( See also Rubella Rubella (See also Congenital Rubella.) Rubella is a viral infection that may cause adenopathy, rash, and sometimes constitutional symptoms, which are usually mild and brief. Infection during early pregnancy... read more and Overview of Neonatal Infections Overview of Neonatal Infections Neonatal infection can be acquired In utero transplacentally or through ruptured membranes In the birth canal during delivery (intrapartum) From external sources after birth (postpartum) Common... read more .)
Congenital rubella typically results from a primary maternal infection. Congenital rubella is now rare in the US because of very successful immunization programs (see Effectiveness and Safety of Childhood Vaccination Childhood Vaccination Vaccination has been extremely effective in preventing serious disease and in improving health worldwide. Because of vaccines, infections that were once very common and/or fatal (eg, smallpox... read more ).
Rubella is believed to invade the upper respiratory tract, with subsequent viremia and dissemination of virus to different sites, including the placenta. The fetus is at highest risk of developmental abnormalities when infected during the first 16 weeks of gestation, particularly the first 8 to 10 weeks. Early in gestation, the virus is thought to establish a chronic intrauterine infection. Its effects include endothelial damage to blood vessels, direct cytolysis of cells, and disruption of cellular mitosis.
Symptoms and Signs of Congenital Rubella
In a pregnant woman, rubella may be asymptomatic or characterized by upper respiratory tract symptoms, mild fever, conjunctivitis, lymphadenopathy (especially in the suboccipital and posterior auricular areas), and a maculopapular rash. This illness may be followed by joint symptoms.
In the fetus, there may be no effects, death in utero, or multiple anomalies referred to as congenital rubella syndrome (CRS). The most frequent abnormalities include
Intrauterine growth restriction
Cardiac defects (patent ductus arteriosus Patent Ductus Arteriosus (PDA) Patent ductus arteriosus (PDA) is a persistence of the fetal connection (ductus arteriosus) between the aorta and pulmonary artery after birth. In the absence of other structural heart abnormalities... read more and pulmonary artery stenosis)
Less common manifestations include thrombocytopenia with purpura, dermal erythropoiesis resulting in bluish red skin lesions, adenopathy, hemolytic anemia, and interstitial pneumonia. Ongoing observation is needed to detect subsequent hearing loss, intellectual disability, abnormal behavior, endocrinopathies (eg, diabetes mellitus), or a rare progressive encephalitis. Infants with congenital rubella infections may develop immune deficiencies such as hypogammaglobulinemia.
Diagnosis of Congenital Rubella
Maternal serum rubella titers
Viral detection in the mother via culture and/or reverse transcriptase–polymerase chain reaction (RT-PCR) of amniotic fluid, nose, throat (preferred), urine, cerebrospinal fluid (CSF), or blood specimens
Infant antibody titers (measured serially) and viral detection as above
Pregnant women routinely have a serum rubella IgG titer measured early in pregnancy. Titer is repeated in seronegative women who develop symptoms or signs of rubella; diagnosis is made by a positive serologic test for IgM antibody, IgG seroconversion, or a ≥ 4-fold rise between acute and convalescent IgG titers. Virus may be cultured from nasopharyngeal swabs but is difficult to cultivate. RT-PCR can be used to confirm culture results or detect viral RNA directly in patient specimens as well as allow for genotyping and epidemiological tracking of wild-type rubella infections.
Fetal infection can be diagnosed in a few centers by detecting the virus in amniotic fluid, detecting rubella-specific IgM in fetal blood, or applying RT-PCR techniques to fetal blood or chorionic villus biopsy specimens.
Infants suspected of having congenital rubella syndrome should have antibody titers and specimens obtained for viral detection. Persistence of rubella-specific IgG in the infant after 6 to 12 months suggests congenital infection. Detection of rubella-specific IgM antibodies generally also indicates rubella infection, but false-positive IgM results can occur. Specimens from the nasopharynx, urine, CSF, buffy coat, and conjunctiva from infants with CRS usually contain virus; samples from the nasopharynx usually offer the best sensitivity for culture, and the laboratory should be notified that rubella virus is suspected.
Other tests include a complete blood count (CBC) with differential, CSF analysis, and x-ray examination of the bones to detect characteristic radiolucencies. Thorough ophthalmologic and cardiac evaluations are also useful.
Treatment of Congenital Rubella
Possibly immune globulin for the mother
No specific therapy is available for maternal or congenital rubella infection.
Women exposed to rubella early in pregnancy should be informed of the potential risks to the fetus.
Some experts recommend giving nonspecific immune globulin (0.55 mL/kg IM) for exposure early in pregnancy, but this treatment does not prevent infection, and the use of immune globulin should be considered only in women who decline pregnancy termination.
Prevention of Congenital Rubella
Rubella can be prevented by vaccination. In the US, infants should receive a combined measles, mumps, and rubella vaccine Measles, Mumps, and Rubella (MMR) Vaccine The measles/mumps/rubella vaccines (MMR vaccines) effectively protect against all 3 infections ( measles, mumps, rubella). Historically, people who are given the MMR vaccine according to the... read more . The first dose is given at 12 to 15 months of age and the second dose is given at 4 to 6 years of age (see Childhood Vaccination Schedule Childhood Vaccination Schedules Vaccination has been extremely effective in preventing serious disease and in improving health worldwide. Because of vaccines, infections that were once very common and/or fatal (eg, smallpox... read more ). Postpubertal nonpregnant females who are not immune to rubella should be vaccinated. (CAUTION: Rubella vaccination is contraindicated in immunodeficient or pregnant women.) After vaccination, women should be advised not to become pregnant for 28 days.
Efforts should also be made to screen and vaccinate high-risk groups, such as hospital and child care workers, military recruits, recent immigrants, and college students. Women who are found to be susceptible during prenatal screening should be vaccinated after delivery and before hospital discharge. Theoretically, vaccination of nonimmune people exposed to rubella might prevent infection if done within 3 days of exposure, but this treatment has not proved to be beneficial.
People with documented vaccination with at least one dose of live-attenuated rubella virus-containing vaccine after age 1 year or who have serologic evidence of immunity can be considered immune to rubella.
Maternal rubella infection, particularly during the 1st trimester, can cause intrauterine growth restriction and serious developmental abnormalities.
Routine rubella vaccination has made congenital rubella rare in the US.
Rubella vaccine is contraindicated in pregnancy, so pregnant women with rubella or exposed to it should be informed of the potential risk to the fetus.