Chickenpox in PregnancyChickenpox in Pregnancy

Max Brinsmead MB BS PhD Max Brinsmead MB BS PhD January 2015January 2015

VaricellaVaricella

Caused by Herpes zosterCaused by Herpes zoster Different epidemiology in temperate and tropical Different epidemiology in temperate and tropical

climatesclimates CausesCauses

ChickenpoxChickenpox ShinglesShingles Fetal varicella syndrome (FVS)Fetal varicella syndrome (FVS)

In pregnancy maternal risks of pneumonitis In pregnancy maternal risks of pneumonitis (10%) are greater than the fetal risks of FVS (10%) are greater than the fetal risks of FVS (2%)(2%)

Fetal Varicella SyndromeFetal Varicella Syndrome

Greatest risk is maternal infection 13 – 20wGreatest risk is maternal infection 13 – 20w Mental retardation 50%Mental retardation 50% Skin scarringSkin scarring Eye defects (micropthalmia, chorioretinitis and Eye defects (micropthalmia, chorioretinitis and

cataracts)cataracts) Limb hypoplasiaLimb hypoplasia Bowel/Bladder dysfunctionBowel/Bladder dysfunction Ultrasound or fetal blood sampling for HZV PCR Ultrasound or fetal blood sampling for HZV PCR

may be diagnosticmay be diagnostic

Fetal Varicella DiagnosisFetal Varicella Diagnosis

Best managed at a tertiary centreBest managed at a tertiary centre Refer all those that seroconvert <28 weeksRefer all those that seroconvert <28 weeks Requires amniocentesis and PCRRequires amniocentesis and PCR Has a strong negative predictive value for FVS Has a strong negative predictive value for FVS

but poor positive predictive valuebut poor positive predictive value Delay amnio until skin lesions have healedDelay amnio until skin lesions have healed

Neonatal VaricellaNeonatal Varicella

Risk is greatest if maternal rash occurs 5 days before Risk is greatest if maternal rash occurs 5 days before delivery and up to 2 days afterdelivery and up to 2 days after

Transmission rate 20 – 60%Transmission rate 20 – 60%

30% neonatal mortality if untreated30% neonatal mortality if untreated

Acyclovir recommendedAcyclovir recommended

Consultation recommendedConsultation recommended

Maternal Varicella in PregnancyMaternal Varicella in Pregnancy

Pneumonitis 10%Pneumonitis 10%

HepatitisHepatitis

EncephalitisEncephalitis

Acyclovir requiredAcyclovir required

Consultation recommendedConsultation recommended

Recommendations*Recommendations*

Prenatal screening and/or Immunisation*Prenatal screening and/or Immunisation* Serum HZV IgG at the 1Serum HZV IgG at the 1stst antenatal visit* antenatal visit*

Advise non immune women to avoid contact with Advise non immune women to avoid contact with Chickenpox and ShinglesChickenpox and Shingles

ZIG for non immune women who come into ZIG for non immune women who come into close contact with Varicellaclose contact with Varicella Effective up to 10 days after contactEffective up to 10 days after contact Effective for 3w. Repeat if re exposed after thisEffective for 3w. Repeat if re exposed after this

Treat exposed women as potentially infectious Treat exposed women as potentially infectious for up to 28 days after exposurefor up to 28 days after exposure Isolate them in the waiting roomIsolate them in the waiting room

**Not practised in the UKNot practised in the UK

Acyclovir for Zoster in PregnancyAcyclovir for Zoster in Pregnancy

Not licensed for use so discuss pros and cons Not licensed for use so discuss pros and cons with each womanwith each woman

Of use for those >20 weeks and may be Of use for those >20 weeks and may be required <20w for serious infectionsrequired <20w for serious infections

Can be given IV for severe infectionsCan be given IV for severe infections Consider prophylactic oral Acyclovir for Consider prophylactic oral Acyclovir for

exposure >20wexposure >20w Hospitalize if respiratory symptoms developHospitalize if respiratory symptoms develop Treat secondary bacterial infectionsTreat secondary bacterial infections

Peripartum InfectionsPeripartum Infections

Timing of delivery is individualised Timing of delivery is individualised Delay delivery >7 days after rashDelay delivery >7 days after rash Avoid skin lesions with the epidural needleAvoid skin lesions with the epidural needle Neonatal ZIG and Acyclovir for high risk neonateNeonatal ZIG and Acyclovir for high risk neonate Recommend breast feedingRecommend breast feeding

Other measuresOther measures Immunise health care workersImmunise health care workers Exclude those non immune to Varicella from care of Exclude those non immune to Varicella from care of

pregnant women for 8 – 21days after possible pregnant women for 8 – 21days after possible infectioninfection

Any Questions or Any Questions or Comments?Comments?

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