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- [00:08]
News Anchor
A measles outbreak in the US has grown to nearly 100 cases, most in the state of Texas. It's the largest outbreak in that state in three decades, affecting mostly children and teenagers. Sixteen are in the hospital. There are more cases in New Mexico, meanwhile, and health officials expect that number to grow. So let's talk about it.
- [00:28]
Dr. Smith
So that was a recent CBS News brief focusing on the new contagion in the US Specifically two states right now. But if we've learned anything over the last several years is that what happens in one location doesn't stay there. Okay. Because we're such mobile people, there's such a rate of, of travel and people go to one place or the other for work or whatever is that what happens in one place does not stay there. So this is the problem. So I thought, you know, originally I was going to do desensitization of aspirin in pregnancy. I still may do that as a next episode because that's a brand new publication that just came out on February 17th in the gray Journal about desensitization for those who have NSAID allergy. Super fascinating. But I thought maybe we should put that on hold because this is making progress right now. Is the U.S. measles outbreak. Yes, it's related right now to West Texas and parts of eastern New Mexico. But get ready because this is likely going to go all throughout the US So we've got to talk about this as to how it affects and what are the implications for obstetrics and gynecology. Now, obviously, I mean, it's bad for, you know, a variety of people, older immunocompromised children and pregnant women. But nonetheless, you know, you're if you just do gynecology only that's important to talk about in those patients as well. But no question the higher risk in women is in the pregnant state. So we're going to talk about this because it's a good reminder of what to look for. What do we do for post exposure prophylaxis? What's the timeframe for that? What are the days where it's actually effective? And we're going to review something we all learned in medical school or nursing school or PA school or whatever kind of school you trained about what this looks like. Because something starts as an exanthem, a skin rash on the chest and then move outward, something start from the top down. You remember that. So we're going to talk about all this in this episode. So this is our measles refresher because we have to. So we're Going to talk about this. The college did have recent guidance on this. Through a practice advisory. We're going to highlight CDC information. We're going to highlight best practice for keeping patients safe from this new contagion. So here we go. Let's talk about measles. It is highly contagious. So let's get into that. Coming up next. This is clinical Pearls. Jack.
- [04:12]
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- [04:57]
Dr. Smith
All right, let's say it right away. Let's just knock it out. Let's just get the elephant in the room. Out of the room. Yes, this is largely, of course, in unvaccinated individuals. I'm not anti vax. However, I also understand the mistrust of the medical community, especially in certain populations, otherwise known as the Hispanic and predominantly African American communities, where they're like, I'm not taking that. I remember Tusigi. I remember some stuff. I mean, let's just be honest. We did that to ourselves. Now, I don't mean that us personally. I mean the medical community, government agencies, it is what it is. That's why there is an inherent distrust of vaccinations. I get that. Now, I'm not saying I endorse that. I'm saying I get that. All right, so be very clear. I'm not anti vax. But I also respect somebody's deep rooted concerns. And so our job is as clinicians, as medical educators is to help bridge that gap. Not ridicule anybody, not punish anybody. Jugger what I'm talking about. I mean, we have to be respectful here and understand some people's hesitancy to do that. I get that. Now, whether you like it or not, that's. That is completely their choice. Okay? So I get that that goes for HPV vaccination, that goes for anything else. So I just want to make that clear because one of the new sources that we searched while we were looking to do the intro to this episode. I mean, it was. I mean, some of this stuff is just. Just poking the bear. So there was a national news source that said, well, this infection is predominantly an unvaccinated individual. You don't say, wow, well, that's brilliant. That's newsworthy, right? That statement is newsworthy. Of course it's an unvaccinated people, because vaccination is highly effective against the condition. My point is that we can say the information without trying to blame or shame or pick on anybody for whatever they choose to do with their vaccination. Okay, can we just say that out there? I mean, let's just. Let's be honest. All right, Having said that, measles is a problem. It's highly contagious. It's a problem during