Rubella and Pregnancy

RUBELLA AND PREGNANCY

A Study of 47 Cases HARRY OxoRN,

M.D., F.R.C.S.(C.),

MoNTREAL, QuEBEC

(From the Mo11treal Obstetrhal and Gynaecological Society)

W nal rubella HI J,B the

of congeuita] anomali{'s in the newborn to mater· wdl ''stablished, the degref' of ri'>k of an almormal child's being born has not heen establishE'd conclusively. Th<' published figm·es vat·y grratly. In 194:1 Swan and assoeiatt•s' estimatetl that the risk of malfot·mation was nearly 100 per eent in women who had rubella in the first 2 months of pregnancy, and 50 per cpnt in the third month. 1'his conclusion was, howevt>t', based on retrospecth·<' studies, in that mothers of children with congenital malformations were a~ked to recall whether they had had rubella while pregnant. More recent and tnOI'f' accurate prospe~:tive studies, where Jll'(:gnant women who had rubella WN't> followed to ter·m, have not eonflrnwrl thP original and extremely pessimistit• outlook. Th1· risk of serious and l't>adily detectable abnonnalities sePms to he in the OI·der of hetwet·n JO and 20 per cent. 11 Tndividual experiencr is small. awl it will he hy the pooling of many S{'!'i(·H of east'S that a reliablt' indicHtioH of tlw
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Material An epidemic of rubella began iu 19G5 iu Montreal. A eommittt>e of the Montreal Obstetrical alJ(l Gynaecological Hociety was appointed for the pUI'pose of following the women who had rubella during pregnancy. 'l'he majority of the patients studied were delivered in 1956, having had rubella in the latter half of 19;,5 or· the early part of 19fifi. Our sedes consists of 4-7 cases of rubella during pregnancy. Bight women ha
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RUBELLA AND PREGNANCY

629

Thus there were 31 patients with rubella during the first trimester whost' pregnaneies were carried to term. In this group 25 healthy children and 6 abnormal babies were born. Most people are aware that abnormal embryos are -usually aborted spontanrouf;ly in the first trimester. The prospeetiv<' pan•nti'l want to know, therefore, what the risk is of the birth of an abnormal fetus if the woman goes to term. In our series the incidence of defectivl' ehildnm born to mothers who carried to term nftet· having had rubella in the first trimester was 19 per cent, or one in fin. Hr·ief descriptions of the 6 abmmnal child rei! follow: ( :.u;~ 1.-Deadborn macerated infant. Examination re\·ealed a Ilatent foramen ovale. a patent ductus arteriosu~. and a~piration of meconium. ( 'AH~: :.!.-Catarad8 of both eyes, congenital heart dJsPa~e, aml thromho~,rtopen i" purpura. lJies at birth and surviwd. ]t has t•oJt· :::-••nita] <'at11raets and h('art diseasP. < 'ASE 5.-This child wa~ born with microphthalmus, hut is otherwise well. <'ARE fl.-Developt>d a heart murmur Rt 6 Wt't>ks of age, and is alive a.nil •n•ll.

Thus, of the 6 abnormal children, one was born dead and 2 died at 3 weeks Three survived, one with microphthalmus, one with a heart murmur. and onp with congenital cataracts and heart disease. Fom children were small at birth. Two of these had abnormalities, whilP the othel' 2, weighing 2.250 and 1,700 g-rams, respectively. were born alive antl well. Ten women were given gamma globulin. 'l'wo of thesf' eontrart.Pd tlw rubPJla in the secm1d trimester. Of the 8 who had rubella in the first trimester, one aborted, one had a live baby with heart disease, and one had a maeerated deadhorn baby. ( >ne woman had idiopathic thrombocytopenic purpur·a as well, and l'eeein.>d Meticorten therapy from the fi:fth month to term. She had a no1·mal rhild. Four women had had trouble with previous children and wPre of special concern: (1) Had a stillbirth after a long labor and a difficult drliveJ'Y· (~) Had a child with spina bifida. (3) Had a premature baby which did not survive. (4) Had two normal children; the third was found dead in thP eat·riage at 11 weeks of age, and the fourth had aneneepha.ly assoeiated with matemal hydramnios and died. All four women had normal ehildrrn in the prrsent pregnancy associated with rubella. of ag·e.

