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RUBELLA IN

PREGNANCY
HM Sulchan Sofoewan
Departement of Obstetrics and
Gynecology Faculty of Medicine
Gadjah Mada University

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

CONGENITAL RUBELLA
SYNDROME
The most common abnormalities
associated with 1st trim infection are:
hearing loss in 60%-75%; eye defect: 5090%%; heart disease: 40-85%;
psychomotor retardation: 25-40%
Other abnormalities are: IUGR,
hepatosplenomegaly
Less frequent: thrombocytopeni,
meningoencephalities

EPIDEMIOLOGY
Also called German measles, caused by
rubella virus
Minor infections in the absence of
pregnancy
During pregnancy directly responsible for
inestimable wastage, as well as for severe
congenital malformation

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Transmission from direct contact with the
nasopharyngeal secretion of an infected
person
The most contagious periode is the few
days before the onset of a maculopapuler
rash
The incubation period range 14 21 days

MATERNAL INFECTION
Symptomatic in 50%-70%
Mild, maculopapular rash for 3 days
Low fever, headache, loss of appetide,
and sore throat
Generalized lymphadenopathy (especially
postauricular, occipital)
Transient arthritis

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

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

CONGENITAL RUBELLA
SYNDROME

Eye lesions: catarract, gloucoma,


microphthalmia
Heart disease: patent ductus arteriosus,
septal defect, pulmonary artery stenosis
Sensorineural deafness
Central nervous system defects:
meningoencephalitis
Fetal growth restriction

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Throbocytopenia and anemia


Hepatitis, hepatosplenomegaly, jaundice
Chronic diffuse interstitial pneumonitis
Osseous changes
Chromosomal abnormalitis

DIAGNOSIS
Serology, because viral isolation
technically difficult, result of tissue culture
take up 6 weeks
Antibody detection methods
hemagglutination inhibition, RIA latex
agglutination
Fourfold or greater increase in titer or
seroconversion indicates acute infection

Monitoring Serologi pada infeksi Rubella


IgG+/IgMPasien Imun

IgG-/IgM-

IgG-/IGM+
IgG+/IgM+

Retest 1-4 mgg lagi

IgG+/IgM+

-infeksi promer?
-infeksi lama dg sisa
IgM
IgG-/IgM+
Aviditas IgG

Tdk terinfeksi

Infeksi primer

Terapi

IgM nonspesifik

Tinggi

Rendah

Terapi

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

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

MANAGEMENT
Pregnant women should undergo rubella
serum evaluiation
A clinical hystory of rubella unreliable
If the patient is nonimmune, she should
receive rubella vaccine after delivery
Contraception should be used for a
minimum 3 months after vaccination
Theoretical risk of teratogenecity if vaccine
is used during pregnancy

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

TO ERADICATE THE DISEASE


COMPLETELY
Education of health care providers and
general public on the dangeres of rubella
Vaccination of susceptible women
including collega health service
Vaccination of susceptible women visiting
family planning clinics

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

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

THANK YOU