Rubella

Rubella is one of the most harmless viral illnesses there is for adults – and one of the most dangerous for an unborn child in the first weeks of pregnancy. Everything there is to say about rubella in gynaecology follows from that contradiction: it is not about the illness but about protection from it, and that protection has to be in place before the pregnancy.

Why rubella matters in gynaecology

An adult who catches rubella notices nothing at all in half of cases. In the rest it runs as a mild illness with a fine-spotted rash, swollen lymph nodes behind the ears and in the neck, a slight fever and, in adults, frequently joint pain. After a few days it is over.

If, on the other hand, a pregnant woman is infected in the first weeks, the virus reaches the baby through the placenta and disrupts the organ development taking place there. The result is called congenital rubella syndrome and is one of the most severe consequences an infection in pregnancy can have.

That is why rubella protection comes near the top of every consultation before a pregnancy. And that is why measuring rubella antibodies is part of the first major blood test in the Eltern-Kind-Pass. It is just that this point is already too late for a vaccination – more on that below.

What happens with an infection in pregnancy

The timing is decisive. The risk of damage falls steeply as the pregnancy progresses, and so markedly that the whole of the counselling follows from it.

The classic triad consists of heart defects, eye damage with clouding of the lens, and inner ear deafness. Growth restriction, enlargement of liver and spleen, disorders of blood formation and damage to the central nervous system frequently come with it. Some of the consequences appear only years later, such as diabetes or progressive hearing loss.

The frequency of miscarriage is raised as well. There is no treatment that would protect the baby – neither a medicine nor the administration of antibodies. That is exactly what distinguishes it from many other infections: all that counts is whether vaccination happened beforehand.

Rubella protection: what the result means

Protection is determined from antibodies in the blood. Two doses of a measles-mumps-rubella vaccine count as full protection; on current knowledge it lasts for life. If the vaccination status is documented, the vaccination card is enough – an antibody test is then not strictly necessary.

The other situation is more common: the card is lost, incomplete, or shows only a single dose. Then the antibody titre is measured. If sufficient antibodies are present, there is protection. If they are not, or the value is borderline, vaccination follows – but not during pregnancy.

An important point for interpreting a result: in Austria the rubella titre has for some years been interpreted more cautiously than before. Two documented vaccinations count as protection, even if the measured titre is low. Anyone who has been vaccinated twice and presents a borderline value therefore as a rule needs no further vaccination and no worry.

Why the vaccination belongs before the pregnancy

The measles-mumps-rubella vaccine is a live vaccine: it contains weakened but reproducing viruses. Such vaccines are not given in pregnancy. No harm has occurred in any of the studies in which women were inadvertently vaccinated in early pregnancy – but a theoretical residual risk cannot be excluded, and so the caution remains.

In practice that means: after an MMR vaccination, pregnancy should be avoided for a month. Anyone who finds during pre-conception counselling that protection is missing therefore loses a cycle – not a great price, but one that can be avoided altogether with timely planning.

And conversely: if vaccination has inadvertently been given in an existing pregnancy, that is no reason for further measures. In the registers in which such cases were collected, not a single case of congenital rubella syndrome occurred.

After the birth, on the other hand, the vaccination is unproblematic and expressly recommended where protection is missing – including while breastfeeding. The best opportunity is the postnatal visit: if the Eltern-Kind-Pass records missing rubella protection, do not carry it over to the next pregnancy.

What to do if there was contact during pregnancy

The first step is always to look at the vaccination status. With two documented doses or proven antibodies there is protection, and the worry is settled with that.

If the status is unclear, blood is taken straight away. Two classes of antibody are looked for: IgG points to past contact or vaccination, IgM to a recent infection. Because the values are hard to interpret depending on timing, the measurement is repeated after one to two weeks and, in case of doubt, supplemented in a specialist laboratory with an avidity test, which estimates the age of the antibodies.

If a recent infection in early pregnancy is confirmed, a detailed conversation follows about the actual risk, about further investigations and about the options that follow from them. These conversations are hard, and they belong in unhurried surroundings – not on the telephone and not between two appointments.

Giving immunoglobulins after contact is regarded today as unreliable: it can soften or mask an infection, but protection of the baby is not established. It is in no case a substitute for vaccination beforehand.

How rubella is recognised – and what it is confused with

The rash begins behind the ears and on the face and spreads over the whole body within a day. It consists of small, bright red spots that stay separate and do not run together, and it disappears again after one to three days. More typical than the rash are the swollen lymph nodes behind the ears and in the neck, which appear beforehand and stay longer.

In adults, particularly in women, joint symptoms in the fingers, wrists and knees come with it. They usually last one to two weeks, occasionally longer, and heal without consequence.

Rubella is regularly confused with measles, in which the rash is large-spotted, runs together and is accompanied by high fever and a marked feeling of illness; with scarlet fever, in which the rash feels rough like sandpaper and spares the area around the mouth; and indeed with slapped cheek disease. From a distance and without experience these distinctions cannot be made reliably.