Comment The birth of an abnormal child to a mother who had had rubella during· het· pregnancy was noted in 1882. It was not until Gregg's 4 work that the J'elationship of the two conditions was established. In 1939 many pregnant \Vomen in Australia had rubella. In 1941 an unusually large number of cases of congenital cataract was observed in Sydney. Gregg recognized the relationship between the two events, and showed that rubella in the mother was responsible for these congenital anomalies in the children. Stoekard's 6
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:'>larch, 195'1

2. 'l'he earlier the arrest. the more numerous will be the types of defect found; the later the arrest, the more limited is the variety of the deformities, as there are fewer org-ans to hr affected in their rapidly proliferating stages. :}. If development is affected at a period when no unusually rapid change:-> are taking place. the embryo may f•seape injury. 4. The same ahnorma]ity may he (•anscd hy a variPty of ag('tlts. Bffrcts on the Fetus.- \:Vhe11 a pl'r>g·Hant woman ennt1'tWtB mlwlla, or· solH~" other a<•nte inft>(•tion. thert> an• a nmHhPr of po;:;;siblr rNmlts 8 :

·1. 'l'he eonceptus may hP nnaf!'<·('h•(l. :!. The embrvo m· tf'tm; Hill\' diP nt thP iinw of tlw (Hst>ast\ with resultant ahortion or ~;tillhirth. · :1. Tn early pregmtll\'Y tht> infeetiott lll ad to lol'<~l roHgrnital almot·mn 1iti<'s and may haYe. as \Veil, a general drlf'terious rffeet on tlw ('mhryo. 'l'lw damage<} emhrvo mav: (a) he unahle to sm·•·ive to teJ'm an<1 will he ahorted or d<'livered prernatn~t~ly; (h) Jiw to tt•rnJ, hnt lw nnablr to snrviYI? thl? tr·aunHl of the hh·th pror.ess. and be stillborn: (e) lin• to tPrm, he hom alive. but eon-

g'<'nitallv defPctiv<'. ftregg suggested that these abnonnali.ties were the result of an a.nt>st in to viral and other infl'ctinns. 7 Tt is hreoming rl€'aJ' that it is the low vintlencP of rubella which t>nnhles the emhryo to survive. thongh oftf'n jn a damttg,'f'nt thP frtnx will lw affected. 'J'he rritieal prl'iod is the firxt trimestet·. Obsen~atinnR CnneerninrJ th11 lllothel'.~f\lllgeHital malfonnations simllar· 1o those assoeiate(l with rubella han~ h<•f'n seen whNI the mother was llf'rfr(•tly wrll throughout her pregnancy. 8 Thr majority of pt·egnant women wlJO l1avc rnht>lla give hi rt h to normal ('hildn:n. 11 Congenital a nom a !irs have lwen r<•portrd in ehildr<'n whoBr coneeption took plnce as long- as :1 months following mat<>rnal ruhella. 1 '\Vomen who have given birth to defrrti'n: rh11dren aftpr an nttark of rubella han hatl normal rhildren snhseqnr;ntly. 8 The Natu./'1 of the Conu~nitullhffcets. maiiily r,ataraetB; (2) <1eaf mutism; c:-n cardiac malformations; · (-+) mieJ·ocephaly; (fi) mental dcficif•ney or rrtanlation; (6) Mongolism; ( numerous miseellanenus ahnormalitirs.~ C'er·t~tin fat'ts in <'Ol1l1N'tion with th<·Bc abnormal rhildrPn haw hP<'n pointed out4 : (l) Apparently ehildr<'n are not affected when the rlisease oe.\•Url'l aftrr the fourth month of pr·egnaney. (2) 'rhr most common dt>f<•ets a1·e deaf mutism, eyr, and ht>art diRense, aml possibly nwntal defieiency. (:l) Thrre is no relation hetwe<•n the SP\'<>r·ity of the rnhella and the natur·e of tlw defect in the child. (4) Many rhildl'en :{re lwlow normal average hirtl1 ~weight. (!l) Many are late in sitting and walking. (fi) FcE?ding p1·oblems are frequent. (7) General nervous instability ix emumml. (8) Few children are mentally defective, though many an• mentally rl'tanh•r1. The majority can ht> Nlncatt>d. (9) Ruhella in pregnam•y is not hm·mful to the mother. Propose(l Preventi1•r: J ction.--~everal plan•.:; of action have been proposed in attemr1ts to Jlrennt 1h(· hirtlr of
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631