pregnancy. We're gonna get into that, obviously. But I wanna talk about big scale here. What does exposure look like? What does this rash look like? What do we do with a patient, especially who is pregnant? When do we offer them MMR vaccination? Spoiler? Not during pregnancy. And when do we offer them internal terms of post exposure prophylaxis? We're going to talk about this. Measles is an acute viral respiratory illness that comes with fever, malaise, cough, there's conjunctivitis. Remember the little dots in the mouth? Anyone? Anyone? Those are pathognomonic for the infection. Those are called Koplik spots. You all remember that? K, O, P, L, I, K, coplic spots. Then comes the maculopapular rash. Now, it's important to remember what this coplic spots look like. So somebody comes in, they look kind of achy. You swab them for the flu. Like, look, it's not influenza A or B. It's not Covid. You're fine. No, no, you gotta look in the mouth. Because small white, little pinpoint lesions that are surrounded by a red halo, that can be coplyx spots. And if you do that, you gotta send the appropriate swabs, including blood, for serology to see what's going on. All right, Most of these things are pcr. But don't ignore the mouth. Now, this usually appears opposite the lower molars. They can be present as isolated or in clust. They can be scattered. So look in the mouth. These are small, little white or bluish white in color by a red halo. Look in the lower parts of the. Of the oral mucosa by the molars. All right, so those are complex spots. The idea here Guys, here's a clinical pearl viral illness. Look in the mouth, look in the mouth. Just make sure you're not missing anything. It takes two seconds. That is characteristic of measles. And they typically appear one to two days before the onset of the rash. So again, guys, clinical pearl, look in the mouth because you're going to see that first and then you're going to get the rash. So the rash is one of the later manifestations of measles that is pathognomonic of the infection. Super important. Now, speaking about the rash, remember we said something start at the trunk and then move outwards. That's not the case for measles. Guys, we're going to give you a lot of quick, high heating, high yield facts here about measles that we have to remind ourselves. This rash, top down, this rash, top down, the rash spreads from the head, then it goes to the trunk and then it goes to the lower extremities. So head, trunk, legs, head, trunk, legs, Head, trunk, legs. Super important. Patients are typically contagious from about four days before the rash to four days after the rash appears. So the four days before is what sucks. Okay? After you're like, you know, you got like leprosy and like no one's going to touch you coming over to your house because they know what you got. It's the four days before. That's a trick. Okay? So a couple of high yield facts that we've already learned about measles. First look in the mouth because you're going to see that first. Then comes the rash from top down and then the number four. The number four is big for measles. Contagious four days before, up to four days after the rash. Now it's important to note that if somebody is on some kind of immunomodulation drug or their immunocompromised, they may not get the rash. Okay? They feel achy, they have some malaise. Look in the mouth because once again, the mouth is going to be telling before the rash actually happens. Super important right now, before we leave this clinical presentation, we have to say kind of a time frame here that the rash usually appears around 14 days, two weeks after the person who is susceptible is exposed. Right. So typically it's around two weeks, although there is some variance there. Some have said that incubation could be as long as 21 days or as short as six days. The point is, it's going to happen definitely typically anywhere from one to two weeks after exposure. So you have this time where it's kind of cooking, kind of replicating, and then boom. And then things start to happen. All right? The prodrome happens first. That's where you get the fever, the malaise. You get some. Some runny nose, some conjunctivitis. That's why it's important. Gu. Somebody pops up here and we're towards the end. We're entering spring, right? We're kind of over the flu season. Ish. For the majority of the country, the main bulk of flu, it's important to ask these questions. Hey, have you been immunized? What's going on? Anybody else in your family have these weird spots all over them? And look in the mouth, look in the mouth. Because prodrome happens first, including coplic spots, and then, as we mentioned, about two days later, then comes the rash in average, on average, around 14 days after exposure. Now, here's the important thing, guys. Here's why this matters in pregnancy. And this is super important for antenatal preconceptual consults. But few people get a preconception consult. But nonetheless, we'll get to that in a minute because. Well, let me just say