Aboubakr elnashar

1. Chickenpox in Pregnancy
Green top guidelines, 2015
Prof Aboubakr Elnashar
Benha university Hospital, Egypt

2. CONTENTS
I. Introduction
II. Maternal risk
III. Fetal risk
IV. Neonatal risk
V. Management of varicella-zoster contact in pregnancy
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3. I. INTRODUCTION
Varicella-zoster virus (VZV)
highly contagious DNA virus of the herpes family.
transmitted by
respiratory droplets
direct personal contact with vesicle fluid.
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4. Primary infection
Fever
Malaise
Pruritic rash.
During pregnancy
illness more severe than in childhood
pneumonia
encephalitis
myocarditis.
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5. Incubation period
7-21 days
Person is infectious
48 h before the rash appears
continues to be infectious
until the vesicles crust over
typically 5 days.
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6. In UK:
90% of the antenatal population
Seropositive for VZV-specific IgG antibody
infection is uncommon
1 in 1000 pregnancies.
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7. Following primary infection
virus remains dormant in sensory nerve root ganglia
can become reactivated to give a vesicular
erythematous skin rash in a dermatome distribution,
i.e. shingles.
It is possible to acquire the infection from exposed
sites.
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8. II. MATERNAL
1. Diagnosis
For a woman with
no previous history of chickenpox and
 significant history of exposure
risk to the woman can be determined by
serological evidence of VZV IgG.
The diagnosis itself is made from
examination of the classic rash.
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12. 2. PREVENTION
1. Varicella vaccination
prepregnancy or postpartum is an option that should
be considered for women who are found to be
seronegative for varicella-zoster virus
immunoglobulin G (VZV IgG).
2. Postpartum immunisation for
Seronegative women identified in pregnancy
it is safe to breastfeed.
Varicella vaccine
a live attenuated vaccine
pregnancy should be avoided for 1-3 months after
administration.
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13. 3. Women booking for antenatal care
should be asked about previous chickenpox/shingles
infection.
Women who have not had chickenpox, or are known
to be seronegative for chickenpox, should be advised
to
avoid contact with chickenpox and shingles
during pregnancy
inform healthcare workers of a potential exposure
without delay.
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14. 4. When contact occurs with chickenpox or shingles
careful history must be taken to
confirm the significance of the contact and
susceptibility of the patient.
5. Blood test to determine VZV immunity or non-
immunity in Pregnant women with
an uncertain or no previous history of chickenpox, or
who come from tropical or subtropical countries
have been exposed to infection
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15. 6. If the pregnant woman is not immune to VZV and she
has had a significant exposure
she should be offered varicella-zoster
immunoglobulin (VZIG) as soon as possible.
VZIG is effective when given up to 10 days after
contact (in the case of continuous exposures, this is
defined as 10 days from the appearance of the rash
in the index case).
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16. 7. Non-immune pregnant women who have been
exposed to chickenpox
should be managed as potentially infectious
from 8–28 days after exposure if they receive
VZIG and
from 8–21 days after exposure if they do not
receive VZIG.
8. When supplies are limited
issues to pregnant women may be restricted
clinicians are advised to establish the availability of
VZIG before offering it to pregnant women.
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17. 9. Women who have had exposure to chickenpox or
shingles (regardless of whether or not they have
received VZIG)
should be asked to notify their doctor or midwife early
if a rash develops.
10. A pregnant woman who develops a chickenpox rash
should be isolated from other pregnant women when
she attends a general practice surgery or a hospital
for assessment.
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18. 11. A second dose of VZIG
may be required if
further exposure is reported and
3 w have elapsed since the last dose.
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19. 3. Maternal risks of varicella in pregnancy
1. increased morbidity associated with varicella
infection in adults, including
1. Pneumonia
2. Hepatitis
3. encephalitis.
2. Rarely, it may result in death.
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20. 4. Care of pregnant woman who develops
chickenpox
immediately contact their general practitioner.
1. Avoid contact with potentially susceptible individuals,
e.g. other pregnant women and neonates, until the
