Practice Advisory: Management of Pregnant and Reproductive-Aged Women during a Measles Outbreak

Background
The United States is currently experiencing the greatest number of reported cases of measles, also known as rubeola, since the disease was eliminated in 20001. Outbreaks have been confirmed in 22 states and the number of cases and their distribution is increasing rapidly. These measles outbreaks have been linked to travelers bringing back cases of measles from other countries. This situation combined with low vaccination coverage among certain communities in the United States leads to pockets of vulnerable communities and contributes to outbreaks such as the one we are currently experiencing.  

Measles is highly contagious.  An estimated 92-95% of individuals in a community must be immune to prevent ongoing transmission.  Measles can cause serious illness and infects approximately nine out of every ten susceptible individuals exposed in close-contact settings2.  Anyone who is unvaccinated or is undervaccinated is at risk. Certain individuals, including unvaccinated and undervaccinated pregnant women, infants 12 months of age or younger, and severely immunocompromised persons are at increased risk of severe illness and complications of measles2.  The two-dose series of the measles-mumps-rubella (MMR) vaccine is safe and is 97% effective at preventing measles infection2.  

Measles Infection during Pregnancy 
Measles infection in pregnant women is associated with several adverse events including increased risk of hospitalization and pneumonia3. Measles infection during pregnancy is also associated with significant risks to the fetus4-6, including:

  • Miscarriage
  • Stillbirth
  • Low birth weight
  • Increased risk of preterm delivery

Recommendations
The University of Washington has developed a consensus statement including algorithms for guidance in managing high risk pregnant patients – those living in, or traveling to, areas with an active outbreak. Providers who care for pregnant women are encouraged to refer to the recommendations and algorithms in this ACOG-Supported consensus statement for additional information7.  

Selected points from the ACOG-supported University of Washington consensus statement, ACOG, and the Centers for Disease Control and Prevention (CDC) are highlighted below.

Women Considering Pregnancy

  • Women of reproductive age and those contemplating pregnancy should assess their measles immune status with their primary health provider prior to pregnancy7 (see algorithm) and receive the measles-mumps-rubella (MMR) vaccine if nonimmune*.

  • After receiving the MMR vaccine, women should wait 4 weeks prior to attempting pregnancy given theoretical risks to the fetus with live vaccines; however, inadvertent MMR vaccination in the periconception period or in early pregnancy should not be considered an indication for termination of pregnancy4.

Pregnancy

  • One documented dose of MMR vaccine is sufficient for low risk individuals (including pregnant women). For people at high risk of contracting measles, a documented history of two prior MMR vaccine doses is needed to confirm immunity. However, obstetrician-gynecologists should consult their local health departments when determining immunity from vaccination (e.g. number of doses necessary).

  • In areas of ongoing outbreaks where there is sustained transmission in close-knit communities, serologic testing for measles IgG can be considered in pregnant women without documented immunity to measles.

  • Pregnant women with suspected measles exposure but without immunity should receive intravenous immunoglobulin (IGIV) treatment2,4,7 within 6 days of measles exposure.

  • If serologic testing and obtaining results are not available in a timely manner, and measles exposure is suspected in a non-immune pregnant woman, the patient should receive measles immunoglobulin (IGIV).

  • While most women have immunity to measles due to prior MMR vaccination, given risks associated with measles in pregnancy, possible infection or exposure to measles should be carefully and expediently investigated2. Obstetrician-gynecologists should follow local health department guidance for testing (see algorithm in reference7).  

Postpartum

  • MMR vaccine should be administered postpartum* to women who lack evidence of measles immunity.

    • Breastfeeding has not been shown to affect the immune response to MMR.

    • MMR vaccine is safe in breastfeeding women and has not been shown to have adverse effects in neonates8,9

Addressing vaccination with your patients

  • Parental choice to opt-out of infant and childhood vaccination allows population immunity to drop below the threshold levels needed to stop outbreaks of measles, placing vulnerable patients such as pregnant women, infants under 12 months of age, and immunocompromised individuals at increased risk.

  • During prenatal visits, discuss the importance of vaccination, especially measles, with your patients and encourage them to vaccinate their children.

    • Most women start the decision-making process about vaccinations for their children before or during pregnancy. This is especially important for first-time parents who tend to be more vaccine hesitant10.

    • A randomized control trial showed that prenatal or postnatal education of mothers on childhood vaccinations resulted in higher infant immunization rates11.

ACOG will continue to provide updates as available while these outbreaks progress. For additional information please check the Centers for Disease Control and Prevention’s Measles Cases and Outbreaks webpage, along with the ACOG-Supported University of Washington’s Obstetric Consensus Statement: Measles & the MMR Vaccine: Recommendations Around Pregnancy, Including the Periconception and Postpartum Periods.