of the disease and the susceptibility of the individual. Where there arc young girls there are usually pregnant women, and the procedure may turn out to be dangerous. 2. The isolation of all pregnant women from rubella. 10 Not only would this be difficult to achieve, but many women are exposed to the disease before they realize they are pt·eg·nant. Certainly ·women in the early months of pregnaney should stay away from large groups of children. :1. The use of convalescent serum from women who have had rubella has !wen suggested, hut most workers have found this to he ineffective.' 4:. The value of gamma glohulin has not heen prowd. 5 • 10 1t iH low in antibodies. and may give a false sense of security. It is helieved that the gamma globulin can do the mother no harm, but it may mask the clinical Rigns in thP mother without proteeting- the child from damage. fi. Attempts are being made to develop an inoculation aga.inst rulwlla.~· 7 ' " This seems to he the most practical hope. fi. Certa.inly women who have rubella should wait at least three months bdor;; hctoming pregnant. i. Some investigators believe that rubella in the first trimester of preg1 natH',V L'> a valid indication for induced abortion. • 5 • 8· 10

Summary I

1. In our series 47 women had rubella while they were pregnant. ') Nine of these were affected in the second and third trimesters a11d gave hirth to normal children. :1. ~even women who had rubella in the first trimester had spontane.ous o1· incllwPd abortions. 4. Thirty-one wornen who had rulwlla in the first tt·imestcr of pregnancy <'aniecl to term. G. Twenty-five of these :n had normal children, and 6 babies were born with congenital defeds. Of these fi, one was hom dead, 2 died at 3 weeks of age, and~~ surviv€'d. 6. rrhe incidence of abnormal babies born to women who carried to term afte1· having rubella in the first trimester of pregnancy was 19 per cent, or one in five. '!'hanks are due to Drs. N. H. Chapman, J'.I. M. Gelfand, C. C. Lindsay, E. A. ~[ac Callum, and .J. G. Mulcair for their assistance in collecting the data. Cases were frmn the following Montreal hospitals: Catherine Booth, Herhert Reddy, Jewish General. Montreal General, Queen Elizabeth, Royal Vietoria, and Saint Mary's.

References 1. Abel, S., and Van Dellen, T. R.: J. A.M. A. 140: 1210, 1949. :.l. Aycock, W. L., and Ingalls, T. H.: Am. J. M. Sc. 212: 366, 1946. 3. Erickson, C. A.: .J. Pediat. 25: 281, 1944. 4. Gregg, N. MeA.: Tr. Ophth. Soc. Australia 3: 35, 1941. 5. Krugman .. S., and Ward, R.: J. Pediat. 44: 489, 1954. 6. Stockard, C. R.: Am . .J. Anat. 28: 115, 1920. 7. Swan, C., Tostevin, A. L., ::\'foore, B., Mayo, H., and Black, G. H. B.: 2: 201, 1943. 8. Swan, C.: J. Obst. & Gynaec. Brit. Emp. 56: 341 and 591, 1949. 9. Wesselhoeft, C.: New England J. Med. 236: 943 and 978, 1947. 10. Wesselhoeft, C.: New England J. Med. 240: 258, 1949. 11. Editorial: Lancet 2: 1103, 1957.

M. J. Australia