Perinatal measles: How to handle treatment and infection control for parents and neonates

Canadian physicians are having to plan and manage a situation likely new to most of them: perinatal cases of measles. There are numerous infection prevention and control implications for both the birthing parent and the infant to prevent and control infection and reduce the risk of subacute sclerosing panencephalitis (SSPE).Ontario’s current measles outbreak alone includes 22 cases of pregnant patients as of April 24, data from Public Health Ontario reveal. The majority of cases (94%) in Ontario’s outbreak are in people who are either unvaccinated or don’t know their vaccination status. Pediatric infectious disease experts shared perinatal measles cases in an April 23 webinar organized the Association of Medical Microbiology and Infectious Disease Canada (AMMI). Details were changed to protect the patients’ privacy.The lessons from the cases suggest that planning for perinatal measles should include getting access to a negative pressure room for both the delivery and postnatal period, having conversations with the family about infection control and prevention and deciding on level of infection control in the NICU (including for visitors) prior to birth. Risks of perinatal measles to the birthing parent and the infantTwo case-control studies, one from Namibia and one from Saudi Arabia, provide some details on outcomes after perinatal infection of measles. “Measles is a major trigger for preterm delivery,” explained Dr. Michelle Barton, division chief of infectious disease at London Health Sciences Centre’s Children’s Hospital and an associate professor at Western University. Perinatal measles also increases the risk of stillbirth or miscarriage. The birthing parent is at increased risk of hepatitis, lower respiratory tract infections, obstetric hemorrhage, sepsis and death.Newborns are at higher risk of measles infection, either congenital infection or a postnatal infection through airborne transmission or aspiration of blood or birth products. Basically, if a rash appears before the tenth day of life, the infant probably has a congenital infection. If a rash appears after the first 10 days of life, it is a postnatal infection. Measles transmission through the placenta bypasses the prodromal stage in the infant and a rash could appear within a day after birth.Infants born in cases of perinatal measles are also at an increased risk of low birth weight and a higher risk of subacute sclerosing panencephalitis (SSPE). There’s currently no evidence that a perinatal measles infection produces a teratogenic effect.Read: Ontario reports 95 new measles cases, sending total above 1,000 since outbreak beganLab result considerationsThe presence of antibodies in the birthing parent following a measles infection may be difficult to detect. On average, an immune response should be present within two days of a rash appearing in an immunocompetent person, noted Dr. Michelle Science, a pediatric infectious diseases physician at the hospital for Sick Children (SickKids). The transfer of any maternal antibodies to the fetus depends on timing of the prenatal/perinatal infection. Measles in pregnancy has also been associated with prolonged RNA detection with unknown transmission risk, compared to healthy adults. That prolonged RNA detection may or may not be associated with transmission risk. Measles increases the risk of a preterm infant, and the duration of the illness may be difficult to assess in an infected preterm infant, so more than one test may be needed. ManagementIf a pregnant patient has been exposed to measles and is not vaccinated or not sure of their vaccination status, their physician should contact public health and an infectious disease specialist for advice. Physicians should arrange for diagnostic lab testing.Post-exposure prophylactic (PEP) immunoglobulin (Ig) may be possible, depending on when the birthing parent was exposed. Intravenous Ig is recommended as PEP for nonvaccinated/uncertain of vaccination pregnant individuals within six days of exposure, according to most recent National Advisory Committee on Immunization (NACI) recommendations and Public Health Ontario. Data on effectiveness of PEP in pregnant individuals is limited, noted a recent systematic review of PEP for the prevention of measles by Canadian researchers.Management in neonates is mostly supportive and includes vitamin A supplementation and follow-up to watch for respiratory infections or SSPE. Immediate testing of the newborn is suggested, and consider Ig as PEP, as per NACI recommendations and infectious disease specialist recommendations.Infection controlIn birthing parents, the extent of the prenatal infection control required depends on a number of factors, including vaccine history, timing of exposure, intensity of exposure, presence of rash, gestational age and how close they are to delivery. The family’s exposure, infection and immunization history is also important to consider.Pregnant patients with perinatal measles or who have been exposed to measles should be put in airborne isolation at admission. Health Canada released updated recommendation for infection prevention and control for measles in January. In most cases, pregnant patients with confirmed or suspected perinatal measles should remain in a negative pressure room for delivery. In some cases, the birthing parent may no longer be infectious, but the infant may be born infectious.For the neonate, the level of infection control depends if they can go home or if they need to go to NICU. If they don’t need to go to the NICU, can they stay in a negative pressure room with the birthing parent? Can the birthing parent breastfeed the infant? This depends on timing (and/or resolution) of the birthing parents’ infection and if the infant was already exposed to measles. If the infant already has a congenital infection they can usually breastfeed.Read: Case report: Measles?If they go into NICU, they should have airborne, droplet and contact precautions. Consider if the birthing parent and the other parent’s measles status means they can go visit the infant or not. This would depend on immunization status and exposure and/or infection history. If they are safe to be in the NICU, consider the precautions they should they take. Some centres require confirmation of IgG positivity of any family members before visiting the NICU.There’s limited data on cases of perinatal measles. Before vaccination for measles was available, pregnant patients were considered immune from measles as they had probably contracted it in childhood, said Dr. Science. Now, some pregnant people are unvaccinated, or are immunocompromised. While unlikely, there could also be waning titres in pregnancy and/or a high level of exposure to measles that may cause an infection. Due to the lack of evidence, the information could change as new findings emerge. Up to April 5, there have been 748 confirmed cases of measles and 132 probable cases reported in Canada in 2025, with cases in New Brunswick, Ontario, Alberta, Manitoba and Quebec, according to the measles and rubella weekly monitoring report. Of these, 79% were unvaccinated and 16% had an unknown vaccination status. The majority are under 18 years old.

Perinatal measles: How to handle treatment and infection control for parents and neonates

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