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management of chickenpox in pregnancy

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Consult expert advice.

  • assay varicella zoster antibodies if suspected exposure to chickenpox (or shingles) and uncertain if woman has had previous chickenpox
    • tested by urgent serology (turn-around time usually 24-48 hours) to check for IgG antibody to varicella zoster

A pregnant woman who gives a history of contact with chickenpox or shingles:

  • if chickenpox in pregnancy, or a woman is varicella zoster (VZ) antibody negative and is exposed to chickenpox during pregnancy, then immediately consult expert advice
    • if woman is VZ antibody negative and has had significant exposure to possible chickenpox infection (contact in the same room for 15 minutes or more, face-to-face contact and contact in the setting of a large open ward with an individual with chickenpox or shingles):
      • VZ virus immunity should be checked by a blood test (1)
      • zoster immune globulin (VZIG) should be given for VZ antibody negative contacts exposed at any stage of pregnancy
        • VZ immune globulin does not prevent infection (even when given within 72 hours of exposure). However it may attenuate disease even if given up to 10 days following exposure (1). The outcome in pregnant women is not adversely affected if there is a delay in administration of VZ immune globulin for up to 10 days after the initial contact whilst the VZ antibody status is determined (2)
        • if VZIG is administered, the pregnant women should be regarded as potentially infectious from 8-28 days after VZIG (1)
        • the decision on whether to give VZ immune globulin is generally made by the local microbiologist or virologist
          • duration of protection from immunoglobulin is limited
          • a second dose should be given if further exposure occurs and 3 weeks have lapsed since the first dose - in this situation, varicella antibody status should be checked again before giving a second dose of VZ immune globulin as subclinical infection may have occurred
        • oral aciclovir prophylaxis should be given to susceptible pregnant women exposed to varicella who have underlying risk factors for severe disease and who did not receive VZ immune globulin

A pregnant woman who develops chickenpox

  • if woman has chickenpox in pregnancy:
    • infected pregnant women should avoid contact with other pregnant women and neonates for about 5 days after the onset of rash or till the lesions have crusted over (1)
    • diagnosis can be made clinically in most instances (3)
    • referral and possible admission to hospital:
      • most pregnant women with chickenpox do not need to be hospitalised, but can be reassured and sent home for review daily or earlier if their illness worsens (2)
      • if severe disease develops, the woman should be urgently admitted to a specialist isolation facility that has access to the expertise of an obstetrician, an infectious disease specialist and a paediatrician
    • pregnant women with chickenpox may benefit from oral aciclovir (3)
      • likely effectiveness of such therapy depends on the timing of onset of the rash. If the mother presents within 24 hours of the first observed lesion and  if they are more than 20 weeks gestation, aciclovir should be offered, because it has been shown in infants, children and adolescents to decrease the severity and duration of chickenpox (3,1)
        • oral aciclovir 800 mg five times a day for 7 days will reduce the duration of fever and other symptoms (1)
        • giving aiclovir more than 24 hours after onset of the rash - sometimes tried if there is a significant risk of complications from infection
        • aciclovir should be used carefully before 20 weeks of gestation (1)
    • VZ immune globulin has no place in treatment once chickenpox has developed
    • for severe or progressive maternal or neonatal infection use IV acyclovir as it is safe - not embryotoxic - and may improve outcome significantly
    • termination of the pregnancy is not justified without ultrasound evidence of major abnormality as the risk is small and unpredictable
    • zoster immune globulin should be given to neonates of women who develop chickenpox (but not herpes zoster) in the period 7 days before delivery to 28 days after delivery (2)
    • note that premature infants (who are born before 28 weeks gestation or have a birth weight of less than 1000g) may not possess maternal antibody despite a positive history of chickenpox in the mother (2)

Notes:

  • evidence indicates that there is a small risk of development of fetal varicella syndrome where the mother develops chickenpox after 20 weeks of pregnancy, with the risk extending to at least week 28 (5)

Reference:

  1. The Royal College of Obstetricians and Gynaecologists 2007. Green-top Guideline No. 13 – Chickenpox in pregnancy
  2. The Green Book. Immunisation against infectious disease. HMSO. London 1996.
  3. Drug and Therapeutics Bulletin 2005; 43(9): 69-72.
  4. BMJ 1993; 306: 1079.
  5. Drug and Therapeutics Bulletin 2005; 43(12):94-95

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