Transcript Maternal Rubella and the Effects on the Fetus

Maternal Rubella and the
Effects on the Fetus
GNRS 5631: NNP I
Presented by: Leann Henson
Objectives
 Maternal and fetal pathophysiology
 Impact of the maternal condition on the fetus
 Clinical manifestations and diagnostic evaluations
of the neonate
 Therapeutic approaches and treatment options
 Pertinent theories and Evidence based practice
 Economic, emotional and social implications on the
family unit
Maternal and fetal
pathophysiology
 Contracting rubella, also known as the German
measles, is typically a mild, self-limiting disease, known
by its characteristic rash.
 A person is contagious from seven days before to five
to seven days after the onset of the rash
 It can be asymptomatic in 25-50 % of cases
 The rash usually starts on the face and then spreads to
the trunk and the extremities. It resolves in the same
order as it appears (Dontigny, Arsenault, & Martel,
2008).
Maternal and fetal pathophysiology
 While the disease rubella is self-limiting in
most people, for the developing fetus it
can have devastating effects.
 It can result is spontaneous abortion,
fetal infection, stillbirth, or intrauterine
growth restriction.
 The maternal-fetal transmission is by
hematogenous spread and it varies with
the gestational age of the fetus.
 Evidence supports the spread of the
rubella virus through the vascular system
of the developing fetus after infecting the
placenta.
 The defects that result from this infection
are from cytopathic damage to blood
vessels and ischemia to the affected
organs (Riley, 2014).
Maternal and fetal pathophysiology
 Maternal infection in the first 16 weeks of pregnancy poses
the greatest concern (Riley, 2014).
 In the first trimester fetal infection rates are close to 80%.
 The rates drop to 25% as the pregnant woman nears the
end of the second trimester and then rises again to 35% at
27-30 weeks gestation.
 Beyond the 36 week mark, infection rate increases to 100%
(Dontigny, Arsenault, & Martel, 2008).
 The sequelae of intrauterine growth restriction are
associated with the third trimester infections.
 Also, there is no known risk to the fetus if the mother
contracts rubella immediately prior to pregnancy.
 Of note, there have been cases of congenital rubella
syndrome (CRS) after the woman has been reinfected
during pregnancy (Riley, 2014).
Impact of the maternal condition on
the fetus
 The clinical manifestations of the rubella virus on the infant
can be transient, permanent or of late-onset appearance
(Morice, Ulloa-Guitierrez & Avilla-Aguero, 2009).
 Some of the birth defects that are seen with CRS are
auditory (sensorineural deafness) and ophthalmic which
include cataracts, microphthalmia, glaucoma, and
chorioretinitis.
 The cardiac defects include patent ductus arteriosus,
peripheral pulmonary artery stenosis, and atrial or
ventricular septal defects.
 There are also neurologic abnormalities such as
microcephaly, meningoencephalitis, and mental retardation.
 Some other associated conditions are radiolucent bone
defects, hepatosplenomegaly, thrombocytopenia, and
purpuric skin lesions (Saraswathy, Rozainanee, Asshikin &
Zainah, 2013).
Impact of the maternal condition
on the fetus
 During the first eight weeks of pregnancy, when
organogenesis occurs, rubella causes congenital heart
disease.
 The most common lesion is patent ductus arteriosis. It
may occur alone or with pulmonary artery or valvular
stenosis. There may be stenosis of other vessels
also (Baley & Toltzis, 2011).
 Some other common problems are microcephaly and
neuropsychiatric problems. Long-term outcome studies
have shown that 26% of the children who have CRS
were severely mentally retarded (Baley & Toltzis, 2011).
Impact of the maternal condition
on the fetus
 Prognosis for infants exposed in utero
depends on the severity of the symptoms
and also on the number of organs
involved.
 When there is multisystem involvement,
the mortality rate in the first year of life
can approach 80%.
 Sometimes the consequences of
congenital rubella are not seen at first.
The may appear months later, making it is
necessary for ongoing follow-up and
evaluation after discharge.
 Problems that can arise are
communication disorders, hearing defects,
and mental or motor retardation (Askin &
Diehl-Jones, 2010).
