+ Pasien imun retest 1-4mggu infeksi primer? infeksi lama dg sisa IgM IgG-/IgM- IgG+/IgM+ IgG-/IgM+ aviditas IgG Tdk terinfeksi inf primer IgM nonspesifik Tinggi rendah terapi terapi

If seropositive on the first titer, no risk to the fetus • Primary rubella confers lifelong immunity however may be incomplete • Antirubella IgM can be found in both primary and reinfection rubella • Reinfection rubella usually is subclinical, rarely is associated with viremia

PRENATAL DIAGNOSIS • Identification IgM in fetal blood by direct puncture under US guidance at 22 weeks of gestation or later • The presence of rubella specific IgM antibody in blood obtain by cordocentesis indicates congenital rubella infection, because IgM does not cross the placenta

MANAGEMENT • Pregnant women should undergo rubella serum evaluiation • A clinical hystory of rubella unreliable • If the patient is nonimmune, she should receive rubella vaccine after delivery • Contraception should be used for a minimum 3 months after vaccination • Theoretical risk of teratogenecity if vaccine is used during pregnancy

If pregnant women is exposed to rubella, immediate serologic evaluation • If primary rubella is diagnosed, the mother should be informed about the implications of the infection for the fetus • If acute infection is diagnosed during the first trim, the option of therapeutic abortion shoud be considered

TO ERADICATE THE DISEASE COMPLETELY • Education of health care providers and general public on the dangeres of rubella • Vaccination of susceptible women including collega health service • Vaccination of susceptible women visiting family planning clinics

Identification and vaccination of unimmunized women immediately after childbirth or abortion • Vaccination of nonpregnant susceptible women identified by premarital serology • Vaccination of all susceptible hospital personnel who might be exposed to patient with rubella or who might be have contact with pregnant women

Rubella vaccination should be avoided shortly before or during pregnancy, because the vaccin contains attenuated live virus