lesions have crusted over.
This is usually about 5 days after the onset of the
rash.
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21. 2. Symptomatic treatment and hygiene
{prevent secondary bacterial infection of the lesions}
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22. 3. Oral aciclovir
should be prescribed for pregnant women with
chickenpox if
they present within 24 hs of the onset of the rash
they are 20+0 w of gestation or beyond.
Use of aciclovir before 20+0 w should also be
considered.
seronegative women with
significant contact with varicella-zoster
immunoglobulin
no evidence to prove that it reduces the risk of trans-
mission of VZV to the fetus.
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23. 4. Intravenous aciclovir
should be given to all pregnant women with severe
chickenpox.
VZIG
no therapeutic benefit once chickenpox has
developed
not be used in pregnant women who have
developed a chickenpox rash.
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24. 5. Referral to hospital
 The pregnant woman with chickenpox should be
asked to contact her doctor immediately if she
develops
1. respiratory symptoms or
2. any other deterioration in her condition.
 Indications:
 symptoms or signs of severe chickenpox
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25. 1. Assessment in an area where she will not come into
contact with other pregnant women.
2. multidisciplinary team
 an obstetrician
 fetal medicine specialist
 Virologist
 neonatologist.
3. Nursed in isolation from
 Babies
 potentially susceptible pregnant women or
 non-immune staff.
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26. 6. Delivery
The timing and mode
must be individualised.
When epidural or spinal anaesthesia is undertaken
site free of cutaneous lesions should be chosen
for needle placement.
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27. III. FETAL INFECTION
1. Fetal risks
 is gestation dependent.
In the first trimester
fetal infection may lead to spontaneous
miscarriage.
3 to 28 w
fetal varicella syndrome (FVS)
1-2% until 20 w
20-28w:
rapidly declining incidence of FVS
after 28 w
No cases
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28. 2. Fetal varicella syndrome
It does not occur at the time of initial fetal infection but
results from a subsequent herpes zoster reactivation in
utero and only occurs in a minority of infected fetuses.
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29. Characterized by one or more of the following:
1. skin scarring in a dermatomal distribution
2. eye defects:
microphthalmia, chorioretinitis, cataracts
3. hypoplasia of the limbs
4. neurological abnormalities
microcephaly, cortical atrophy, mental restriction
and dysfunction of bowel and bladder sphincters
Common manifestations:
limb deformity
Microcephaly
Hydrocephaly
soft tissue calcification
IUGR.
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30. Diagnosis
1. ultrasound findings.
 Women who develop chickenpox in pregnancy
should be referred to a fetal medicine
specialist, at 16–20 w or 5 w after infection, for
discussion and detailed ultrasound
examination.
{There is usually a time lag of at least 5 weeks
after the primary infection before fetal
differences are seen}.
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31. 2. Amniocentesis
 should not be performed before the skin lesions
have completely healed.
 may be performed to confirm the diagnosis with
PCR identification of VZV DNA.
 In the absence of ultra-sound scanning finding
 positive amniocentesis has a high sensitivity
but low specificity for the development of VZV.
 If the PCR is positive but the ultrasound normal at
17-21 w
 risk of FVS is low
 if repeat ultrasound scanning at 24 w is also
normal then the risk of FVS is almost zero.
 The risk, conversely, is very high if there are
ultrasound features and positive PCR [D].ABOUBAKR ELNASHAR

32. 3. Treatment and prevention
no intrauterine treatment currently available.
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33. IV. NEONATAL RISKS
1. If maternal infection occurs in the last 4 w of a
woman’s pregnancy,
 there is a significant risk of varicella infection of
the newborn.
 A planned delivery
 should normally be avoided for at least 7 days
after the onset of the maternal rash
 allow for the passive transfer of antibodies from
mother to child
 provided that continuing the pregnancy does
not pose any additional risks to the mother or
baby.
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34. 2. A neonatologist
should be informed of the birth of all babies born to
women who have developed chickenpox at any
gestation during pregnancy.
3. Breastfeeding
if they wish to and are well enough to do so.
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35. Management of varicella-zoster contact in pregnancy
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