1. Common dilemmas in Pregnancy Andy Lindop

2. Chickenpox Can cause problems for Mum to be and her unborn Can cause problems for Mum to be and her unborn Incidence 3 in 1000 Incidence 3 in 1000 Situations commonly encountered in practice: Situations commonly encountered in practice: Contact no evidence yet (incubation is 10-21 days) Contact no evidence yet (incubation is 10-21 days) Developing classical rash Developing classical rash

3. Why worry? Maternal Complications Pneumonitis Pneumonitis Encephalitis Encephalitis Hepatitis Hepatitis Myocarditis Myocarditis Glomerulonephritis Glomerulonephritis Appendicitis Appendicitis Pancreatitis Pancreatitis Clotting disorders Clotting disorders

4. Risks of complications for Mum are increased if Smoker or have a lung condition, such as bronchitis or emphysema Smoker or have a lung condition, such as bronchitis or emphysema Are taking steroids, or have taken steroids during the previous three months Are taking steroids, or have taken steroids during the previous three months Are more than 20 weeks pregnant. Are more than 20 weeks pregnant. Up to one in 10 pregnant women with chickenpox develop pneumonia (inflammation of the lungs). Up to one in 10 pregnant women with chickenpox develop pneumonia (inflammation of the lungs).

5. How about risks to baby? Foetal Varicella syndrome Foetal Varicella syndrome Risks less than 1% in first 20 weeks Risks less than 1% in first 20 weeks 0% after 28 weeks 0% after 28 weeks Neonatal chickenpox Neonatal chickenpox Neonatal chickenpox can be severe when the maternal rash appears between five days before delivery and two days after delivery. Neonatal chickenpox can be severe when the maternal rash appears between five days before delivery and two days after delivery. Mortality may be as high as 30% without active treatment Mortality may be as high as 30% without active treatment

6. What is Foetal Varicella Syndrome like? Skin loss scarring limb hypoplasia/paresis Skin loss scarring limb hypoplasia/paresis Microcephaly, hypotonia ophthalmological probs. Microcephaly, hypotonia ophthalmological probs. If ultrasound examination is suggestive of the syndrome then amniotic fluid can be tested for varicella zoster virus-DNA If ultrasound examination is suggestive of the syndrome then amniotic fluid can be tested for varicella zoster virus-DNA

7. Miscarriage? There is no evidence that uncomplicated chickenpox in the mother significantly increases the likelihood of spontaneous abortion during the first 20 weeks of pregnancy There is no evidence that uncomplicated chickenpox in the mother significantly increases the likelihood of spontaneous abortion during the first 20 weeks of pregnancy Women should be offered referral to a specialist centre for detailed ultrasound examination at around 5 weeks after her varicella infection to look for the specific anomalies of fetal varicella syndrome Women should be offered referral to a specialist centre for detailed ultrasound examination at around 5 weeks after her varicella infection to look for the specific anomalies of fetal varicella syndrome

8. What counts as contact? Contact in the same room for 15 minutes or more, Contact in the same room for 15 minutes or more, Face-to-face contact Face-to-face contact Contact in the setting of a large open ward with an individual with chickenpox or shingles Contact in the setting of a large open ward with an individual with chickenpox or shingles

9. Management of Contact Establish if immune Establish if immune Assay varicella zoster antibodies if suspected exposure to chickenpox (or shingles) and uncertain if woman has had previous chickenpox Assay varicella zoster antibodies if suspected exposure to chickenpox (or shingles) and uncertain if woman has had previous chickenpox If not immune consider treatment-seek specialist advice re If not immune consider treatment-seek specialist advice re

10. Use of Immunoglobulin Zoster immune globulin (VZIG) should be given for VZ antibody negative contacts exposed at any stage of pregnancy 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 However it may attenuate disease even if given up to 10 days following exposure VZ immune globulin does not prevent infection However it may attenuate disease even if given up to 10 days following exposure 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 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

11. Management of well Mum with Chickenpox Pregnant women with chickenpox may benefit from oral aciclovir Pregnant women with chickenpox may benefit from oral aciclovir Caution advised before 20 weeks Caution advised before 20 weeks VZ immune globulin has no place in treatment once chickenpox has developed VZ immune globulin has no place in treatment once chickenpox has developed

12. Management of ill Mum with overt Chickenpox Admit to hospital (preferably somewhere with access to specialists in obstetrics, infectious diseases, and paediatrics) IF Admit to hospital (preferably somewhere with access to specialists in obstetrics, infectious diseases, and paediatrics) IF Fever persists Fever persists The woman has chest symptoms, The woman has chest symptoms, Neurological symptoms other than headache, haemorrhagic rash or bleeding, Neurological symptoms other than headache, haemorrhagic rash or bleeding, Severe disease (e.g. dense rash with or without numerous mucosal lesions), Severe disease (e.g. dense rash with or without numerous mucosal lesions), or Significant immunosuppression. or Significant immunosuppression.

13. UTI Asymptomatic finding –should we treat? Asymptomatic finding –should we treat? Lower urinary tract -how long and with what? Lower urinary tract -how long and with what? Upper or Pyelonephritis-management? Upper or Pyelonephritis-management?

14. Who should have iron? Why not everyone? Why not everyone? May actually increase perinatal mortality and low birth weight is increased May actually increase perinatal mortality and low birth weight is increased Side effects risks to other children in house Side effects risks to other children in house Who then? Who then? High risk of significant anaemia High risk of significant anaemia Hb less than 10 in last trimester Hb less than 10 in last trimester