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All right, get ready, sweet pea, because we're going to do this really fast because I already covered this stuff in February, so it's just going to be fast. But it's a good reminder and we're going to go rapid fire, rapid fire just to give you some quick things and to be on the lookout. And even though that original outbreak in the not too long ago history was in New Mexico and in Texas, of course there have been measles cases kind of scattered throughout the country. And this is why it's a good reminder. First of all, as we mentioned in the intro, remember that we're talking about Rubiola. Okay, so there's rubella, that's the lat, that's the R in mmr. And then there's Rubiola, which is the first M, which is measles. So measles, mumps and rubella. The first M, of course is Rubeola, otherwise known as measles. It is a single stranded negative sense RNA virus. Okay, we're not microbiologists. Just remember, people always want to know, is it DNA or RNA double stranded, single stranded? Well, most are single stranded, but this is RNA RNA single stranded and it is an enveloped virus. So measles Rubiola virus is a single stranded negative negative. That's called negative sense negative RNA virus. All right, fine. Anyway, very quickly in terms of reminders, we can go fast what this thing looks like. So somebody first gets exposure, kind of hangs out in the body, kind of replicates. And that can take one to three weeks. One to three weeks. In other words, seven to 21 days is typical incubation. Then after that, measles typically starts as this weird kind of prodrome that involves fever and the three Cs. Okay, the three Cs. Remember, that's cough Coryza. That's a runny nose and conjunctivitis so it pretty much looks like any other kind of. Kind of a cold or almost like the flu. So cough coryza and runny nose, or runny nose and then conjunctivitis. Cough Coryza and conjunctivitis. These sometimes are associated with photophobia. Now, here's the catch. That's why in anybody who is rubio negative. Now, we've covered this. Again, I'm not going to get into it, but while ACOG says yes, we check for rubella, I've advocated for. And it's fine to do some argue against this and some argue for it, I think it's super easy. You're gonna draw their balloon anyway, especially if you have a very migrant population like we do. We also check for rubiola immunity. And as we said in the intro, we've had plenty of rubella immune, but rubiola non immune. We would have missed that opportunity to offer mmr and above that, they come back with some weird viral thing before we, you know, just rule out Covid and influenza, especially during flu season, which is the right thing to do. But we gotta remember that measles, if they are immune, is still a consideration. Okay? So remember, if they have any sick contacts, incubation of seven to 21 days, then typical fever, and then the three Cs, cough, Coryza and conjunctivitis. Now, it doesn't have to be all three. It doesn't not have to be all three. It can be at least one of the three with fever in a susceptible patient, which would raise your suspicion that they are infected. Okay? So it doesn't have to be all three. It's just one of the three C's. Cough, coryza or conjunctivitis, although they typically run as a pack. Now, as a good reminder, and we talked about this in February, you gotta look in the mouth. You gotta look in the mouth because of the little spots that are pathognomonic for measles. Y' all remember, this starts with a K. It's Koplix spots. See, it's a good reminder of basic virology and microbiology because we learned this in med school. And then kind of, you know, leaves through the hippocampus and out the ear. Out the ear, because we forget. But complex spots are a big deal. I think as obgyn, we're so, you know, involved with procedural technique and surgical issues and new medications. We forget some basic stuff. I think family medicine and family medicine OB is much more attuned to this. Cause you also See this more in kids. But again, coplic spots are a big deal. They are pathognomonic for measles. And while they're not in every single patient, like 70%, some say up to 80%, but this narrative review says it's 70%. 