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, Riehle Colarusso & 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, Ulloa Gutierrez & 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 & Avila Aguero, 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, Ulloa Guitierrez & 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 16 th 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. (4 th ed. pp. 838-839). St Louis, MO: Saunders Elsevier.
Baley, J.E. & Toltzis, P. (2011). Perinatal viral infections. In R.J. Martin, A.A. Faranoff & M.C. Walsh (Eds.). Neonatal- Perinatal medicine. Diseases of the fetus and infant. (9 th ed., pp. 876-877). St. Louis, MO: Mosby, Inc.
Berghella, V., Buchannan, E., Pereira, L., & Baxter, J.K. (2010). Preconception care. CME Review Article. 65(2), 119-131. Dewan P. & Gupta P. (2012). Burden of congenital rubella syndrome (CRS) in India: a systematic review. Indian Pediatrics, 49(5), 377-99. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference &D=medl&NEWS=N&AN=22700664.
References cont.
Dontigny, L., Arsenault, M., Martel, M. (2008). Rubella in pregnancy. Society of Obstetrics and Gynaecologists of Canada. 30(2): 152-158 Retrieved from http://sogc.org/wp content/uploads/2013/01/guiJOGC203CPG0802.pdf
Forsey, J.T., Elmasry, O.A. & Martin, R.P. (2009). Patent arterial duct. Orphanet Journal of Rare Diseases, 4 17. Doi:10.1186/1750-1172-4-17 Modrzejewska, M., Lachowicz, E., Karczewicz, D., & Zdanowska, A. (2011). Chorioretinitis in infants. Klinika Oczna, 113(10-12), 352-6. Retrieved from ttp://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference& D=medl&NEWS=N&AN=22384654.
Morice, A., Ulloa-Guitierrez, R., & Avila-Aguero, M.L. (2009). Congenital rubella syndrome: progress and future challenges. Expert Review of Vaccines, 8, 323-31. Doi:10.1586/14760584.8.3.323
References cont.
Oster, M.E., Riehle-Colarusso, T. & Correa, A. (2010). An update on cardiovascular malformations in congenital rubella syndrome. Birth Defects Research, 88, 1-8. doi:10.1002/bdra.20621
Rasmussen, S.A. (2012). Human teratogens update 2011: can we ensure safety during pregnancy?. Birth Defects Research, 94, 123-8. doi:10.1002/bdra.22887
Riley, L.E. (2014). Rubella in pregnancy. UptoDate. Retrieved from http://www.uptodate.com/contents/rubella in-pregnancy Saraswathy, T.S., Rozainanee, M.Z., Asshikin, R.N. & Zainah, S. (2013). Congenial rubella syndrome: a review of laboratory data fro 2002 to 2011. Southeast Asian Journal of Tropical Medicine & Public health, 44(3), 429-35. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference &D=medl&NEWS=N&AN=24050074.