(B19) Infection in Pregnancy

the foundations of the current study, and we are grateful for 7 Rothman KJ. Modern epidemiology. Boston: Little, Brown, 1986. his willingness to make these data available to us. We are also 8 Ederer F, AMantel N. Confidence limits on the ratio of two Poisson sariables. AmJ Epidemiol 1974;100:165-7. grateful to Mr Glen Mandahl from the New Zealand Returned 9 Gardner MJ, Altman DG. Siatistics with conidence. London: British Miedical Services Association and Dr Graham Gulbransen for their Journal, 1989. support and excellent cooperation. We thank Professor Sir 10 Mantel N, Hacnszel W. Statistical aspects of the analysis of data from retrospective studies of disease. fI 1959;22: 19-48. Richard Doll, Dr Elisabeth Cardis, Dr Sarah Darby, and Dr 11 Darby SC, Kendall GM, Fell TP, et al. A summary of mortalhtv and incidence Ichiro Kawachi for their comments on the draft report; the of cancer in men from the United Kingdom who participated in the United staff at the National Health Statistics Centre and New Kingdom's atmospheric nuclear weapons tests and experimental pro- BMJ: first published as 10.1136/bmj.300.6733.1166 on 5 May 1990. Downloaded from Zealand Cancer Registry and at the Justice Department; grammes. Br AfedJ7 1988;296:332-8. 12 Checkoway H, Pearce NE, Crawford-Brown DG. Research metlhods in occupa- Regina Winkelmann of the International Agency for Re- tional epidemiologv. New York: Oxford University Press, 1989. search on Cancer for supplying data on New Zealand 13 Cardis E. Ionizing radiation and electromagnetic fields. In: Higginson J, Aluir mortality and incidence of cancer; and Trevor Williams, CS, Munoz N, Sheridan Mi, eds. The epidemiologv and causes ofhumnan cancer. Cambridge: Cambridge University Press, 1990. department of community health, Wellington School of 14 Gardnier M. Cancer among participants in tests of British nuclear weapons. Medicine, for his clerical and administrative help with this BrMedj 1988;296:309-10. study. Finally, Jackie Auld and Gail de Boer thank the 15 Darby SC, Nakashima E, Kato H. A parallel analysis of cancer mortalit\ Director General of Health for granting permission to among atomic bomb survivors and patients with ankylosing spondylitis given X-ray therapy. JNCI 1985;75:1-21. publish. 16 Greene MH. Non-Hodgkin's lymphoma and mycosis fungoides. In: Schotten- feld D, Fraumeni JF, eds. Cancer epidemiology and preveniion. Philadelphia: I Crawford JAB. The involvement of/the Royal Nea Zealand Navy in the British W B Saunders, 1982. nuclear testing programmes of 1957 and 1958. Wellington: Ministry of 17 Boice JD, Land CE. Ionizing radiation. In: Schottenfeld D, Fraumeni JF, eds. Defence, 1989. Cancer epidemiology and prevention. Philadelphia: W B Saunders, 1982. 2 Pearce NE, Prior IAM, Methven D, et al. Mortality and cancer incidence in Newv 18 Beebe GW. A methodologic assessment of radiation epidemiology studies. Zealand participants in United Kingdom nuclear weapons tests in the Pacific. Health Phv.s 1984;46:745-62. Wellington: Department of Community Health, Wellington School of 19 Gulbransen G. New Zealand radiation veterans: Christmas Island 1957-58. Medicine, 1990. N Z General I'ractice 1989;2: 11-15. 4 World Health Organisation. Manual of the international statistical classification 20 Caldwell GG, Kelley D, Zack Mi, Falk H, Heath CW. Mortality and cancer of diseases, injuries, and causes of death. 9th Revision, 1975. Geneva: WHO, frequency among military nuclear test (Smoky) participants, 1957 through 1977. 1979.JAMA 1983;250:620-4. 5 Foster FH. The New Zealand Cancer Registry. N Z Med j 1977;86:341-3. 21 Beebe GW. Ionizing radiation and health. Am Scientist 1982;70:35-44. 6 Coleman Al, Douglas A, Hermon C, et al. Cohort study analysis with a FORTRAN computer program. Intj Epidemiol 1986;15:134-7. (Accepted 10 April 1990) Prospective study of human parvovirus (B19) infection in pregnancy Public Health Laboratory Service Working Party on Fifth Disease Abstract the cause of transient aplastic crisis in patients with Objective-To determine the fetal infection rate chronic haemolytic anaemias2 and of erythema infec- and outcome of pregnancy among women who tiosum (fifth disease).' In 1984 the first case reports of acquire infection with human parvovirus (B19) in the B19 having an adverse effect in pregnancy were antenatal period. published.4 At least 20 fetal deaths have been described in which fetal tissues contained B19 DNA.6 The virus Design-Prospective study of infected pregnan- http://www.bmj.com/ cies till time of delivery or abortion with virological replicates in erythroid progenitor cells,7 which may investigation of fetuses, neonates, and 1 year old cause profound anaemia and congestive cardiac failure infants. in the fetus. Setting-England and Wales during 1985-8. Fifth disease is a common childhood exanthem and Patients -190 Pregnant women with serologically the recognition that its causative agent was potentially confirmed B19 infection in pregnancy, their fetuses, embryopathic