Clinical manifestations and diagnostic
evaluations of the neonate
 A high index of suspicion is necessary for early diagnosis
of infants with CRS to facilitate early intervention for
specific disabilities.
 Infants that are moderately to severely affected are
easier to recognize at birth.
 When an infant only has one sign or symptom, a hearing
defect is the most common.
 Deafness and cardiac abnormalities may only be
detected months to years later, or may not ever be
detected(Saraswathy et al., 2013).
Clinical manifestations and diagnostic
evaluations of the neonate
 Infants with CRS may shed the virus in the
urine, feces and skin and may be infectious
until their first birthday; 60% of infants may
shed the rubella virus up to four months of
age.
 Appropriate infection control
measures need to be enforced.
 The virus can be transmitted by
airborne droplets from the upper
respiratory tract of active cases;
therefore early diagnosis is imperative
to prevent the spread of the virus.
 Pregnant women who are not immune must
not be exposed to infants with CRI
(Saraswathy et al., 2013).
Clinical manifestations and diagnostic
evaluations of the neonate
 Serological testing must be performed to diagnose maternal rubella as
using clinical findings is unreliable.
 If it is unknown if the mother has received prior vaccination at the time
she presents with a rash illness, acute phase titers should be obtained
within seven days of the illness.
 If she is seropositive, there is prior immunity and very little risk of
infection of the fetus. If a woman has very low titers, she is at risk for
reinfection.
 If there is an increase in serum antibody titers in the acute phase, it
should be repeated in the convalescent phase, 10 to 14 days later; and
should be run in the same laboratory.
 After four weeks of exposure and antibody is not present
another serum sample should be tested at the six week
mark for certainty (Baley & Toltzis, 2011).
Clinical manifestations and diagnostic
evaluations of the neonate
 Diagnosis of CRI and CRS can be difficult. It focuses on
virus isolation from nasal, throat and urine samples.
 It can be done by virus detection by RT PCR. It also is
done by detection of rubella specific IgM in the cord or
serum samples from the child.
 The most common method to confirm infection is by
detection of the virus specific IgM and IgG in serum
because it is simple to perform and does not require
sophisticated equipment or specialized training
(Saraswathy et al., 2013).
Clinical manifestations and diagnostic
evaluations of the neonate
 An infant that is suspected to have CRS or born to a
mother that was suspected of being exposed to the
rubella virus should have a complete evaluation and
diagnostic workup.
 Isolation of the rubella virus from the infant is a definite
diagnosis.
 While the virus is usually isolated from the nasopharynx,
blood, and urine samples, it can also be isolated from
the lens of the eye or CSF years later (Baley & Toltzis,
2011).
Therapeutic approaches and
treatment options
 Rubella treatment may include acetaminophen for relief of
symptoms.
 Patients that are suffering from complications such as
thrombocytopenia or encephalopathy may be treated with
glucocorticoids, platelet transfusion and other supportive
measures.
 The pregnant woman's prognosis is excellent, but because
of the devastating effects on the fetus, the woman should
be counseled about the maternal-fetal transmission.
 With this in mind, she should be offered pregnancy
termination if she contracted rubella prior to 16 weeks
gestation.
 In the patient that is past the 20 week gestation mark,
management should be individualized.

Parents should also be counseled about delayed effects and
consequences of the rubella infection.
 At this time, there is no treatment that is beneficial in utero
for the exposed or affected fetus (Riley, 2014).
Therapeutic approaches and
treatment options
 Immune globulin therapy for pregnant women who are
infected with rubella is considered controversial.
 No data exists that suggests IgG has any benefit to the
fetal response to the disease.
 The Centers for Disease Control and Prevention (CDC)
recommends limited use to women who have declined
pregnancy termination and are known to be exposed to
the rubella virus (Riley, 2014).
Therapeutic approaches and
treatment options
 Patent ductus arteriosis (PDA) is the most common fetal
cardiovascular malformation (CVM) associated with congenital
rubella syndrome (CRS).
 This was first noted by Gregg in 1941 and was confirmed by
Campbell in 1961 in his review of the literature stating that
65% of the cases he reviewed with CRS and a CVM had a PDA.
 These findings were based primarily on clinical examination,
but now more advanced diagnostic techniques such as
catheterization or echocardiography can be used.
