A suspected viral rash in pregnancy

What you need to know

·         Consider country of originin a woman presenting with a rash in pregnancy and ask for immunisationhistory.

·         Test for measles andrubella IgM and IgG antibodies, particularly if immunisation history is notclear.

·         Refer women with an activeinfection to the fetal medicine unit for fetal monitoring.

 A pregnant woman at 12 weeks’gestation seeks help for a red rash covering her back and chest. She is worriedthat the rash might be caused by a virus. She is originally from Bangladesh andis unsure about her vaccination history.

Viral exanthema can cause rash in apregnant woman and should be considered even in countries that havecomprehensive vaccination programmes. In the UK, for example, three cases ofcongenital rubella syndrome have been notified in recent years in women bornoutside the UK.¹ Thisarticle focuses on viral rashes. For a more general overview of rash inpregnancy, see the review by Vaughan-Jones et al.²

Vaccination coverage for viral infectionsvaries globally. The World Health Organization estimates that adult varicellaimmunity is greater than 95% in the US but only 75% in India.³ Similarly,global measles and rubella immunisation coverage is only 85% and 44%,respectively.⁴

These infections have consequences formother and fetus. Measles and rubella can cause intrauterine death.Intrauterine infection with rubella can lead to congenital rubella syndrome inthe liveborn baby, characterised by deafness, eye abnormalities, congenitalheart disease, and learning disability.^5- 6 Meanwhile,the current Zika virus epidemic has garnered international attention for itslink to microcephaly and birth defects.⁷

What you should cover

 History

    Ask about

- Location ofthe rash; speed, and date of onset.

 -Associated symptoms: fever, sore throat, and malaise suggest an infectiouscause. Itching is usually suggestive of a non-viral cause (fig 1).⁸

- Vaccination.Has the patient received two doses of measles, mumps, and rubella vaccine?Public Health England recommends asking pregnant women for this information attheir initial antenatal appointment.⁴ Ifavailable, review documented evidence of vaccination, as patients might not recallor be familiar with the vaccines.⁹ In somecountries, measles and rubella vaccines are administered separately and youmight need to ask about each.

- History ofchickenpox or if the woman has received the vaccine.

- Antibodytesting for viral infections in previous pregnancy, or if she has beenvaccinated since.

- Country oforigin, as vaccination coverage can vary.

- Recent travelto countries where rubella and measles are endemic. Travel to South America orthe Caribbean in the last two weeks should prompt consideration of Zika virus.¹⁰

- Contact withunwell people with a rash, or with someone who has travelled to an endemiccountry recently.

- Sexual historyfor suspected Zika virus infection and HIV.⁷

- Duration ofpresent pregnancy. Rubella poses the highest risk in the first trimester.Varicella can cause congenital varicella syndrome if the mother is infected inthe first 20 weeks of pregnancy, or neonatal chickenpox if infected in thethird trimester.⁸

- Drug history.If the patient is on immunosuppressants or steroids, herpes zoster may be morelikely. Some medications can cause rashes and a careful drug history iswarranted.

Fig 1 Diagnosticflow chart for rash in pregnancy.⁸ CMV:cytomegalovirus. EBV: Epstein Barr virus. Source: adapted from HealthProtection Agency Rash Guidance Working Group, Guidance on viral rashin pregnancy; 2011

Examination

Assess general wellbeing and vitalparameters. A fever should prompt consideration of infectious causes.

Examine the rash:

·Is the rash vesicular or maculopapular? (fig 1, fig2, fig 3) A vesicular rash suggests varicella or herpes infection.¹¹ Ifmaculopapular, consider other viral infections.

· Distribution of the rash: a viral exanthem isfrequently found on the trunk and limbs. Varicella often follows a dermatomalpattern, and herpes simplex can present with genital lesions. Appearance of therash might vary based on skin complexion.

·Associated examination findings: neck stiffnesscould suggest meningitis; generalised lymphadenopathy could suggest HIV.

