(pregnant)

INVESTIGATION OF RUBELLA IN PREGNANT WOMEN OF UNKNOWN RUBELLA IMMUNITY STATUS 11/27/ S.R.Tabatabaei MD,MPH - PIRC

 Rubella is the first virus demonstrated as a teratogen.  Humans are the only natural host of rubella virus(EXCLUSIVELY) 11/27/2007 S.R.Tabatabaei MD,MPH - PIRC 3

 What happened when a pregnant woman exposed to RUELLA? 11/27/2007 S.R.Tabatabaei MD,MPH - PIRC 4

 When a pregnant woman is exposed to rubella What should we do? 11/27/ S.R.Tabatabaei MD,MPH - PIRC

Gregg was the first to describe the 3 characteristic manifestations of CRS: -heart disease -cataracts -deafness 11/27/2007 S.R.Tabatabaei MD,MPH - PIRC 6

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 Why?  Maternal Infection  Maternal viremia  Intrauterine Transmission  CRS 11/27/2007 S.R.Tabatabaei MD,MPH - PIRC 8

 The most important determinant of fetal infection & fetal defects is: GESTATIONAL AGE 11/27/2007 S.R.Tabatabaei MD,MPH - PIRC 9

 When will a pregnant mother get VIREMIA ?  Maternal immunization : - vaccine-related - Previous Infection Re-infection: 2%, especially <12 wk, CRS(rare) Lit. Review: 30 Re- infection in adults and children 11/27/2007 S.R.Tabatabaei MD,MPH - PIRC 10

 What happened for mother when she exposed to RUELLA?  Immunity(+) “ (-): -nothing -Infection -subclinical, symptomatic 11/27/2007 S.R.Tabatabaei MD,MPH - PIRC 11

 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. 11/27/2007 S.R.Tabatabaei MD,MPH - PIRC 12

 maculopapular rash  lymphadenopathy  fever  arthropathy (up to 60% of cases) 11/27/ S.R.Tabatabaei MD,MPH - PIRC

 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?) 11/27/2007 S.R.Tabatabaei MD,MPH - PIRC 14

 The most important thing is: GESTATIONAL AGE  Fetal Inf. (Miller & colleagues) 90% <11 wk G.A 67% % % Third trimester 100%(last month of pregnancy)  Congenital defect: 90% if maternal infection < 11wk (<8wk,first month) 33% wk 11% % Uncommn >16 11/27/2007 S.R.Tabatabaei MD,MPH - PIRC 15

 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 pregnancy 11/27/2007 S.R.Tabatabaei MD,MPH - PIRC 16

 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 11/27/2007 S.R.Tabatabaei MD,MPH - PIRC 17

 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 11/27/2007 S.R.Tabatabaei MD,MPH - PIRC 18

 CRS is not a static disease  ¾ of infected infants show NO apparent involvement at birth but experience consequences years later Sonography (NL?) conselling 11/27/2007 S.R.Tabatabaei MD,MPH - PIRC 19

Recommendation: all rashes in pregnancy be investigated 11/27/ S.R.Tabatabaei MD,MPH - PIRC

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

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 immunity 3-A significant rise in IgG Ab (paired sera) or positive IgM Ab test indicates recent infection 4-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 11/27/ S.R.Tabatabaei MD,MPH - PIRC Rubella in Pregnant Women

Note that in reinfection, IgM is usually absent or only present transiently at a low level 11/27/ S.R.Tabatabaei MD,MPH - PIRC

 1- IG  2- VACCINE  3- Termination of pregnancy  4- NOTHING 11/27/ S.R.Tabatabaei MD,MPH - PIRC

 No recommendation for routine use in pregnant women  0.55 mg/kg IG (IM): 1- ↓ viral shedding 2- ↓ Rate of the viremia Points: 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. 11/27/ S.R.Tabatabaei MD,MPH - PIRC

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

BUT in pregnant women:  A small % of offspring in such acses had signs of infection, but no defects.  Rubella vaccine during pregnancy ≠ termination 11/27/ S.R.Tabatabaei MD,MPH - PIRC

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

 The only effective way to prevent CRS is to terminate the pregnancy  But it is not an easy decision  Why? Evaluation of mother/baby 11/27/ S.R.Tabatabaei MD,MPH - PIRC

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

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

Vaccination of women In child-bearing age 11/27/ S.R.Tabatabaei MD,MPH - PIRC

11/27/2007S.R.Tabatabaei MD,MPH - PIRC 33 الگوریتم نحوه برخورد با خانم باردار در مواجهه با روبلا * بلافاصله گرفتن نمونه و بررسی از نظر IgG و IgM اختصاصی * کنار گذاشتن یک نمونه فریز شده برای تست های احتمالی بعدی + - recent infection احتمال بیشتر مصون است + نمونه مجدد 3-2 هفته بعد و چک همزمان آن با نمونه اول نمونه مجدد 6 هفته بعد از مواجهه و چک همزمان با نمونه اول Inf رخ نداده است - IgGIgM + -

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