Hence a practical rule for pregnancy: diagnosis by sight does not count. Neither your own nor anyone else’s. If contact is suspected, the blood test decides – not what the rash looked like or what was said at the nursery.

How rubella is transmitted

By droplets when speaking, coughing and sneezing. The time between infection and onset is two to three weeks. An affected person is infectious from about a week before to a week after the rash appears – so also at a time when nobody yet knows it is rubella. In the half of cases that run without a rash, nobody ever knows at all.

That is precisely the problem for pregnant women: you cannot rely on avoiding contacts, because you do not recognise them. The only reliable protection is your own, and the only reliable route to it is vaccination.

A baby with congenital rubella sheds the virus for months and is infectious during that time – one reason why rubella protection among staff is watched in children’s hospitals.

Slapped cheek disease is something completely different

Hardly any confusion causes so much unnecessary worry in antenatal care – and sometimes so much overlooked genuine danger – as that between rubella (German measles) and slapped cheek disease, called “Ringelröteln” in German. The names resemble each other; the viruses have nothing to do with one another.

Slapped cheek disease is caused by parvovirus B19. In children it shows itself with a strikingly red cheek, as if someone had slapped it, and afterwards with a lace-like rash on the arms and legs. In adults the rash is often absent, and joint pain that can last for weeks is in the foreground instead.

For pregnancy slapped cheek disease is certainly relevant, but in a different way: it causes no malformations. The virus attacks the precursors of red blood cells and can lead to severe anaemia in the baby, in the worst case to hydrops fetalis. The risk exists above all between the 13th and 20th week and amounts overall to a few per cent of infections.

The decisive difference in practice: there is no vaccine against slapped cheek disease, but there is a treatment. If an infection is identified in pregnancy, the baby is monitored for weeks with ultrasound and Doppler; if anaemia appears, a blood transfusion into the umbilical cord can save the baby. With rubella it is exactly the other way round: vaccination yes, treatment no.

So if you hear about a rash at nursery, take the name precisely. And anyone working with children should know that a ban on employment can apply for slapped cheek disease too – here, however, not because a vaccination was missed, but because there is none.

Where rubella stands among pregnancy infections

In the first major blood test of the Eltern-Kind-Pass several infections are checked. It helps to know the logic of each, because it is different every time.

Rubella stands at the most awkward place in this list: it is the only line in which there is neither a treatment nor a rule of conduct that would still help during the pregnancy. Everything that counts has either happened beforehand or not.

That also explains why rubella serology remains part of the fixed programme despite good vaccination coverage. It does not investigate an illness but a gap – and the earlier that gap is known, the better it can be handled: by avoiding contacts, by paying attention where there is suspicion, and by vaccination immediately after the birth.

Alongside rubella, the same blood test establishes the blood group and includes an antibody screen, plus a blood count, syphilis and, after counselling, HIV. Toxoplasmosis is repeated later if the first result is negative. Which examination falls due when is worked out from your estimated due date by the maternity passport planner.

Occupational contact and bans on employment

Anyone working with children – in a nursery, school, childcare, paediatric practice or children’s hospital – should know their own rubella protection before a pregnancy occurs. In Austria a lack of protection in such work can lead to a ban on employment under the Maternity Protection Act.

That is not a formality but has immediate consequences for daily life and income. And it can be avoided entirely with two vaccinations and an entry in a vaccination card. If you work in one of these occupations and are planning a pregnancy, settle your vaccination status early – not only when the first test is positive.

How things stand with rubella in Austria

The rubella vaccination is part of the free childhood immunisation programme and is given as a measles-mumps-rubella combination in the first and second year of life. For adults without sufficient protection, the MMR vaccination is also available free of charge in Austria – regardless of age, at the public vaccination services.

Congenital rubella has become very rare as a result. Rare does not mean gone, however: rubella continues to circulate in parts of the world, and vaccination rates in Europe vary. For an individual woman the statistics are not the relevant figure anyway – her own protection is.

What else needs checking before a pregnancy – thyroid, iron, vitamin D, folic acid from four weeks before conception – is in the screening planner. When the examinations of the Eltern-Kind-Pass fall due is worked out by the maternity passport planner.

What this means for you

If you are planning a pregnancy or even think one possible: look in your vaccination card. If two MMR doses are recorded, the matter is settled. If there is one or none, or you cannot find the card, have the titre measured – that is one blood test, nothing more.

If protection is missing, two doses are given at least four weeks apart, and then you wait a month. That is the whole effort. Measured against what it prevents, it is the best bargain in the whole of antenatal care.

To settle your vaccination status, for pre-conception counselling or for antenatal care: make an appointment.

A last thought for perspective. Rubella is one of those subjects where the consultation almost always ends in reassurance: the great majority of women have had two doses and are protected, and the conversation takes a minute. Precisely this unspectacular course is the result of a vaccination programme that has worked for decades – and the reason why an illness that used to bring severely damaged children into the world every year now appears in training almost only as a chapter. That it has become so rare does not make the individual look in the vaccination card superfluous but worthwhile: it is the contribution that keeps it that way.