Congenital Rubella

In a pregnant patient, 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 and neonate, there may be no symptoms or there may be intrauterine fetal demise or multiple congenital abnormalities referred to as congenital rubella syndrome (CRS). The most frequent abnormalities include

• Preterm delivery

• Intrauterine growth restriction

• Microcephaly

• Meningoencephalitis

• Cataracts

• Retinopathy

• Hearing loss

• Cardiac defects (patent ductus arteriosus and pulmonary artery stenosis)

• Hepatosplenomegaly

• Bone radiolucencies

Less common clinical 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 infection may develop immune deficiencies such as hypogammaglobulinemia.

• Maternal serum rubella titers

• Viral detection in the mother via cell culture and/or polymerase chain reaction (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 patients routinely have a serum rubella IgG titer measured early in pregnancy. Titer is repeated in people 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. PCR or viral culture also can be used to confirm infection.

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 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 or increase in rubella-specific IgG in the infant after 6 to 12 months suggests congenital infection. Detection of rubella-specific IgM antibodies typically also suggests congenital rubella infection, but false-positive IgM results can occur. PCR of specimens obtained from the nasopharynx or throat is the preferred method of detection. Collection of ≥ 1 specimen type (eg, nasopharyngeal, urine, cataract) increases sensitivity. Nasopharyngeal samples 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 radiographic examination of the bones to detect characteristic radiolucencies. Thorough ophthalmologic and cardiac evaluations are also useful.

• Supportive care

No specific therapy is available for maternal or congenital rubella infection.

Pregnant patients who are not immune to rubella (negative rubella IgG) and are exposed to rubella early in pregnancy should be informed of the potential risks to the fetus. Serial antibody testing is performed to detect IgM, which indicates acute infection, followed by the presence of IgG. Routine use of immune globulin for postexposure prophylaxis in nonimmune pregnant patients is not recommended by the American Academy of Pediatrics (1) but is recommended in some countries (2).

Rubella can be prevented by vaccination. In the United States, infants should receive a combined measles, mumps, and rubella (MMR) vaccine. The first dose is given at 12 to 15 months of age and the second dose is given at 4 to 6 years (see Childhood Vaccination Schedule).

People capable of becoming pregnant who do not have serologic evidence of immunity should receive at least 1 dose of the MMR vaccine (1). (CAUTION: Rubella vaccination is contraindicated in immunodeficient or pregnant patients.) After vaccination, people 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. Pregnant patients who are found to be susceptible during prenatal screening should be vaccinated after delivery (typically before hospital discharge).