RUBELLA IN PREGNANCYHM Sulchan SofoewanDepartement of Obstetrics and Gynecology Faculty of Medicine Gadjah Mada University

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

CONGENITAL RUBELLA SYNDROMEThe 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, hepatosplenomegalyLess frequent: thrombocytopeni, meningoencephalities

EPIDEMIOLOGYAlso called German measles, caused by rubella virusMinor infections in the absence of pregnancyDuring pregnancy directly responsible for inestimable wastage, as well as for severe congenital malformation

ContinueTransmission from direct contact with the nasopharyngeal secretion of an infected personThe most contagious periode is the few days before the onset of a maculopapuler rashThe incubation period range 14 21 days

MATERNAL INFECTIONSymptomatic in 50%-70%Mild, maculopapular rash for 3 daysLow fever, headache, loss of appetide, and sore throatGeneralized lymphadenopathy (especially postauricular, occipital)Transient arthritis

FETAL INFECTIONAt least 50% infected fetuses when primary maternal infection occurs in the 1st trim, when the greatest risk of congenital anomalies exiestsMultiple organ system involvementPermanent congenital defect: cataracts, microphthalmia, glaucoma, PDA, pulmonary artery stenosis, atrioventricular septal defect, deafness, microcephaly, encephalopathy, mental retardition and motor impairement

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

CONGENITAL RUBELLA SYNDROMEEye lesions: catarract, gloucoma, microphthalmiaHeart disease: patent ductus arteriosus, septal defect, pulmonary artery stenosisSensorineural deafnessCentral nervous system defects: meningoencephalitisFetal growth restriction

ContinueThrobocytopenia and anemiaHepatitis, hepatosplenomegaly, jaundiceChronic diffuse interstitial pneumonitisOsseous changesChromosomal abnormalitis

DIAGNOSISSerology, because viral isolation technically difficult, result of tissue culture take up 6 weeksAntibody detection methods hemagglutination inhibition, RIA latex agglutinationFourfold or greater increase in titer or seroconversion indicates acute infection

Monitoring Serologi pada infeksi RubellaIgG+/IgM-Pasien ImunIgG-/IGM+Retest 1-4 mgg lagiIgG-/IgM-IgG+/IgM+IgG-/IgM+Tdk terinfeksiInfeksi primerIgM nonspesifikIgG+/IgM+-infeksi promer?-infeksi lama dg sisa IgMAviditas IgGTinggiRendahTerapiTerapi

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

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

MANAGEMENTPregnant women should undergo rubella serum evaluiationA clinical hystory of rubella unreliableIf the patient is nonimmune, she should receive rubella vaccine after deliveryContraception should be used for a minimum 3 months after vaccinationTheoretical risk of teratogenecity if vaccine is used during pregnancy

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

TO ERADICATE THE DISEASE COMPLETELYEducation of health care providers and general public on the dangeres of rubellaVaccination of susceptible women including collega health serviceVaccination of susceptible women visiting family planning clinics

ContinueIdentification and vaccination of unimmunized women immediately after childbirth or abortionVaccination of nonpregnant susceptible women identified by premarital serologyVaccination of all susceptible hospital personnel who might be exposed to patient with rubella or who might be have contact with pregnant women

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

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