Chickenpox in Pregnancy Max Brinsmead MB BS PhD January 2015

Varicella Caused by Herpes zoster Caused by Herpes zoster Different epidemiology in temperate and tropical climates Different epidemiology in temperate and tropical climates Causes Causes Chickenpox Chickenpox Shingles Shingles Fetal varicella syndrome (FVS) Fetal varicella syndrome (FVS) In pregnancy maternal risks of pneumonitis (10%) are greater than the fetal risks of FVS (2%) In pregnancy maternal risks of pneumonitis (10%) are greater than the fetal risks of FVS (2%)

Fetal Varicella Syndrome Greatest risk is maternal infection 13 – 20w Greatest risk is maternal infection 13 – 20w Mental retardation 50% Mental retardation 50% Skin scarring Skin scarring Eye defects (micropthalmia, chorioretinitis and cataracts) Eye defects (micropthalmia, chorioretinitis and cataracts) Limb hypoplasia Limb hypoplasia Bowel/Bladder dysfunction Bowel/Bladder dysfunction Ultrasound or fetal blood sampling for HZV PCR may be diagnostic Ultrasound or fetal blood sampling for HZV PCR may be diagnostic

Fetal Varicella Diagnosis Best managed at a tertiary centre Best managed at a tertiary centre Refer all those that seroconvert <28 weeks Refer all those that seroconvert <28 weeks Requires amniocentesis and PCR Requires amniocentesis and PCR Has a strong negative predictive value for FVS but poor positive predictive value Has a strong negative predictive value for FVS but poor positive predictive value Delay amnio until skin lesions have healed Delay amnio until skin lesions have healed

Neonatal Varicella Risk is greatest if maternal rash occurs 5 days before delivery and up to 2 days after Risk is greatest if maternal rash occurs 5 days before delivery and up to 2 days after Transmission rate 20 – 60% Transmission rate 20 – 60% 30% neonatal mortality if untreated 30% neonatal mortality if untreated Acyclovir recommended Acyclovir recommended Consultation recommended Consultation recommended

Maternal Varicella in Pregnancy Pneumonitis 10% Pneumonitis 10% Hepatitis Hepatitis Encephalitis Encephalitis Acyclovir required Acyclovir required Consultation recommended Consultation recommended

Recommendations* Prenatal screening and/or Immunisation* Prenatal screening and/or Immunisation* Serum HZV IgG at the 1 st antenatal visit* Serum HZV IgG at the 1 st antenatal visit* Advise non immune women to avoid contact with Chickenpox and Shingles Advise non immune women to avoid contact with Chickenpox and Shingles ZIG for non immune women who come into close contact with Varicella ZIG for non immune women who come into close contact with Varicella Effective up to 10 days after contact Effective up to 10 days after contact Effective for 3w. Repeat if re exposed after this Effective for 3w. Repeat if re exposed after this Treat exposed women as potentially infectious for up to 28 days after exposure Treat exposed women as potentially infectious for up to 28 days after exposure Isolate them in the waiting room Isolate them in the waiting room * Not practised in the UK

Acyclovir for Zoster in Pregnancy Not licensed for use so discuss pros and cons with each woman Not licensed for use so discuss pros and cons with each woman Of use for those >20 weeks and may be required 20 weeks and may be required <20w for serious infections Can be given IV for severe infections Can be given IV for severe infections Consider prophylactic oral Acyclovir for exposure >20w Consider prophylactic oral Acyclovir for exposure >20w Hospitalize if respiratory symptoms develop Hospitalize if respiratory symptoms develop Treat secondary bacterial infections Treat secondary bacterial infections

Peripartum Infections Timing of delivery is individualised Timing of delivery is individualised Delay delivery >7 days after rash Delay delivery >7 days after rash Avoid skin lesions with the epidural needle Avoid skin lesions with the epidural needle Neonatal ZIG and Acyclovir for high risk neonate Neonatal ZIG and Acyclovir for high risk neonate Recommend breast feeding Recommend breast feeding Other measures Other measures Immunise health care workers Immunise health care workers Exclude those non immune to Varicella from care of pregnant women for 8 – 21days after possible infection Exclude those non immune to Varicella from care of pregnant women for 8 – 21days after possible infection

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