now, yes, we should be absolutely asking patients if they have immunity to measles. And of course, very few people go, yes, I am immune. How do you know that? I mean, ask if they were vaccinated with mmr, if they had previous infection, and if it's unclear, yes, we should absolutely be checking for serology. We should be checking for immunity to measles, just like we do for rubella, and we should also do that for varicella. Now, most of these have fallen to the importance on the antepartum prenatal preconception consult right before they get pregnant. But very few do that. Most patients, especially in our population, don't have coverage until they get pregnant. So, yes, a short answer is, as we check for rubella and highlight who is non immune to give them mmr, we should be checking especially now, immunity status to measles and immunity status to varicella. Okay? Yes. And that's not my opinion. This is out of ACOG guidance, which actually goes back to March of 2024, almost one year ago through that practice advisory talking about this new contagion. Okay? So, yes, as part of prenatal care, somebody comes in, they're 10 weeks, hey, congrats, yada, yada, yada. Here's all of the labs. We're gonna check for rubella, we're going to check for measles immunity, and we're going to check for varicella Just important things to note. Not because you're going to give them the MMR vaccine during pregnancy, but it's important to note who is at risk, because, remember, what happens in one area does not stay there. And this is a big deal in pregnancy, it's bad for the mom because there's a risk of hospitalization. Pneumonia, encephalitis, it could cause hepatitis, a kind of viral hepatitis, and it's bad for the child. All right, so miscarriage has a odds ratio of around 5, based on who you read something as high as 5.9, it can cause stillbirth, it can cause low birth weight, it can cause preterm delivery. And here it is, guys. Here's a big clinical Pearl. Measles for neonatal sequelae. If it doesn't happen, that is affected by stillbirth, preterm birth, low birth weight, or miscarriage based on gestational age. Neonatal consequences can be hearing loss, can be encephalitis or neonatal death. Okay? Now, have you ever asked, oh, my gosh, measles. Is my baby gonna have birth defects? Well, not in terms of gross organ or structure anomaly. So here's a clinical Pearl. There does not seem to be an increase in the risk of congenital malformations, congenital defects, between those infected with measles and those non infected. Okay? So, yes, measles is bad for pregnancy, measles is bad for mom, measles is bad for baby, but it is not an increased risk of congenital anomalies. Right, so this is in terms of function, like the encephalitis, like the hearing loss or death, but it's not a structural issue. Okay? So that's, I guess, the good part of it. It is not linked to an increased risk of congenital malformations. Now, if the patient has a rash within the first 10 days of life for the child. Okay, so remember the several numbers here. The number four, four days before, four days after the rash in terms of contagious, and the number 10. If the mother has a rash within the first 10 days of life, then vertical transmission could be a risk here. All right, so baby delivers, and the rash is either 10 days before or 10 days after. There is a risk of congenital measles. This has an increased risk for the child of increased mortality. It can cause subacute sclerosing paen encephalitis. So the idea is delivering within 10 days of this rash, either pre or after, is bad for the child, and that needs specific PDID input. Right. So we're not gonna get into that. Cause I'm not, you know, I'm staying in my lane. But just remember that 10 days of delivery within the rash could be potentially bad for the child. Okay, so I think we've done that there. We've already talked about assessing immunity. That. Yes, we should be checking to see if mom has MM or previous immunity to this because that's vital. Now for those who are non pregnant, so let's say we're doing a antepartum consult, then the MMR is for them. So if they're doing an antepartum prenatal consultation, give them the mmr. If they're either rubella or measles, non immune, and then they should wait. Remember, four weeks prior to attempting pregnancy, there's a number four again, y'all. Is this good or what? So remember certain things with measles top down. Remember measles number four and then remember measles 10 in terms of delivery and the rash, and then four for four weeks. Get MMR, wait at least four weeks to attempt pregnancy. All right, why don't we take a little break here and then we're going to talk about testing for those suspected of having the condition post exposure prophylaxis, and then ultimately, of course, treatment, which is the same thing as the post exposure prophylaxis part. And then we're going to go ahead and take this home. So we'll be right back with testing post exposure prophylaxis and then we will call it a day. We'll be right back.