*Live vaccines, such as MMR, are not recommended during pregnancy due to theoretical risks to the mother and fetus; however, adverse effects on fetuses when live vaccines are inadvertently administered during pregnancy have not been found to occur.  

This Practice Advisory was developed by the American College of Obstetricians and Gynecologists’ Immunization, Infectious Disease, and Public Health Preparedness Expert Work Group with Linda O’Neal Eckert, MD and Laura E. Riley, MD in collaboration with Alisa Kachikis, MD and the University of Washington.

References

  1. Centers for Disease Control and Prevention. Measles cases and outbreaks. Atlanta (GA): CDC; 2019. Available at: https://www.cdc.gov/measles/cases-outbreaks.html. Retrieved April 24, 2019. 
  2. Centers for Disease Control and Prevention. Measles (rubeola): for healthcare professionals. Atlanta (GA): CDC; 2018. Available at: https://www.cdc.gov/measles/hcp/index.html. Retrieved April 24, 2019. 
  3. Atmar RL, Englund JA, Hammill H. Complications of measles during pregnancy. Clin Infect Dis 1992;14:217-26. Available at: https://academic.oup.com/cid/article-abstract/14/1/217/354295. Retrieved April 24, 2019.
  4. McLean HQ, Fiebelkorn AP, Temte JL, Wallace GS. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). Centers for Disease Control and Prevention [published erratum appears in MMWR Recomm Rep 2015;64:259]. MMWR Recomm Rep 2013;62(RR-4):1-34. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6204a1.htm. Retrieved April 24, 2019.
  5. Manikkavasagan G, Ramsay M. The rationale for the use of measles post-exposure prophylaxis in pregnant women: a review. J Obstet Gynaecol 2009;29:572-5. Available at: https://www.tandfonline.com/doi/full/10.1080/01443610903104478. Retrieved April 24, 2019.
  6. Rasmussen SA, Jamieson DJ. What obstetric health care providers need to know about measles and pregnancy. Obstet Gynecol 2015;126:163-70. Available at: https://journals.lww.com/greenjournal/Fulltext/2015/07000/What_
    Obstetric_Health_Care_Providers_Need_to_Know.25.aspx
    . Retrieved April 24, 2019.
  7. Kachikis A, Oler E, Shree RS, Waldorf KA, Hitti J, Eckert L. Measles and the MMR vaccine: recommendations around pregnancy, including the periconception and postpartum periods. Obstetric consensus statement. Seattle (WA): University of Washington; 2019. Available at: https://www.uwmedicine.org/provider-resource/measles-mmr-vaccine-recommendations-around-pregnancy-including-periconception-and Retrieved April 24, 2019. 
  8. Centers for Disease Control and Prevention. Measles, mumps, and rubella (MMR) vaccination: what everyone should know. Atlanta (GA): CDC; 2019. Available at: https://www.cdc.gov/vaccines/vpd/mmr/public/index.html. Retrieved April 24, 2019. 
  9. National Library of Medicine. Measles-mumps-rubella-varicella vaccine. In: Drugs and Lactation Database (LactMed). Bethesda (MD): NLM; 2018. Available at: https://www.ncbi.nlm.nih.gov/books/NBK501687/. Retrieved April 24, 2019. 
  10. Corben P, Leask J. To close the childhood immunization gap, we need a richer understanding of parents' decision-making. Hum Vaccin Immunother 2016;12:3168-76. Available at: https://www.tandfonline.com/doi/full/10.1080/21645515.2016.1221553. Retrieved April 24, 2019.
  11. Saitoh A, Nagata S, Saitoh A, Tsukahara Y, Vaida F, Sonobe T, et al. Perinatal immunization education improves immunization rates and knowledge: a randomized controlled trial. Prev Med 2013;56:398-405. Available at: https://www.sciencedirect.com/science/article/pii/S0091743513000728. Retrieved April 24, 2019.


A Practice Advisory is issued when information on an emergent clinical issue (e.g. clinical study, scientific report, draft regulation) is released that requires an immediate or rapid response, particularly if it is anticipated that it will generate a multitude of inquiries. A Practice Advisory is a brief, focused statement issued within 24-48 hours of the release of this evolving information and constitutes ACOG clinical guidance. A Practice Advisory is issued only on-line for Fellows but may also be used by patients and the media. Practice Advisories are reviewed periodically for reaffirmation, revision, withdrawal or incorporation into other ACOG guidelines. 

This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publications may not reflect the most recent evidence. Any updates to this document can be found on www.acog.org or by calling the ACOG Resource Center.

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The American College of Obstetricians and Gynecologists (ACOG), is the nation's leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, ACOG strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women's health care. www.acog.org

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