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10/1/2008

Parvovirus in Pregnancy

Parvovirus B19 is a single stranded DNA virus which causes erythema infectiosum, also known as fifth disease. Clinical manifestations include flu-like signs and symptoms, low-grade fever, malaise, arthralgia, and a classic “slapped cheek” rash. Maternal infection is most often contracted from an affected child. The secondary infection rate may be up to 50% in susceptible household contacts, although many pregnant women have pre-existing immunity. Maternal infection is typically mild or asymptomatic. Pregnant women with suspected exposure should have testing done to evaluate the need for monitoring for seroconversion. Infection is confirmed with acute and convalescent maternal serology documenting the presence of IgM antibody or a four-fold rise in IgG antibody. When a pregnant woman with a recent parvovirus exposure is negative for both IgG and IgM, parvovirus B19 DNA PCR testing should be considered as up to 15% of infected women do not demonstrate IgM.  PCR analysis of amniotic fluid can be performed for diagnosis of fetal infection.

Maternal to fetal transmission is estimated to occur in 17 to 33% of maternal infections in pregnancy. Fetal infection may resolve without sequelae but adverse outcomes are possible. Fetal infection can result in profound anemia and fetal hydrops, presumably secondary to aplastic crisis, but other etiologies have been proposed. Acute infection during pregnancy is associated with an increased risk of fetal death during early pregnancy (8-17% when diagnosed from 9-20 weeks), although infection diagnosed later carries a risk of fetal loss of only 2-6%. Parvovirus is a potential cause of non-immunologic hydrops. Hydrops most commonly occurs within eight weeks after the primary infection, with the median occurrence at 3 weeks. Fetal surveillance with weekly ultrasound examinations to evaluate for signs of hydrops during this time is reasonable. Middle cerebral artery peak systolic velocity waveform measurements can be used to determine fetal anemia. Spontaneous resolution of the associated hydrops has been reported in some cases, although this appears unlikely when hydrops is severe. If fetal hydrops develops, fetal intravascular intrauterine transfusion is recommended and is most often curative. Long-term sequelae are unusual in the absence of fetal hydrops.

Further Reading:

Duff P, Creasy RK, Resnik R, et al., Maternal-Fetal Medicine: Principles and Practice. Maternal and fetal infections.  8th Edition, Saunders, 2018.

American College of Obstetricians and Gynecologists. Practice bulletin no. 151: Cytomegalovirus, parvovirus B19, varicella zoster, and toxoplasmosis in pregnancy. Obstet Gynecol. 2015 Jun;125(6):1510-25. doi: 10.1097/01.AOG.0000466430.19823.53.

Enders M, Weidner A, Rosenthal T, et al.  Improved diagnosis of gestational parvovirus B19 infection at the time of nonimmune fetal hydrops.  J Infect Dis. 2008 Jan 1;197(1):58-62. doi: 10.1086/524302.

Initial approval October 2008; Revised January 2015. Revised July 2016. Reaffirmed January 2018. Minor Revision July 2019. Reaffirmed March 2021. Reaffirmed September 2022. Minor Revision September 2024.

 

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