 With the advances came the discovery of other cardiac lesions
in association with CRS, such as pulmonary artery stenosis.
 With further study of the CVMs of CRS, an improved
understanding of the pathogenic effects of rubella on the fetus
and the cardiac embryology may be reached (Oster, RiehleColarusso & Correa, 2009).
Pertinent theories and Evidence based
practice
 In 1941, Norman Gregg identified
rubella as a human teratogen when he
observed congenital cataracts in 78
infants and that 68 of the infants were
born to mothers who had contracted
rubella during pregnancy.
 After this discovery, development of a
vaccine against rubella and a program
for vaccination was implemented.
 Subsequently, elimination of the rubella
virus from the United States was
achieved (Rasmussen, 2012).
Pertinent theories and Evidence based
practice
 The only effective way to prevent rubella during
pregnancy is through immunization.
 According to the World Health Organization (WHO), in
2002 there were 123 countries that were using the
vaccine routinely. In some countries immunization was
introduced among certain populations. In Malaysia,
female school children 12 years old and reproductive age
women were given the monovalent rubella vaccine.
 Even though high vaccine numbers were reported there
were still CRS cases.
 Also, about forty percent of the female population of
child bearing age was susceptible (Saraswathy et al.,
2013).
Pertinent theories and Evidence based
practice
 In 1972, Costa Rica initiated vaccination against the rubella
virus to specific target groups and with very low coverage.
 After the passing of several decades, universal vaccination
for young children was introduced with the combined triple
viral measles, mumps and rubella (MMR) vaccine.
 Initially, the targeting of both adolescents and child-bearing
age mothers was not planned.
 A shift of susceptible age groups was seen over the years to
adolescents and adults so the vaccination strategy was
readdressed and focused on men and women of child
bearing age.
 A national action plan was started to work toward the
elimination of CRS and this also led to a postpartum
vaccination strategy.
 In May 2001, a national catchup immunization plan for
adults was started (Morice, Ulloa-Gutierrez & Avila-Aguero,
2009).
Pertinent theories and Evidence based
practice
 Prior to the rubella vaccine, preschool and school age
children had the highest rates of infection.
 Vaccinations targeted this population in order to
interrupt the virus circulation and limit the exposure risk
of women at childbearing age.
 This did drastically reduce the number of cases but it
shifted the risk groups to adolescents and young adults.
 This pattern was reported by the United States and by
some European countries.
 The pattern of rubella shows a different pattern when
comparing pre and post vaccination data (Morice, UlloaGutierrez & Avila-Aguero, 2009).
Pertinent theories and Evidence based
practice
 In the population of people over 15 years of
age, the proportion of cases shifted in the
United States.
 In 1966 to 1968, this population reported 23%
of the cases and in 1975 to 1977 the cases
jumped to 62%.
 By the year 2000, 87% of the cases were in the
age group 15 to 39.
 Even though the number of cases reported in
the USA had gone down, the cases of CRS were
continuing to occur.
 Because of these findings, changes in
immunization strategies were employed
allowing for the elimination of the disease.
 As of 2004, the USA has enough evidence to
confirm that the country interrupted the
endemic transmission of the rubella virus
(Morice, Ulloa-Gutierrez & Avila-Aguero, 2009).
Pertinent theories and Evidence based
practice
Most experts agree that the primary purpose of
controlling rubella is to stop CRS.
 To achieve this it is necessary to maintain elevated
coverage rates in children and in adults (predominantly
childbearing age women) and to keep adequate records for
surveillance of rubella and CRS.
 The seroprevalence status of the population in different age
and gender groups affects the incidence of rubella infection.
 The immunity that results from vaccination and from
infection with the virus itself is high and protects the person
from acquiring the infection for the remainder of their life.
 It is necessary to perform timely interventions when
outbreaks are detected (Morice, Ulloa-Gutierrez & AvilaAguero, 2009).
Pertinent theories and Evidence
based practice
A study was conducted to try to determine the
etiology of chorioretinitis.
 Out of a group of 984 children, a group of four infants with
chorioretinitis were selected. Out of these four, one was born at
term and three were born before term. Three of the children
were male and one was female. They were all physiologically
born and breastfed on demand.
