SDMS ID: P2010/0478-001 WACSClinProc1.

15 Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Parvovirus B19 and Rubella Exposure in Pregnancy New Guideline Exposure and management of rash illness in pregnancy Midwives and medical officers, QVMU Parvovirus B19, rubella P2010/0317-001Varicella-Zoster Virus Exposure and Infection in Pregnancy and Newborn Period

Purpose: Viral illness during pregnancy can have detrimental effects on the developing fetus. Apart from varicella in the seven days before delivery, the infections which may have a specific impact on the fetus (rubella, parvovirus B19, varicella zoster) only do so if infection occurs in the first 20 weeks of gestation. All women with a non-vesicular rash should be investigated for rubella and parvovirus B19. Definition: Significant exposure is defined as living in the same household, or direct face-to-face contact for at least 5 minutes, or being in the same room for at least one hour. Parvovirus B19 There are a wide range of potential consequences of parvovirus B19 infection, ranging from minor febrile illness to erythema infectiosum (slapped cheek syndrome), generalised rash illness, arthralgia and persistent infection in the immunocompromised. Parvovirus B19 infection is common, with some 50 -60% of adults having been infected. No vaccine or preventive measures are available and increased incidence occurs every three to four years, largely in schoolchildren. Pregnant woman with significant exposure to parvovirus should have serum collected, as soon as possible after contact, and tested for parvovirus B19 specific IgG and IgM. Failure to detect parvovirus B19 specific IgM excludes infection in the four weeks prior to collection of the serum. Hence, infection cannot be excluded if investigation commences more than four weeks after the onset of rash. If parvovirus B19 IgM is detected in the first 20 weeks of pregnancy, confirmation is required by an alternative assay. Repeat testing will demonstrate a decline in IgM reactivity and provide an additional confirmation method. Parvovirus B19 is a small single-stranded DNA virus and a potent inhibitor of erythropoieses. Infection during pregnancy can cause several serious complications in the fetus, such as fetal anaemia, neurological anomalies, hydrops fetalis and fetal death. If maternal infection has occurred, ultrasound investigation of the fetus and measurement of the peak systolic flow velocity of the middle cerebral artery are sensitive non-invasive procedures to diagnose fetal anaemia and hydrops. Ultrasound scanning of the fetus is started at 4 weeks post onset of illness or date of seroconversion, and then at 1 -2 weekly intervals until 30 weeks gestation. An increase in middle cerebral artery (MCA) peak systolic velocity results from increased cardiac output and decreased velocity of fetal blood in the response to anaemia. Referral to a fetal medicine unit for fetal intrauterine transfusion can improve the outcomes.
Parvovirus B19 and Rubella Exposure in Pregnancy May-11 WACSClinproc1.15

Investigation for parvovirus B19

Parvovirus B19 and Rubella Exposure in Pregnancy May-11

WACSClinproc1.15

Management of Confirmed Parvovirus B19 Infection in Pregnancy

Parvovirus B19 and Rubella Exposure in Pregnancy May-11

WACSClinproc1.15

Rubella The risk to the fetus is primary rubella in the first 16 weeks of gestation with major and varied congenital abnormalities being associated with infection in the first trimester, and a lesser risk, limited to deafness, in the fourth month. Rubella infection prior to the estimated date of conception or after 20 weeks carries no documented risk, and rubella between 16 and 20 weeks gestation carries a minimal risk of deafness only. If a woman has had one of the following, she should be reassured that the likelihood of rubella is extraordinarily remote, that specific investigation is not required, but to return if a rash develops: at least two previous rubella antibody screening tests which have detected antibodies at least two documented doses of rubella vaccine one documented dose of vaccine followed by rubella antibody screening test which has detected antibodies. If rubella susceptibility is possible, a serum should be obtained as soon as possible after contact. It should be tested rubella-specific IgG and IgM. If rubella-specific IgG is detected, and rubella-specific IgM is not detected there is no evidence of recent primary rubella. In a pregnant woman with the onset of a rash in the previous 10 days, if a low concentration of rubella specific IgG is detected, a further serum should be requested even if a rubella-specific IgM is not detected.

Investigation for Rubella

Parvovirus B19 and Rubella Exposure in Pregnancy May-11

WACSClinproc1.15

If primary rubella is confirmed by laboratory tests in the first 12 weeks of pregnancy the risk of congenital defects is very high and termination of pregnancy should be offered. Prenatal diagnosis may be useful to assess the risk to the fetus when rubella occurs during 12 18 weeks gestation, when laboratory diagnosis is inconclusive and when rubella reinfection occurs before 12 weeks gestation. Amniotic fluid is the preferred sample as amniocentesis is less invasive than feta blood sampling.

Attachments
Attachment 1

References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years via Policy and Procedure working group coordinated by the Clinical and Quality improvement midwife. November 2009 Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: _13 December 2007_

Parvovirus B19 and Rubella Exposure in Pregnancy May-11

WACSClinproc1.15

ATTACHMENT 1 REFERENCES Best, J 2007 Rubella, Seminars of Fetal & Neonatal Medicine, vol. 12, p. 182- 192. De Jong, E, De Haan, T, Kroes, A, Beersma, M, Oepkes, D & Walther F 2006 Parvovirus B19 infection in pregnancy Journal of Clinical Virology, vol. 36 p. 1-7. De Santis, M, Cavaliere, A, Straface, G & Caruso, A 2006 Rubella infection in pregnancy, Reproductive Toxicology, vol. 21, p. 390-398. Enders, M, Schalasta, G, Baisch, C, Weidner, A, Pukkila, L, Kaikkonen, L, Lankinen, H, Hedman, L, Soderlund-Venermo, M & Hedman, K 2006 Human parvovirus B19 infection during pregnancy Value of modern molecular and serological diagnostics Journal of Clinical Virology, vol.35, p.400-406. Frydenberg, A & Starr, M 2003 Slapped cheek disease: How it affects children and pregnant women Australian Family Physician, vol. 32, no. 8, p. 589-592. Morgan-Capner, P & Crowcroft, NS 2002 Guidelines on the management of, and exposure to, rash illness in pregnancy (including consideration of relevant antibody screening programmes in pregnancy Communicable Disease and Public Health, vol. 5, no. 1, p. 59-71. Servey, J, Reamy, B & Hodge, J 2007 Clinical presentations of parvovirus B19 infection American Family Physician, vol. 75, no. 3, p. 373-376.

Parvovirus B19 and Rubella Exposure in Pregnancy May-11

WACSClinproc1.15