7 0. That's pretty good. These happen before the rash and then stick around for about the first two days, 48 hours after the rash onset. These are little punctate, little bluish white little lesions, and they sit on a red base, okay? All inside the buccal mucosa. So look inside. Little white or bluish specks surrounded by a red ring. That is a complex spot. Now, the prodrome phase typically lasts about two to four days. And then you get this characteristic erythematous, this maculopapular rash. And how it starts is key because remember that measles is top down. Measles is top down. It begins on the face, on the head, and then it spreads down to the trunk and the extremities. So it's important how rashes start. Okay? So pubs or things related to pregnancy, typically on the abdomen first and then go outwards. But measles is top down. Approach. So it starts on the face and the head and then goes caudally goes down the trunk and the extremities. Now, here's the rule of four, okay? This is why this is important. So we've talked about exposure, we talked about incubation period, complex spots. And here's when patients can pass this to others. So when they are infectious is four. Four. That's called the rule of four. Okay? So patients are infectious from four days before the rash. So that sucks, because you're like, oh, damn. At that point, you're like, well, they didn't have a rash then, right? But they are infectious during that time. That's why it's important to catch this. If they present early, if there's fever, if there's one of the three Cs, if they are susceptible to measles, and you look in their mouth and you see that, you got to catch this because those coplic spots are going to happen before the rash, okay? That's why you got to tell your patients that are pregnant if something's off, you just got to come in. You got to come in and try not to feel stuff too much on the phone because it's worth looking into their mouth. And I know what you're saying. You're bringing everybody in with a cold. Well, how do you know it's a cold? It's worth swabbing for Covid flu and then taking a look for other things. And that's just our practice. We're very conservative. We say, come on in. We want to check that out. Okay, so the rule of four is patients are infectious from four days before the rash onset through four days after it starts. Okay? So four days before, and then four days after its appearance. So a total of eight. Four days before the rash, Boom, you get the rash, and then four days after they are infectious. That's the rule of four. So four, four. Everybody good? Everybody good? All right, so just again, quick reminder. Even though we talked about this, that's why we're. We're intentionally moving quickly, because I want to do this fast yet still do it. You know, respect and honor. Since it just came out two days ago, it is a good reminder about Rubiola. Now, is measles worse in pregnancy? Well, it depends on who you read. And in general, yeah, it might could. Once again, as my wife says, remember, my wife is two master's degrees, licensed EMDR therapist. She's very good at what she does, but sometimes she still says, yeah, we might. Could. Yeah. So measles, it might could be really severe in pregnancy, although not all the data show that. But with a possible mortality rate of 4.3%, yeah, it's a big deal. Now, pneumonia is much more likely at about 18%. Hepatitis happens at around 11%. The point is, multiple studies that have compared outcomes in pregnant versus non pregnant populations consistently show that measles, yes, absolutely, can have severe complications maternal during pregnancy. So don't take it lightly. Now, it doesn't mean that everybody has to be brought into the hospital. Now, if they have respiratory issues or bad pneumonia, that's obviously, yes, you can manage these as an outpatient with isolation precaution in general, but it still can go south pretty quickly. Once again, measles infection during pregnancy is associated with some bad stuff for the mom and for the child. It's also associated with some risks, as you would think, for any severe viral illness. That's preterm birth, it can cause low birth weight, fetal growth restriction, and in the first trimester, it can cause fetal loss. The data on stillbirth is a little gray, but, yes, some studies have also showed an increased rate of stillbirth that is much higher compared to those who obviously were not infected. So measles in pregnancy is bad. I'm trying to make it easy as possible to remind ourselves, because, again, we covered this in February, but measles in pregnancy Is bad. The good news, if we have to find some good news, because it really isn't a lot. But the one good news, one good piece of good data on this is that at least it doesn't seem to be a known teratogen. Okay, so the question is, is measles related to some birth defects? There's no one constellation or grouping of birth defects of anomalies that are syndromic. For measles, that's good news. Okay, rubella is something else. But for rubeola, measles is not a known teratogen. That's good news. However, the child is not out of the woods. Okay, once again, the take home message. Measles is bad. Bad for mom, bad for baby in terms of low birth weight, potentially spontaneous AB, stillbirth and preterm delivery. That's true. However, there is still the possibility if measles infection happens during pregnancy. Guys, remember this as the importance to the number 10, okay? The importance of the number 1010 is important for two things. Onset of a rash, okay? Onset of a rash in