Rubella and pregnancy

Rubella is a mild viral infection also known as German measles or three-day measles. It's typically so mild that little treatment is necessary. If you contract rubella during the first 20 weeks of pregnancy, however, there's a serious risk that your baby may develop congenital rubella syndrome (CRS), which can result in miscarriage, stillbirth or severe birth defects.


Causes/associated factors
Rubella is caused by a virus. It occurs most often in late winter and spring. Once the virus lodges within the upper respiratory tract, it reproduces and spreads to the lymph nodes (small, round structures located throughout the body that help protect the body from invasion by bacteria or other organisms) and bloodstream. The virus may eventually affect the skin, central nervous system and, for pregnant women, the developing fetus. Once you contract rubella, you're not likely to develop it again.
Since rubella immunization programs were introduced in the United States in 1969, the number of reported cases of rubella has dropped significantly. Before the vaccine was available, preschool and elementary school children were at the greatest risk of rubella. Today, it's most prevalent in adults who were never properly immunized.


Transmission
The rubella virus is spread by inhaling or having direct contact with infected respiratory droplets. The incubation period (time from exposure to appearance of symptoms, if they appear at all) is from 12 to 23 days. You're contagious for about a week before and after the rash appears, if it appears at all. You're considered contagious during the same time frame even if you have mild symptoms or none at all.

Signs/symptoms
Twenty to 50 percent of all people who contract rubella have no symptoms. For others, symptoms may be so mild they're overlooked. If symptoms do appear, the most prominent are extremely enlarged lymph nodes around the ears and back of the neck, which develop up to a week before a rash breaks out. The lymph nodes may remain swollen for several weeks. This red and sometimes itchy rash has raised pinpoints. It often starts on the face and quickly spreads from head to foot, lasting three to four days. Remember, not everyone with rubella will develop a rash.
Other symptoms may include:

fever up to 101°F
fatigue
runny nose
inflammation of the lining of the eyes
headache
joint pain or swelling, especially for adults

Diagnosis
Diagnosis is based on symptoms if they're present. This can be unreliable, however, because rubella can resemble other infections. Blood tests are done routinely during the first prenatal visit to check for rubella antibodies. If you're not immune to rubella and are exposed to the disease, consult your doctor immediately. If rubella is suspected, you'll be monitored for symptoms. About two to four weeks after exposure, blood will be drawn and compared to your original blood sample. If antibodies develop in the later sample, you'll be diagnosed with rubella and your fetus may be at risk of developing congenital rubella syndrome.
The rubella virus can be identified through tissue or fluid samples taken from the nose, throat, blood, urine or spinal fluid. This test is not standard practice because it takes a while to complete and isn't available in many labs, but it's especially useful if congenital rubella syndrome is suspected.


Treatment
If you've been exposed to the virus, consult your doctor about the possible risks. If you have a first trimester infection, you and your doctor may choose to terminate the pregnancy. If you decide against therapeutic abortion or it's not an option, you may be given a medication called immune globulin, which acts as an antibody to help your body fight the infection. There is no proof congenital rubella syndrome can be prevented, however.
Other treatment measures are based on your symptoms. Get plenty of rest and closely monitor your symptoms. The doctor may recommend a medication for fever and pain. Because rubella is caused by a virus, an antibiotic won't be effective.

Infants born with congenital rubella syndrome or whose mothers had rubella during pregnancy will be isolated from other infants and any other susceptible people. Treatment will depend on the birth defects present.


Complications
If you're pregnant and have never had rubella or been immunized and contract the virus during the first 20 weeks of pregnancy, there is a serious risk that the virus will travel across the placenta (the structure that develops in the womb to nourish the growing fetus and help discard waste) and cause congenital rubella syndrome. The effect of rubella on the fetus depends on when the infection develops and the stage of fetal organ development at the time. Many babies whose mothers are infected with rubella during the first trimester (12 weeks) develop one or more birth defects due to the infection. Infections contracted after the 20th week are rarely responsible for birth defects.
Congenital rubella syndrome can cause:

deafness
cataracts (a cloudy area in the lens of the eye, the clear structure that focuses light rays onto the retina) and other eye problems
meningoencephalitis (inflammation of the membrane covering the brain and spinal cord)
mental or growth retardation
heart defects
bone disease
liver or spleen damage
an increased risk of diabetes appearing during childhood or as an adult
miscarriage
stillbirth
An infant born with congenital rubella syndrome may sometimes be easily diagnosed at birth. In some cases, however, birth defects may not be identified until several months or even years later. If the doctor suspects that your infant has congenital rubella syndrome, cultures of respiratory droplets and urine can be taken to identify the presence of the rubella virus. These cultures will be repeated periodically until they're negative and the infant is no longer contagious, typically after age 1. While the baby is contagious, he or she may spread the virus through his or her urine or respiratory droplets. Without proper precautions, this puts other infants and susceptible adults at risk, especially pregnant women.

For adults, rubella may lead to encephalitis (inflammation of the brain) or arthritis (inflammation of a joint) that may last up to a month.


Prevention
All women of childbearing age who are not pregnant and are unprotected against rubella should receive a measles, mumps and rubella (MMR) vaccine. If you're not pregnant and are unsure of your immunization status, check with your doctor. If you're pregnant and haven't already had a positive blood test for rubella antibodies, you'll be given the test when you begin prenatal care.
The rubella vaccine is a "watered down" live virus vaccine that can't be given during pregnancy because of the risk of infecting the fetus. If you're pregnant and not immune to rubella, avoid exposure to anyone who's infected. After the baby is born, your doctor may recommend a rubella immunization -- maybe even before you leave the hospital. You'll need to avoid pregnancy for at least one month after the immunization, but breastfeeding is safe immediately.