(pregnant)

1. (pregnant)

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

3. Rubella & Pregnancy • Rubella is the first virus demonstrated as a teratogen. • Humans are the only natural host of rubella virus(EXCLUSIVELY) S.R.Tabatabaei MD,MPH - PIRC

4. Rubella in Pregnant Women • What happened when a pregnant woman exposed to RUELLA? S.R.Tabatabaei MD,MPH - PIRC

5. Rubella in Pregnant Women • When a pregnant woman is exposed to rubella What should we do? S.R.Tabatabaei MD,MPH - PIRC

6. Gregg´s congenital rubella syndrome Gregg was the first to describe the 3 characteristic manifestations of CRS: -heart disease -cataracts -deafness S.R.Tabatabaei MD,MPH - PIRC

7. ”Gregg´s children” at school in 1948 S.R.Tabatabaei MD,MPH - PIRC

8. Rubella in Pregnant Women • Why? • Maternal Infection • Maternal viremia • Intrauterine Transmission • CRS S.R.Tabatabaei MD,MPH - PIRC

9. Rubella in Pregnant Women • The most important determinant of fetal infection & fetal defects is: GESTATIONAL AGE S.R.Tabatabaei MD,MPH - PIRC

10. Rubella in Pregnant Women • 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 S.R.Tabatabaei MD,MPH - PIRC

11. Rubella in Pregnant Women • What happened for mother when she exposed to RUELLA? • Immunity(+) “ (-): -nothing -Infection -subclinical, symptomatic S.R.Tabatabaei MD,MPH - PIRC

12. RUBELLA: • 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 postoccipitallymphadenopathy (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. S.R.Tabatabaei MD,MPH - PIRC

13. Clinical Features • maculopapular rash • lymphadenopathy • fever • arthropathy (up to 60% of cases) S.R.Tabatabaei MD,MPH - PIRC

14. Consequences of CRI during pregnancy : • Maternal rubella during pregnancy can resultin: -miscarriage, -fetal death, -congenital rubella syndrome -Late sequels years later -placental infection ± persistent fetal infection -no infection(counseling?) S.R.Tabatabaei MD,MPH - PIRC

15. Rubella in Pregnant Women • The most important thing is: GESTATIONAL AGE • Fetal Inf. (Miller & colleagues) 90% <11 wk G.A 67% 13-14 25% 23-26 53% Third trimester 100%(last month of pregnancy) • Congenital defect: 90% if maternal infection < 11wk (<8wk,first month) 33% 11-12 wk 11% 13-14 24% 15-16 Uncommn >16 S.R.Tabatabaei MD,MPH - PIRC

16. Rubella in Pregnant Women • 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 S.R.Tabatabaei MD,MPH - PIRC

17. Pathogenesis: • 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 S.R.Tabatabaei MD,MPH - PIRC

18. Rubella in Pregnant Women • 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 S.R.Tabatabaei MD,MPH - PIRC

19. Rubella in Pregnant Women • CRS is not a static disease • ¾ of infected infants show NO apparent involvement at birth but experience consequences years later Sonography (NL?) conselling S.R.Tabatabaei MD,MPH - PIRC

20. Rubella in Pregnant Women Recommendation: all rashes in pregnancy be investigated S.R.Tabatabaei MD,MPH - PIRC

21. S.R.Tabatabaei MD,MPH - PIRC

22. Rubella in Pregnant Women 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 beretested (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 S.R.Tabatabaei MD,MPH - PIRC

23. Typical Serological Events following acute rubella infection Note that in reinfection, IgM is usually absent or only present transiently at a low level S.R.Tabatabaei MD,MPH - PIRC

24. How to Counsel this pregnant women ? • 1- IG • 2- VACCINE • 3- Termination of pregnancy • 4- NOTHING S.R.Tabatabaei MD,MPH - PIRC

25. IG (immune globulin) • 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. S.R.Tabatabaei MD,MPH - PIRC

26. Rubella vaccine: • 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 S.R.Tabatabaei MD,MPH - PIRC

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

28. Children of pregnant women: • 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 S.R.Tabatabaei MD,MPH - PIRC

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

30. Prevention (1) • 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. S.R.Tabatabaei MD,MPH - PIRC

31. Prevention (2) 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. S.R.Tabatabaei MD,MPH - PIRC

32. What is the best strategy? Vaccination of women In child-bearing age S.R.Tabatabaei MD,MPH - PIRC

33. نمونه مجدد 3-2 هفته بعد و چک همزمان آن با نمونه اول احتمال بیشتر مصون است - + نمونه مجدد 6 هفته بعد از مواجهه و چک همزمان با نمونه اول + recent infection - Inf رخ نداده است 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 IgG IgM - + S.R.Tabatabaei MD,MPH - PIRC

34. No Question? S.R.Tabatabaei MD,MPH - PIRC

35. Thank you S.R.Tabatabaei MD,MPH - PIRC