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A 21-year-old woman comes to your office for an MMR vaccination before going off to college. She is in good health and has no medical problems. She smokes cigarettes occasionally and does not drink alcohol. She did not receive MMR vaccination as a child. She grew up in South America and moved to the United States with her family when she was 7 years of age. Physical examination is normal. Which of the following is the most appropriate next step in managing this patient?
A. Administer MMR vaccine
B. Ask her about her sexual history
C. Tell the patient that she probably got these illnesses as a child and there is no need for vaccination now
D. Check the patient™s antibody levels against MMR
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The correct answer is B. Rubella is associated with an increased risk of miscarriage. In addition, congenital rubella syndrome (e.g., deafness, visual problems, cardiac defects, and neurologic abnormalities, including mental retardation) has been estimated to occur in 20 to 85% of infants of women with rubella before 20 weeks of gestation, with the highest risk in those infected in the first month of pregnancy. Therefore, it is necessary to make sure all women are immune to rubella before conception.
Measles, mumps, and rubella (MMR) vaccination is a live attenuated vaccine; it should be given to women who are not pregnant and who do not have evidence of immunity to rubella (choice A).
Almost all women found to be nonimmune to rubella will also be nonimmune to measles and mumps because almost all women born after 1956 achieve immunity to these diseases as a result of MMR vaccination, not by natural infection (choice C).
Additional laboratory evidence to document measles and mumps immunity is not required before administering the vaccine (choice D). Vaccinated women should be advised to avoid conception for 3 months after administration. This vaccine can safely be given to postpartum women who are breast-feeding and to the children of pregnant women, because infection is not transmitted from recently immunized individuals. Once rubella immunity has been documented, it is not necessary to repeat rubella serology with each pregnancy.