the child within the first 10 days of life. In a baby whose mother had measles during pregnancy, that's a flag raised for bad things. Okay? So the Importance of number 10 is if the mother had measles infection in pregnancy and the child develops a rash within the first 10 days of life, that should raise a flag for congenital measles. Okay? Congenital measles. Appearance of the measles rash at birth or within the first 10 days in a child whose mother had measles during pregnancy is congenital measles. And it's bad. Okay? Now why is it bad? Is because congenital measles can have effects down the road like hearing loss, subacute sclerosing panencephalitis that sometimes can. Can show up years later. That's terrible. And of course, the biggest complication to the neonate with congenital measles is that it could lead to death. Okay? So take home message, the big clinical pearl. Measles in pregnancy. Not good. It is bad. It's bad for mom, potentially with respiratory issues, potentially again with death. And for the child in terms of outcomes and for the neonate, because the biggest risk is not anomalies. The biggest risk seems to be with congenital measles, which thankfully, again, it's not very common. It is rare. But congenital measles, a rash developing in the first 10 days of birth can lead to long term complications like death, hearing loss and subacute sclerosing panencephalitis. Subacute Sclerosing panencephalitis. Now, thankfully, again, to talk patients down from the ledge of fear. Thankfully, we gotta say it. Cause I don't wanna scare anybody. The rate of perinatal measles transmission seems to be pretty darn rare. Let me read it directly. Cause this is again another piece of good news. Quote, the rate of perinatal measles transmission is unknown but appears to be rare. End quote. Proving to you that I'm not lying to you. That's good news. However, when it does happen, it tends to be bad. Okay, now the higher the chance of transmission for perinatal transmission, mother to child seems to be when the mother acquired infection in the third trimester or within X number of days before delivery. As you would guess it, guys, that's still part of the significance of the number 10. That's 10 days before delivery. So risk of perinatal transmission is rare, but seems to be higher if mom was infected and sick in the third, third trimester and within 10 days of delivery. Okay, so we've covered the rule of 4, 4/4, which has to do with when they're infectious. The rule of 10, mainly for congenital measles and for maternal infection within 10 days of delivery. Now let's take a quick break, let that settle in. Let that settle in and then we're gonna talk about quickly post exposure prophylaxis. How do we take care of a mother who's been exposed and remember she's susceptible. Once she's been exposed to, what do we do for her to try to decrease the risk of severe outcome? We're going to talk about that and then wrap this up when we come back. You're listening to the ob gyn no spin podcast.

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Bringing this home very quickly before we get into post exposure prophylaxis. And a quick word about assumed immunity to rubiola when rubella immunity is seen. We'll talk about that as we get to the end. But before we do that, a quick word about breastfeeding Can a patient breastfeed with measles? Yes, absolutely. Measles virus is not transmitted in breast milk. However. However, it should be part of, quote, shared decision making, end quote. And as common sense, probably not the best to breastfeed if the breast is full of measles bumps. Always better to kind of pump and give the milk that way. Since measles virus is not transmitted in breast milk, but through shared decision making, yes, it is still allowed. And if they're going to put the child onto the breast, it's important that the mother use a well fitting mask. N95 or the equivalent is preferred. Use proper hand hygiene, of course. But here's a big one. The child also needs to, quote, remain quarantined through 21 days after exposure, end quote. That's right out of this narrative review. Short answer is yes, they can either express breast milk that can be provided to reduce direct contact, or they can engage in breastfeeding. As long as there's no lesions in the way because the virus is not transmitted in breast milk, that's good news. Now a quick word about trying to protect the child. Also, breastfeeding, to do that correctly is a big deal. But it's also important to remember that the aap, that's the American Academy of Pediatrics, does say that all babies, all newborns born to women with suspected or confirmed measles, those babies should have immunoglobulin at a dose of 0.5 mls per kilo with the max being 15 mls as soon as possible or within 6 days of exposure. Okay, so baby's born, mom has suspected or confirmed measles. That child, according to AAP, needs to have IM