Please note that all guidance is currently under review and some may be out of date. We recommend that you also refer to more contemporaneous evidence in the interim.
Rubella is a congenital infection which can occur during pregnancy or the peripartum period. Also referred to as German Measles.
It is one of a number of organisms that can cause congenital neonatal illness with devastating long-term consequences.
The timing of infection is important in regards to the severity of neonatal illness.
Most people develop immunity to rubella (if they are not immunised) during childhood.
In non-immunised populations, 10-20 per cent of women of child bearing age are susceptible.
Other issues to note:
- Re-infection occurs in around 2 per cent of people but is generally subclinical.
- Cases of congenital infection have been described with maternal re-infection.
- Rubella vaccination is effective in almost totally eliminating congenital rubella infection - provided coverage remains high.
Clinical features
Clinical features:
- Most congenital infection is the result of primary maternal infection.
- The mother may have had little, if any, symptoms of infection.
| Onset of maternal infection | Fetal complications |
|---|---|
| < 12 weeks | Congenital rubella syndrome (> 90%) |
| 12-18 weeks | Sensorineural deafness (20%) |
| > 18 weeks | Rare |
Congenital rubella syndrome
Congenital rubella syndrome is a severe, disabling condition. Features include:
- eye disorders 10-25% (cloudy cornea/cataracts, salt and pepper chorioretinitis, microphthalmia)
- sensorineural deafness (60-75%)
- cardiovascular 10-20% (pulmonary stenosis and PDA)
- microcephaly
- growth restriction
- haemopoietic disorders
- hepatosplenomegaly
- lymphadenopathy
- thrombocytopenia
- anaemia
- extramedullary heamopoiesis (blueberry muffin skin appearance)
- long bones radiolucencies seen on x-ray
- pneumonitis with associated respiratory signs
- renal tract abnormalities
- intellectual disability.
Investigations
Diagnosis is usually demonstrated by evidence of maternal seroconversion or rising IgG titres, which occur some 10 days after contact. Issues to note:
- IgM assay is useful where exact 'contact time' is not known.
- IgM persists for around two months after primary infection.
- Re-infection can be identified by seeing a four-fold or more rise in IgG titres.
Fetal diagnosis
Fetal diagnosis is possible from:
- cord blood IgM
- rubella PCR of amniotic fluid.
Postnatal diagnosis
Postnatal diagnosis is by:
- IgM
- isolation of rubella virus (possible form many sites including NPA, eye, throat, CSF, stool and urine for up to 12 months).
Other tests
Other tests include:
- FBE
- renal function and electrolytes
- liver function tests
- cranial ultrasound (looking for discrete calcification)
- echocardiography (looking particularly for pulmonary stenosis and PDA)
- renal ultrasound
- lumber puncture (pleocytosis with elevated protein)
- chest x-ray (indicated if the baby has respiratory symptoms)
- long bone x-rays
- hearing assessment is mandatory, even in babies with no overt disease at birth (deafness may be progressive, and therefore serial hearing assessments over the first few years of life are essential)
- ophthalmological assessment, which is also essential and progressive retinal damage can be seen.
Endocrine problems can occur in the long term including diabetes mellitus and hypothyroidism.
Management
There is no specific treatment for rubella.
Breast feeding is not contraindicated.
Management is supportive and aimed at addressing specific problems present including:
- developmental
- sensory
- endocrine
- cardiac.
Regular assessments (3-6 monthly) necessary in the first few months/ years of life to detect emergence of late abnormalities.
Prevention
Prevention issues for rubella infection:
- Rubella immunisation is offered to all children in combination with measles and mumps vaccination at one year of age.
- Immunisation reduces the ‘viral pool’ in the population and helps protect susceptible pregnant women.
- New arrivals into Australia are a potential group of susceptible individuals.
- All women should be screened at first antenatal clinic appointment and if found to be rubella susceptible offered immunisation in the postpartum period.
- If rubella infection is confirmed in the pregnant woman, then appropriate counselling is essential to provide the woman with information regarding the likely effects on the unborn child and options for management.
- Infants are infectious for at least 12 months after birth & an infection risk for susceptible female staff & pregnant contacts
- Contact isolation is required for congenitally infected infants as they will shed virus for many months.
- Only staff immune should care for the baby in hospital and pregnant visitors should be warned.
Outcome
Issues:
- Children with congenital rubella syndrome are likely to have severe developmental issues.
- Ongoing hearing and vision assessments are essential in babies whose mothers contracted rubella after 12 weeks' gestation.
- Rarely, a form of subacute sclerosing panencephalitis, with demonstration of raised rubella antibodies in CSF, has been documented.
More information
Further reading
- Palasanthiran, P. (et al). 'Management of Perinatal Infections'. Australian Society for Infectious Diseases. 2014 (p. 57-61)
- Isaacs D, Moxon ER. ‘Handbook of Neonatal Infections - a practical guide’. WB Saunders, London. 1999.
- Remington JS, Klein JO. ‘Infectious Diseases of the Fetus and Newborn Infant" 5Th Ed. WB Saunders, Philadelphia. 2000.
- Davies EG, Elliman DAC, et al. ‘Manual of Childhood Infections’. WB Saunders, London, 1996.
- Jeffries DG, Hudson CN. ‘Viral infections in Obstetrics and Gynaecology’. Arnold, London, 1999.
- Murph JR. Rubella and syphilis: continuing causes of congenital infection in the 1990s. Seminars in Pediatric Neurology. 1(1):26-35, 1994 Sep.
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Version history
First published: March 2014
Last reviewed: October 2018
Review by: August 2019
Uncontrolled when downloaded
Page last updated: 17 Feb 2021