provoked considerable public and neonates, and 1 year old infants. professional concern.89 This concern, however, was based either on evidence from small numbers of Results-Of 186 mothers who elected to go to on 29 September 2021 by guest. Protected copyright. term, 156 (84%) delivered a normal baby. Follow up subjects or on case reports and series in which an of 114 of these infants to the age of 1 year disclosed adverse outcome ofpregnancy had led to the retrospec- no appreciable abnormalities, although 27 had tive diagnosis of B 19 infection, thus providing a biased serological evidence of intrauterine infection. The estimate of risk.4" 10-14 We therefore began a prospective overall fetal loss rate (30 cases; 16%) was similar to investigation of a larger population of women with B 19 that in an uninfected antenatal sample (unmatched), infection in pregnancy to determine (a) the risk of but there was a pronounced excess offetal loss in the adverse fetal outcome, (b) the transplacental transmis- second trimester in the B19 infected mothers (11-8%; sion rate, and (c) the neonatal and longer term outcome. 95% confidence interval 6-8% to 17-8%). Based on Long term follow up of the infants is not yet complete, virological findings in the aborted fetuses the risk of but because of the public health implications we report fetal death due to B19 in an infected pregnancy was here our initial results. Public Health Laboratory estimated to be 9%. The transplacental transmission rate was estimated to be 33%. Service Working Party on Subjects and methods Fifth Disease Conclusions-Most women with B19 infection in pregnancy had a satisfactory outcome, but there was Study population and recruitment-The study popula- Members of the working nevertheless a substantial risk of fetal loss in the tion comprised pregnant women who were investigated party and participants in the second trimester. In view of the absence to date of prospectively, usually by their general practitioners study are listed at the end of any evidence of damage to babies who survive (for example, because of a rash or contact with this paper. maternal infection therapeutic termination of preg- erythema infectiosum), and who had B 19 infection nancy is not indicated. confirmed by the presence of B19 IgM. Patients with Correspondence to: Dr S M B19 infection who had been investigated because of a Hall, PHLS Communicable fetal death were excluded. Recruitment took place Disease Surveillance Centre, were 61 Colindale Avenue, between January 1985 and June 1988. Cases London NW9 5EQ. Introduction ascertained when the result for each eligible subject Human parvovirus (B 19), first discovered in 1975 in was sent to the study base by one of the five B 19 BrMedj 1990;300:1166-70 serum from healthy blood donors, is now known to be reference laboratories in England. 1166 BMJ VOLUME 300 5 MAY 1990 Data collection and follow up-The patient's age, for 184 of the 190 mothers. Of these, 168 (910/i) had a parity, obstetric history, date of last menstrual period, rash, ofwhom just under half also had other symptoms reason for B19 testing, contact history, and description -namely, arthralgia or arthritis, non-specific upper of symptoms with date of onset were obtained from the respiratory symptoms, general malaise. Of the 16 general practitioner, who was also asked to inform the mothers with no rash, eight had joint and respiratory investigators of any ensuing adverse outcome of preg- symptoms, two had a non-specific illness, and six were BMJ: first published as 10.1136/bmj.300.6733.1166 on 5 May 1990. Downloaded from nancy. The date of delivery or miscarriage or fetal asymptomatic. death and, if a live birth, the birth weight, gestational The reason for the B19 investigation was provided age, and details ofany neonatal problems were provided for 186 subjects. In 161 cases (87%) it was because of a by the consultant obstetrician. The general practition- rash with negative rubella test findings; in 18 cases ers of the liveborn babies were contacted roughly one (which included the six asymptomatic cases) because of year later and asked to complete a simple form contact either with confirmed erythema infectiosum or concerning the infants' physical and neurodevelop- with an illness thought to be rubella; and in seven cases mental state. because of a flu-like illness, myalgia, or arthropathy. Specimens collected-In the case of adverse outcomes The source of the mother's infection was stated to be any available fetal material, regardless of method of unknown in 146 (77%) cases. Among the 44 subjects preservation, was requested from general practitioners, for whom it was known, 31 had acquired the infection obstetricians, and local microbiologists. In the case of from their other children. Nine subjects acquired B19 successful outcomes cord blood, a placental sample, in the work setting, of whom two were teachers, two and a throat swab from the neonate were requested.

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