In the prevaccination era, 80% of women were already infected by childbearing age.
Clinical Features
maculopapular rash
lymphadenopathy
fever
arthropathy (up to 60% of cases)
Rash of Rubella
Risks of rubella infection during pregnancy
Preconception minimal risk
0-12 weeks 100% risk of fetus being congenitally infected
resulting in major congenital abnormalities.
Spontaneous abortion occurs in 20% of cases.
13-16 weeks deafness and retinopathy 15%
after 16 weeks normal development, slight risk of deafness and retinopathy
Congenital Rubella Syndrome
Classical triad consists of cataracts, heart defects, and sensorineural deafness. Many other abnormalities had been described and these are divided into transient, permanent and developmental.
60% of the population eventually become infected. In some developing countries, the figure is up to 95%.
Congenital Infection
Defined as the isolation of CMV from the saliva or urine within 3 weeks of birth.
Commonest congenital viral infection, affects 0.3 - 1% of all live births. The second most common cause of mental handicap after Down's syndrome and is responsible for more cases of congenital damage than rubella.
Transmission to the fetus may occur following primary or recurrent CMV infection. 40% chance of transmission to the fetus following a primary infection.
May be transmitted to the fetus during all stages of pregnancy.
No evidence of teratogenecity, damage to the fetus results from destruction of target cells once they are formed.
Liver - hepatosplenomegaly and jaundice which is due to hepatitis.
Lung - pneumonitis
Heart - myocarditis
Thrombocytopenic purpura, Haemolytic anaemia
Late sequelae in individuals asymptomatic at birth - hearing defects and reduced intelligence.
Incidence of Cytomegalic Disease
Diagnosis
Isolation of CMV from the urine or saliva of the neonate.
Presence of CMV IgM from the blood of the neonate.
Detection of Cytomegalic Inclusion Bodies from affected tissue (rarely used)
Management
Primary Infection - consider termination of pregnancy.
40% chance of the fetus being infected.
10% chance that congenitally infected baby will be symptomatic at birth or develop sequelae later in life.
Therefore in case of primary infection, there is a 4% chance (1 in 25) of giving birth to an infant with CMV problems.
Recurrent Infection - termination not recommended as risk of transmission to the fetus is much lower.
Antenatal Screening – impractical.
Vaccination - may become available in the near future.
Neonatal Herpes Simplex (1)
Incidence of neonatal HSV infection varies inexplicably from country to country e.g. from 1 in 4000 live births in the U.S. to 1 in 10000 live births in the UK.
The baby is usually infected perinatally during passage through the birth canal.
Premature rupturing of the membranes is a well recognized risk factor.
The risk of perinatal transmission is greatest when there is a florid primary infection in the mother.
There is an appreciably smaller risk from recurrent lesions in the mother, probably because of the lower viral load and the presence of specific antibody.
The baby may also be infected from other sources such as oral lesions from the mother or a herpetic whitlow in a nurse.
Neonatal Herpes Simplex (2)
The spectrum of neonatal HSV infection varies from a mild disease localized to the skin to a fatal disseminated infection.
Infection is particularly dangerous in premature infants.
Where dissemination occurs, the organs most commonly involved are the liver, adrenals and the brain.
Where the brain is involved, the prognosis is particularly severe. The encephalitis is global and of such severity that the brain may be liquefied.
A large proportion of survivors of neonatal HSV infection have residual disabilities.
Acyclovir should be promptly given in all suspected cases of neonatal HSV infection.
The only means of prevention is to offer caesarean section to mothers with florid genital HSV lesions.
Parvovirus
Causative agent of Fifth disease (erythema infectiosum), clinically difficult to distinguish from rubella.
Also causes aplastic crisis in individuals with haemolytic anaemias as erythrocyte progenitors are targeted.
Spread by the respiratory route, 60-70% of the population is eventually infected.
50% of women of childbearing age are susceptible to infection.
VZV can cross the placenta in the late stages of pregnancy to infect the fetus congenitally.
Neonatal varicella may vary from a mild disease to a fatal disseminated infection.
If rash in mother occurs more than 1 week before delivery, then sufficient immunity would have been transferred to the fetus.
Zoster immunoglobulin should be given to susceptible pregnant women who had contact with suspected cases of varicella.
Zoster immunoglobulin should also be given to infants whose mothers develop varicella during the last 7 days of pregnancy or the first 14 days after delivery.
