Clinical Practice Guidelines Antenatal care - Module I

8.4 Rubella

Page last updated: 02 April 2013

Rubella screening in pregnancy does not attempt to identify current affected pregnancies. Instead, it aims to identify women who are nonimmune, so that they can be vaccinated after the birth and future pregnancies are protected against rubella infection and its consequences.

8.4.1 Background

Rubella (German measles) is usually a mild self-limiting disease with few complications. However, if contracted during the first trimester, it can affect the pregnancy and lead to congenital rubella syndrome at birth. Preventing congenital infection relies on maintaining high levels of immunity to rubella in the general population. There is no treatment to prevent or reduce mother-to-child transmission of rubella once infection has been detected in pregnancy. Rubella vaccination is contraindicated in pregnancy.

Rubella infection and immunity in Australia

  • Diagnoses of rubella — In 2008, there were 37 diagnoses of rubella (0.2 per 100,000 population) (NNDSS 2009). The majority were adults, with 83% of the women being of childbearing age (17–47 years).
  • Geographical distribution — Rates of diagnosis of rubella were low and fairly consistent across jurisdictions in 2008, ranging from no reported diagnoses in the ACT, NT and Tasmania to 0.1 per 100,000 population in Queensland, Victoria and NSW and 0.2 per 100,000 population in SA and WA (NNDSS 2009).
  • Congenital rubella syndrome — Only two cases of congenital rubella syndrome in babies of Australianborn mothers (Forrest et al 2003; Gidding et al 2003) have been notified since 2000.
  • Risk factors — In Australia, populations at risk of non-immunity to rubella have been identified as including:
    • women born overseas who may not have received rubella vaccines in their countries of birth (Francis et al 2003; Sathanandan et al 2005) and are twice as likely to be non-immune than Australian-born women, with a higher likelihood of non-immunity among women born in Asia (Sathanandan et al 2005);
    • Aboriginal and Torres Strait Islander women from rural and remote communities, with fewer than 75% of women tested antenatally having adequate levels of immunity (compared with more than 90% of women living in an urban area) (Hunt & Lumley 2004); and
    • women 35 years of age or older, who were found to be twice as likely to be non-immune as younger women, possibly due to declining immunity over time (Sathanandan et al 2005).

Risks associated with rubella infection in pregnancy

Maternal rubella infection can result in spontaneous miscarriage, fetal infection, stillbirth, or fetal growth restriction (Reef et al 2000). Congenital infection is most likely if the maternal infection occurs in the first 16 weeks of pregnancy, with congenital rubella syndrome occurring in all fetuses infected before the 11th week and in 35% of those infected at 13–16 weeks (Miller et al 1982). If infection occurs after 16 weeks of pregnancy, the risk of fetal damage is negligible.

Features of congenital rubella syndrome include cardiac defects, deafness, ocular defects, thrombocytopenic purpura, haemolytic anaemia, enlarged liver and spleen, and inflammation of the meninges and brain (Sanchez et al 2010). Pneumonitis, diabetes, thyroid dysfunction and progressive panencephalitis are other late expressions of the syndrome (Weil et al 1975; Cooper et al 1995).

8.4.2 Screening for rubella non-immunity

Summary of the evidence

The NICE guidelines reviewed the evidence on rubella screening in pregnancy and found:
  • high sensitivity and specificity of tests for immunity (Grangeot-Keros & Enders 1997);
  • high rates of congenital infection among babies born to women with symptoms of rubella in the first 12–16 weeks of pregnancy (Miller et al 1982; Grillner et al 1983); and
  • no association between congenital infections and inadvertent rubella vaccination in pregnancy (CDC 2001).
The lack of association between inadvertent vaccination in pregnancy and congenital rubella syndrome has been substantiated in subsequent prospective cohort studies (Bar-Oz et al 2004; Hamkar et al 2006; Badilla et al 2007), with no cases reported.

Recommendation - Grade B

14. Routinely offer and recommend testing for rubella immunity at the first antenatal visit to identify women at risk of contracting rubella and enable postnatal vaccination to protect future pregnancies.
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Recommendation - Grade A

15. Inform women who have been vaccinated against rubella before they were aware of the pregnancy that the baby is highly unlikely to have been affected by the vaccine.

Practice point

p. Women identified as non-immune to rubella antenatally should be advised to avoid contact with people experiencing possible symptoms of rubella.

