Chickenpox in Pregnancy

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Chickenpox in Pregnancy

• Dr Bindu Singh

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Background

• VZV is a DNA Virus
• Highly contagious transmitted by respiratory
  droplets by direct personal contact with
  vesicle fluid.
• C/P- Fever, malaise, pruritic rash (maculopapular
  -- vesicular -- crust).
• Incubation period-10-21 days. Infectious 48 hrs
  before the rash - vesicle crust over.
• Chicken pox is common childhood disease usually
  mild.

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• Varicella zoster virus (VZV) is 25 times more
  serious in adults than in children.
• gt90 antenatal population are seropositive
  primary VZV infection is uncommon.
• Chickenpox complicates 3 in every 1000
  pregnancies.
• Following primary infection, virus remain dormant
  in sensory nerve root ganglia but can be
  reactivated to cause herpes zoster.

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Varicella in pregnancyMaternal risk

• Greater morbidity- Pneumonia, Hepatitis,
  Encephalitis
• Pneumonia-
• In up to 10 of pregnant women.
• Severity of this complication seems increased in
  later gestation.
• Case fatality rate is lt1 with antiviral drugs.

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Fetal Risklt20 Weeks

• No increased in spontaneous miscarriage in first
  trimester.
• Fetal Varicella Syndrome- -In 1-2 of
  maternal varicella infection. -Characterised
  by skin scarring, eye defects, hypoplasia of
  limbs neurological abnormalities (
  microcephaly, cortical atrophy, mental
  retardation, bladder bowel sphincters
  dysfunction).

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• Fetal varicella syndrome
• Pathogenesis unclear- possibly VZV reactivation
  in utero
• Prenatal diagnosis - Detailed USG, Detection of
  VZV DNA by PCR in amniotic fluid
• No treatment

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Infant with fatal varicella
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Infant with congenital varicella syndrome
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Maternal infection20-36 Wks of Gestation

• Not associated with adverse fetal effect.
• May present as shingles in the first few years of
  life due to reactivation of virus after a primary
  infection in utero.

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Maternal infectiongt36 weeks of gestation

• Causes varicella infection of newborn.
• If maternal infection occurs 1-4 weeks before
  delivery,up to 50 of babies are infected and 23
  of these develop clinical varicella.
• Severe chickenpox is most likely if infant is
  born within 7 days of onset of mothers rash.

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Can varicella be prevented

• In non-immune adult who plans to become pregnant
  - Live attenuated varicella vaccine is safe
  effective in preventing chickenpox but it is not
  available in the UK for this indication. Advise
  to avoid contact with chickenpox.
• At initial antenatal visit Enquire about H/O
  chickenpox.If no such history advised to avoid
  contact to inform health care worker of a
  potential exposure. In case of uncertainty may
  check serum VZV IgG.

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Can varicella be prevented

• Pregnant woman with H/O contact with chickenpox
  -
• Definite past H/O chickenpox- Reassure
• No H/O or any doubt - Do Test for VZ IgG
• If nonimmune - Give VZIG within 10 days of
  exposure
• If rash develops - contact doctor

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Management of pregnant woman who develops
chickenpox

• Initial management
• Avoid contact with susceptible individual.
• Symptomatic treatment.
• Oral acyclovir reduces the duration of symptoms
  if started within 24 hours of development of
  rash.
• No adverse fetal or neonatal effects have been
  reported with the use of acyclovir.

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Management of pregnant woman who develops
chickenpox

• Indications for referral to the hospital
• Development of chest symptoms
• Extensive or haemorrhagic rash
• Smoker
• Chronic lung disease
• Immunosuppressed (On steroids)
• Second half of pregnancy

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Management of pregnant woman who develops
chickenpox

• Delivery during viraemic period may be extremely
  hazardous.
• Maternal risk- bleeding, thrombocytopenia, DIC,
  hepatitis.
• High risk of Varicella of the newborn with
  significant morbidity mortality.
• IV Acyclovir is recommended

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Can the neonatal effects of varicella be
prevented or ameliorated

• If maternal infection occurs at term-
• If practical delivery should be delayed by 5 days
  after onset of illness.
• If delivery within 5 days of infection - Give
  VZIG to neonate.
• If mother develops chickenpox within 2 days of
  delivery- Give VZIG to neonate.
• VZIG does not prevent neonatal infection but
  lowers mortality rate.
• Monitor baby for signs of infection for 14-16
  days.
• If neonatal infection occurs, it should be
  treated with acyclovir.

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• Contact with chickenpox in the first 7 days of
  life
• If mother is immune - no intervention
• If mother is not immune or if neonate delivered
  prematurely. - Give VZIG

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Vaccination of health care workersagainst
chickenpox

• Varicella vaccination is now recommended for
  non-immune healthcare workers (JCVI).
• Pregnancy should be avoided for 3 months
  following vaccination.
• VZIG is not available for exposed non-immune
  healthcare worker unless they are considered at
  high risk of complications of infection.

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Thank you