Update in vzv in preg.
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Transcript of Update in vzv in preg.
UPDATE IN “CHICKENPOX IN PREGNANCY”Hashem Yaseen MD, 4th year OG
Hashem Yaseen MD, 4th year OG 31/10/2016
GENERAL BACKGROUND
VZV is a DNA virus of the herpes family Primary: varicella (chickenpox) secondary: herpes zoster (shingles)
The incubation period is between 1 and 3 week Seroprevelance: ~ 95 % of UK & USA women
immune Incidence of 1ry infection in pregnancy ~ 3:1000
TRANSMISSION
Hashem Yaseen MD, 4th year OG 31/10/2016
Person to person 1. respiratory droplets2. direct personal contact with vesicle fluid3. indirectly via fomites (e.g. skin cells, hair, clothing
and bedding). Mother to infant 1. Intrauterine → transplacental transmission2. Postnatal → respiratory droplets or direct
contact with someone with varicella Passage of varicella zoster virus to the fetus
during zoster is rare, except?!
Hashem Yaseen MD, 4th year OG 31/10/2016
TRANSMISSION ’2 Disseminated zoster Exposed zoster (e.g. ophthalmic) localised zoster in an
immunosuppressed patient
the disease is infectious 48 hours before the rash appears and continues to be infectious until the vesicles crust over. The vesicles usually crust over within 5 days .
Hashem Yaseen MD, 4th year OG 31/10/2016
SYMPTOMS The primary infection - Uncomplicated varicella :1. Fever2. Malaise3. Maculopapular pruritic rash that develops into crops,
which become vesicular and crust over before healing
Maternal risks -Complicated infection:Varicella in pregnancy is often more sever and may be life threatened
as a consequence of: 1. Varicella pneumonia 2. Encephalitis3. hepatitis
FETAL EFFECTS OF VZV INFECTION
Hashem Yaseen MD, 4th year OG 31/10/2016
~ 25% in all trimester. ≤ 20 wks -> 2% risk for Congenital varicella syndrome:1. Cutaneous scars in a dermatomal pattern2. Neurological abnormalities (eg, mental retardation,
microcephaly, hydrocephalus, seizures, Horner’s syndrome)3. Ocular abnormalities (eg, optic nerve atrophy, cataracts,
chorioretinitis, microphthalmos, nystagmus)4. Limb abnormalities (hypoplasia, atrophy, paresis)5. Gastrointestinal abnormalities (gastroesophageal reflux,
atretic or stenotic bowel)6. Low birth weight
a mortality rate of 30 percent in the first few months of life and a 15 percent risk of developing herpes zoster in the first four years of life
Hashem Yaseen MD, 4th year OG 31/10/2016
Neonatal VZV infection results from VZV transmission from a
mother to the fetus just prior to delivery disease within five days before to two
days after delivery are at the greatest risk for severe disease and poor outcome.
VZIG as soon as possible
Fetal Neonatal Varicella
Congenital Varicella
Hashem Yaseen MD, 4th year OG 31/10/2016
Again
1% 20%
Hashem Yaseen MD, 4th year OG 31/10/2016
Hashem Yaseen MD, 4th year OG 31/10/2016
Varicella prevention live attenuated vaccine In two separate doses 4–8 weeks apart. Varicella vaccination prepregnancy or
postpartum is an option. should be advised to avoid pregnancy for
4 weeks after completing the two-dose vaccine schedule
Routine antenatal testing is not recommended
It is safe to breastfeed.
Hashem Yaseen MD, 4th year OG 31/10/2016
Varicella-zoster contact
Past history of chickenpox
No action needed. Reassure and return to normal antenatal care
•Significant contact is defined as contact in the same room for 15 minutes or more, face-to-face contact or contact in the setting of a large open ward
~Varicella: the green book, chapter 34. London: Public Health England; 2012
Hashem Yaseen MD, 4th year OG 31/10/2016
Varicella-zoster contact
Uncertain or no past history of chickenpox, or woman from a tropical
or subtropical country
Check blood (booking sample if available) for VZV IgG
Hashem Yaseen MD, 4th year OG 31/10/2016
Varicella-zoster contact
VZV IgG
present VZV IgG
not present
No action needed. Reassure and return to normal
antenatal care 1. Give VZIG if less than 10 days since contact or, for continuous exposure2. Advise the woman that she is potentially infectious from 8–28 days after contact 3. Discuss postpartum varicella immunisation
Hashem Yaseen MD, 4th year OG 31/10/2016
Presents with chickenpox
1. Avoid contact with potentially susceptible individuals (e.g. neonates and other pregnant women)
2. Symptomatic treatment and hygiene should be advised
3. If the woman presents < 24 hours of the appearance of the rash and she is ≥ 20+0 weeks of gestation, prescribe oral aciclovir
4. If the woman presents < 24 hours of the appearance of the rash and she is < 20+0 weeks of gestation, consider oral aciclovir
5. Intravenous aciclovir should be given to all pregnant women with severe chickenpox.
6. Avoid delivery of the baby until at least 7 days since the rash appeared
Hashem Yaseen MD, 4th year OG 31/10/2016
Presents with chickenpox
•Inform women that infection at < 28+0 weeks is associated with a small (~1%) risk of FVS •Refer to a fetal medicine specialist at 16–20 weeks or 5 weeks after infection •Amniocentesis to detect varicella DNA may be considered