 The ophthalmological exams were done according to standard,
laboratory tests performed, and on the basis of subjective,
objective and additional tests, a diagnosis of chorioretinitis was
made.
 In two of the cases, the disease was caused by CMV infection,
and in the other two cases, it was caused by toxoplasmosis,
rubella, and CMV.
 The treatment plan for these children was generally and locally
administered antibiotics, steroids, and antiviral medications.
 Improvement in both eyes and remission of symptoms was
achieved (Modrzejewska, Lachowicz, Karczewicz, & Zdanowska,
2011).
Economic, emotional and social
implications on the family unit
 The defects that are observed in the
infants and children with congenital
rubella syndrome (CRS) have a
negative impact on the family
environment and therefore the family
dynamics.
 But the impact is not only on the
family but also on society, as the high
cost for healthcare systems for these
children is factored into the economy
and society in general (Morice, UlloaGuitierrez & Avilla-Aguero, 2009).
Economic, emotional and social
implications on the family unit
 A priority to any medical visit by a reproductive age woman
should include asking her about her reproductive health
plan.
 Along with discussing timing of pregnancies, nutrition,
weight, exercise, and supplements, discussion about
vaccines is important.
 Maternal immunity to infections such as rubella should be
addressed and assessed for potential vaccination in the
nonimmune woman.
 This can help eliminate the risk for congenital syndromes
associated with the virus.
 Vaccination should occur at least four weeks prior to
conception with a live-attenuated virus due to the risk of
the live virus affecting the fetus.
 There is evidence that supports specific preconception
interventions in all women and also in women with specific
risk factors (Berghella, Buchanan, Pereira, & Baxter, 2010).
Economic, emotional and social
implications on the family unit
 It is important for women to be aware of the evidence
based recommendations by their doctors and also through
public service awareness campaigns.
 Women and their partners need to take responsibility for
the care of their future offspring and implement the
changes necessary.
 It has been shown that preconception planning increases
cooperation of the women involved and decreases
terminations of pregnancies.
 This leads to cost savings due to fewer hospitalizations for
the mother.
 It also saves due to fewer anomalies for the fetus.
 A child that is suffering due to a consequence of a missed
opportunity for prevention in preconception care is a burden
to not only the family, but for the whole community
(Berghell et al., 2010).
Conclusion
 Rubella, a virus of the Togaviridue family,
Rubivirus genus, is a mild viral illness, but
one of high public health importance due to
the devastating effect on the developing
fetus, including miscarriage, fetal death, or
an infant born with congenital rubella
syndrome (CRS).
 The best way to prevent rubella and CRS is
through universal immunization of all infants
and identification and immunization of
women at risk.
 It is important for diagnosis to be made
quickly, as contact with rubella should be
avoided throughout the first and second
trimester.
 Women should be counseled about the risk
for vertical transmission and possible
termination of the pregnancy if they become
infected prior to the 16th week of gestation.
 Since there is no treatment available for the
infected fetus, prevention is the best
strategy to eliminate all cases of CRS
(Dontigny, Arsenault, & Martel (2008).
References
 Askin, D.F. & Diehl-Jones, W. (2010). Ophthalmologic and
auditory disorders. In M.T.Verklan, M. Walden (Eds.). Core
curriculum for neonatal intensive care nursing. (4th ed. pp.
838-839). St Louis, MO: Saunders Elsevier.
 Baley, J.E. & Toltzis, P. (2011). Perinatal viral infections. In
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References cont.
 Dontigny, L., Arsenault, M., Martel, M. (2008). Rubella in
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 Forsey, J.T., Elmasry, O.A. & Martin, R.P. (2009). Patent
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 Modrzejewska, M., Lachowicz, E., Karczewicz, D., &
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 Morice, A., Ulloa-Guitierrez, R., & Avila-Aguero, M.L. (2009).
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References cont.
 Oster, M.E., Riehle-Colarusso, T. & Correa, A. (2010). An
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 Rasmussen, S.A. (2012). Human teratogens update 2011:
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 Riley, L.E. (2014). Rubella in pregnancy. UptoDate.
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 Saraswathy, T.S., Rozainanee, M.Z., Asshikin, R.N. & Zainah,
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