Figure 1 presents one approach suggestedfor rash in pregnancy.⁸Table 1 showscommon viral causes of rash in pregnancy.

Fig 2 Rash caused by rubella virus

Fig 3 Varicella rash (Shingles) showingvesicles

Table 1  Commonviral causes of a rash in pregnancy

*PCR: Polymerasechain reaction

What youshould do

Investigations

If a viral exanthem is suspected, offertesting for measles, rubella, parvovirus B19, varicella, and possibly Zikavirus. Take blood for serology to test for IgM and IgG antibodies.¹⁵ Seebox 1 for information to be included when requesting the test. Where available,polymerase chain reaction for virus isolation can be requested.

In general, a positive IgM and IgGdemonstrate acute infection; but IgG only positivity reflects previous exposureor vaccination.¹⁶

Counselthe woman regarding the need to screen for these conditions. A helpful phrasemight be, “I’m unsure of the cause of the rash at this point, but I will do x,y, and z to investigate what’s causing it.”

Box 1: Information to be recordedon the blood test request

·         Name, age, date of birth,address

·         Duration of pregnancy inweeks

·         Date of onset of rash,clinical features, type and distribution of rash

·         Antibody testing, if known

·         Vaccine history includingdates and places, if known

·         Any known contacts who areunwell with rash, and dates of contact

·        Source: adapted from HealthProtection Agency Rash Guidance 

Working Group, Guidance on viral rashin pregnancy; 2011

Education into practice

Do youroutinely ask for vaccination history in women of child bearing age when theyregister with your practice?

How patients were involved in thecreation of this article

We askeda pregnant woman with a rash to review the article. She said, “If there'sanything that can be done to prevent things from worsening (eg, situations Ishould avoid, etc). that information would be quite helpful. I would likely bequite concerned about the health of the baby, and I would want the GP to bewilling to answer any questions I have.” We thereby inserted specific ways the GPcould address concerns.

Management

Arrange a follow-up appointment to discussthe results and prepare the patient for possible referral to a fetal medicineunit if the results indicate active infection.^16 17

Be prepared to answer questions aboutpotential risks to the baby, as this will likely be her main concern. Explainthat positive serology in the mother may not correlate with infection in thefetus. Avoid using words like “testing the fetus” or “termination ofpregnancy,” as at this stage it is too early to predict the effect on the fetusfrom initial investigations. The fetal medicine unit might monitor withfrequent ultrasonography rather than perform invasive fetal testing.

Advise avoiding contact with other pregnantwomen or children to minimise transmission. If Zika is suspected, adviseabstaining from sexual intercourse, and to use mosquito nets and repellants.¹³ Mostwomen will need MMR vaccination after the pregnancy if non-immune to measles orrubella.¹⁸

Jack Carruthers, honoraryclinical research fellow¹,

Alison Holmes, professor ofinfectious diseases²,

Azeem Majeed, professor ofprimary care¹

¹Department of Primary Care andPublic Health, Imperial College London, London, UK

²Department of Medicine,Imperial College London, London, UK

Correspondence to JCarruthers [email protected]

This is part of a series of occasionalarticles on common problems in primary care. The BMJ welcomescontributions from GPs.

Thanks to KF for her invaluable input inthe role of providing the patient’s perspective. Imperial College London isgrateful for support from the Northwest London National Institute forCollaboration for Leadership in Applied Health Research and Care and theImperial NIHR Biomedical Research Centre. The views expressed in thispublication are those of the authors.

Contributors: JC was the lead author on thearticle and is the guarantor; AH and AM edited the article; KF contributed thepatient’s perspective and helped to review the manuscript. JC affirms that themanuscript is an honest, accurate, and transparent account of the study beingreported; that no important aspects of the study have been omitted; and that anydiscrepancies from the study as planned (and, if relevant, registered) havebeen explained.

Competing interests: We have read andunderstood the BMJ policy on declaration of interests and declare no competinginterests.

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