immunoglobulin at a dose of no more than 15mls max to protect the child because the data shows, hey, it can reduce the rate and or severity of perinatal infections and even can modulate disease in those with congenital measles. So I'll be very clear. Even if they have congenital measles, giving them immunoglobulin, quote, may modulate disease in neonates with congenital measles, end quote. So it's good for the child. All right, now that's a good segue into post exposure maternal prophylaxis because the treatment is the same agent, obviously in a different dose, but it's the same agent. It is immune globulin. Although for the mom it's not im, it is iv. Okay, we're going to do this and then we're going to start wrapping it up. So very quickly on breastfeeding, yes, they can do it or they can express the milk and feed it to the child as long as they use appropriate hand hygiene, appropriate mask wearing, and as long as, you know, there's no kind of active sores all over the nipple. Just kind of best practice. But breastfeeding by itself is not contraindicated with measles. Okay, so now that we've talked about giving the child im immunoglobulin, which is what's recommended by AAP at no more than a maximum of 15mls, then we talk about maternal prophylaxis. So for the mom, if she's been exposed and again, she's non immune, okay, so she's vulnerable, then the treatment for that to try to prevent infection is post exposure prophylaxis. This is best done within six days of a confirmed measle exposure. Okay, within six days of a confirmed measleen exposure. This is 400 milligrams per kilo of intravenous IVIG. So it's IVIG, intravenous immunoglobulin, IVIG, 400 milligrams per kilo to be given within six days of a confirmed exposure. So again, we covered this in the past. I just thought this is a good reminder since this just came out two days ago from when we're recording this and as the last little reminder and as we've posted again on our social media, a variety of patients who have shown immunity to rubella who are rubiola non immune. We've proven that in our own patient cohort. And though we have a very high risk, a very migratory population from Mexico as well as south and Central America, there's something in this that is a very good reminder. And then we're going to wrap it up. Here we go guys. Quote of note, a positive test for rubella immunity is likely insufficient to predict measles immunity in obstetric patients, although the data is equivocal. End quote. There you go. So, and again, I've said this, I've posted this, I've shared, de identified so we don't violate HIPAA little lab tests that show rubella immune, rubiola non immune in the same patient because it makes sense, because MMR conversion is so effective, but it is not universal at 100%. So be very clear, MMR is very effective for measles, mumps and rubella, but immunity to one does not confer automatic immunity to the other. So if you're checking your patient for rubella immunity, phenomenal. If you have a patient population who likely is at risk for measles because of its potential sequelae for maternal, fetal and long term child outcome risk, Lipan cephalitis. Then consider a check for Rubiola immunity with IgG. That's what we do. Again, not telling you what to do, just as something that fits for our patient population. And it's also something that is addressed briefly in this narrative review from the Green Journal. So the lead author on this, the only author, the sole author, is Nemina Joseph. Great review on measles in pregnancy as we covered in February of this year. So nine months ago, Podcast Family I think we've done what we're supposed to do. It was just a very, very quick reminder for measles in pregnancy that in pregnancy, as the MMR vaccine cannot be given, a single dose of IVIG is the way to go. Otherwise if they weren't pregnant, they would just receive the MMR within 72 hours of exposure. That's just for anybody else who's not currently pregnant. And if they do get MMR vaccine and they're not currently pregnant, remember that that wait interval is 28 days. 28 days after vaccination, just out of consensus and based on the residual time of the live attenuated virus. So anybody else? After exposure, MMR vaccine is recommended within 72 hours, but in pregnancy it is IVIG at 400 milligrams per kilo within six days. That was kind of random at the end. But anyway, Podcast Family, I think we've done what we were supposed to do. Measles in Pregnancy, Clinical considerations and challenges from the new narrative review. As always, we're thankful for you. Thank you for your faithful support. Thank you for sticking with us. And now that we've done all that, Podcast Family Michael, let's take it home. This has been Dr. Chapa Zobichyn, no Spin Podcast Podcast Family. Thank you for your support and thank you for listening. And as always, we'll see you on another episode of the no Spin podcast.