8.4.3 Practice summary — rubella screening

When — Early in antenatal care
Who — Midwife; GP; obstetrician; Aboriginal and Torres Strait Islander health worker; multicultural health worker
  • Discuss rubella non-immunity — Explain that it is important to find out whether a woman is immune to rubella because of the effects that infection can have on the pregnancy and the baby.
  • Document and follow-up — Note the results of rubella screening in the woman’s record. Have a follow-up system in place so that non-immune women are offered vaccination after the birth. Some women may not develop immunity even after repeated vaccination.
  • Take a holistic approach — If a woman is found to be non-immune to rubella, offer advice on symptoms and transmission of rubella so that she can avoid contact as far as possible. Advise vaccination of family members who may also be non-immune.
  • Report inadvertent vaccination — Report inadvertent vaccination with MMR (or MMRV) to the jurisdictional immunisation unit to enable follow-up and collection of data on adverse events following immunisation with this vaccine during pregnancy.

8.4.4 Resources

South Australian Perinatal Practice Guidelines Workgroup (2004; updated 2009; reviewed 2010) Chapter 52 Rubella infection (maternal) in pregnancy. In: South Australian Perinatal Practice Guidelines. Adelaide: SA Health. For more information please visit South Australia Department of Health website.

8.4.5 References

Badilla X, Morice A, Avila-Aguero ML et al (2007) Fetal risk associated with rubella vaccination during pregnancy. Pediatr Infect Dis J 26(9): 830–35.

Bar-Oz B, Levichek Z, Moretti ME et al (2004) Pregnancy outcome following rubella vaccination: a prospective controlled study. Am J Med Gen 130A(1): 52–54.

CDC (2001) Revised ACIP recommendation for avoiding pregnancy after receiving a rubella-containing vaccine. MMWR 50: 1117.

Cooper LZ, Preblub SR, Alford CA (1995) Rubella. In: Remington JS, Klein JO (eds) Infectious Diseases of the Fetus and Newborn. 4th edition. Philadelphia: WB Saunders, p268.

Forrest JM, Burgess M, Donovan T (2003) A resurgence of congenital rubella in Australia? Commun Dis Intell 27: 533–35.

Francis BH, Thomas AK, McCarty CA (2003) The impact of rubella immmunisation on the serological status of women of child-bearing age: a retrospective longitudinal study in Melbourne, Australia. Am J Public Health 93(8):1274–76.

Gidding H, Young M, Pugh R et al (2003) Rubella in Australia: can we explain two recent cases of congenital rubella syndrome? Commun Dis Intell 27: 537–40.

Grangeot-Keros L & Enders G (1997) Evaluation of a new enzyme immunoassay based on recombinant Rubella virus like particles for detection of immunoglobulin M antibodies to Rubella virus. J Clin Microbiol 35: 398–401

Grillner L, Forsgren M, Barr B (1983) Outcome of rubella during pregnancy with special reference to the 17th–24th weeks of gestation. Scand J Infect Dis 15: 321–25.

Hamkar R, Jalilvand S, Abdolbaghi MH et al (2006) Inadvertent rubella vaccination of pregnant women: evaluation of possible transplacental infection with rubella vaccine. Vaccine 24(17): 3558–63.

Hunt JM & Lumley J (2004) Top end rural and remote Indigenous women: an Australian population group vulnerable to rubella. Commun Dis Intell 28(4): 499–503.
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Miller E, Cradock-Watson JE, Pollock TM (1982) Consequences of confirmed maternal rubella at successive stages of pregnancy. Lancet 2: 781–84.

NNDSS (2009) Australia’s Notifiable Disease Status, 2008: Annual Report of the National Notifiable Diseases Surveillance System. NNDSS Annual Report Writing Group.

Reef SE, Plotkin S, Cordero JF et al (2000) Preparing for congenital syndrome elimination: summary of the Workshop on Congenital Rubella Syndrome Elimination in the United States. Clin Infect Dis 31: 85–95.

Sanchez E, Atabani SF, Kaplanova J et al (2010) Forgotten but not gone. Brit Med J 341: c5246.

Sathanandan D, Gupta L, Liu BH et al (2005) Factors associated with low immunity to rubella infection on antenatal screening. Aust NZ J Obstet Gynaecol 45(5): 435–38.

Weil ML, Itabashi H, Cremer NE et al (1975) Chronic progressive panencephalitis due to rubella virus stimulating subacute sclerosing panencephalitis. N Engl J Med 292: 994–98.