- [17:17]
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- [18:24]
Dr. Smith
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- [18:59]
Dr. Smith
Hey, we're glad you're part of our podcast community. You're listening to Clinical Pearls. All right, we're gonna do this as little buckets versus do post exposure prophylaxis. For somebody who says, hey, I'm pregnant and I my kid has little dots all over him and they said I should get checked. Something about measles. Okay, that's a flag. So, so let's do post exposure prophylaxis assuming non immunity. Then we're gonna talk about evaluation of somebody suspected of actually having it. And then we'll wrap this up with a quick word about postpartum. Alright, so for somebody with suspected exposure, let's talk about post exposure prophylaxis. This comes from the CDC as well as from the college. All right, so here it is, quote, pregnant and non pregnant women exposed to measles who cannot readily show that they have evidence of immunity should be offered post exposure prophylaxis. End quote. So unless they say, hey, here's my little card, it looks like I got something called the MMR with my last delivery. That should cover it. Okay, so you should say, okay, I think you're good. Isolate the child, hand wash, respiratory precautions, wear a mask, you know, and stay your distance. That should be enough. However, for those who cannot readily show that they have evidence of immunity, they should be offered IVIG. IVIG. So not an antibiotic, not an oral antiviral. IVIG. And here's the dose, guys. So IVIG at 400. Is that weird or what? How many times? See, the four is big, guys. Four days before the rash, four days after the rash for contagiousness, four weeks for not getting pregnant after immunization, and then 400 milligrams per kilo within six days of measles exposure for IVIG. All right, so number four is big. How wild is that? Number four and then number 10. So 400 milligrams per kilo within six days of measles exposure for IVig. Now, the other idea is if they are not pregnant, so this is a preconception consult, and they have potentially been exposed, then you offer them either it's one or the other, either MMR vaccine within three days of the exposure, or you can do the IVIG within six days of exposure, but not both. If you give both, something ain't gonna work. Okay? So the antibody is gonna go get the measles component of the mmr. Okay? So very clearly, guys, do not give both. You do one or the other, either MMR within three or IVIG within six days. Now, that's that. Now, if somebody presents and they look like they actually have the infection, then it's a combination of testing. You need to do oropharyngeal swabs. You're looking there for a pcr. You need to send the blood. You can also send urine for viral RNA by pcr. Okay, so remember, generalized rash, fever with respiratory symptoms, look in the mouth, and then do nasopharyngeal urine and blood for viral RNA through pcr. Very rarely is this a real culture. This is all done through PCR to make sure that the patient is taken care of. Now, if the patient is actively infected, infected, then it's controversial whether IVIG actually works because they already are sick. But the idea is that it doesn't hurt. And mainly the treatment, the management is more supportive. All right, so giving antipyretics, making sure that they are isolated and not infectious, mainly it is a conservative care for that. Okay, so lastly, as we get ready to wrap this up, a quick word about postpartum care. And so this is a big deal. So then somebody does has been found to not have immunity to this, then you can obviously offer them mmr, just as we do for rubella. So we are already doing this plan for the rubella side, but MMR should also be given even though the rubella immune for measles protection in those who need it. All right, now remember that traditionally vaccination happens starting at age 12 to 15, but for postpartum patients, MMR can also be given for those without evidence of prior immunity. All right? And yes, MMR vaccines, just as we. As we do for rubella, we tell patients absolutely is fine in breastfeeding patients, no adverse issues. So that's totally okay. All right, so remember that post exposure prophylaxis is key here during pregnancy with IVIG at 400 milligrams per kilo within six days if they're not pregnant, they can get either MMR at 3 days 72 hours or IVIG and then postpartum. For those who have been asymptomatic and gone all the way to the postpartum course, then offer them MMR for the measles protection as well. Guys, we have highlighted the CDC information. We've highlighted the ACOG practice advisory from March 2024 concerning measles. So this is a good refresher. Remember the number four. Remember the number 10. 400 milligrams per kilo for IVIG. And that brings us to a wrap. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. Now that we've said all that, now let's take it home. Podcast family, we really are thankful for you. We hope you enjoyed this episode. We'll see you next time on Clinical Pearls.