Acta Pædiatrica ISSN 0803–5253

CLINICAL OBSERVATION

Consequences of varicella in pregnancy: a report of four casesIrena Narkeviciute (irena.narkeviciute@vuvl.lt)Clinic of Children’s Diseases of Vilnius University, Vilnius, Lithuania

KeywordsHerpes zoster, Infant, Neonatal varicella, Pregnancy

CorrespondenceIrena Narkeviciute, Clinic of Children’s Diseases ofVilnius University, Santariskiu 4, 08406 Vilnius,Lithuania.Tel: +370 5 2720270 | Fax: +370 5 2720368 |Email: irena.narkeviciute@vuvl.lt

Received4 January 2007; revised 27 February 2007;accepted 5 April 2007

DOI:10.1111/j.1651-2227.2007.00344.x

AbstractFour infants are reported with varicella-Zoster virus (VZV) infection, whose mothers had varicella

during the second–third trimester of pregnancy. Two newborns had neonatal varicella. One of them,

whose mother contracted varicella 5 days before delivery, had a severe and complicated form of the

disease. The infants who had herpes zoster did not have specific VZV-IgG antibodies at the onset of

the disease.Conclusion: These cases showed that varicella during the second–third trimester of pregnancy may have serious

consequence for infants.

The incidence of varicella in pregnancy has been estimatedto be 1–7 cases per 10 000 pregnancies (1). Varicella duringpregnancy may have serious consequences for mother andneonate. The possible outcome depends on the time of infec-tion and includes foetal loss, foetal malformation, pretermdelivery, foetal growth restriction or post-natal infection (2).In infancy, herpes zoster may be the first clinical manifesta-tion of VZV infection after primary in utero.

Below is a report of four infants who were treated at thePediatrics Center of Vilnius University Children’s Hospitalin 2005 owing to VZV infection. Their mothers had varicelladuring the second–third trimester of pregnancy.

CASE 1A girl, 13.5 months of age, was hospitalized on the 7thday of illness because of restlessness, disturbed sleep anda rash, which developed on the 4th day of restlessness. Typ-ical vesicular skin rashes were seen on the right along T10-12, L1-2 dermatomes. Peripheral blood analysis was normal.The patient received symptomatic treatment for 4 days andwas discharged in satisfactory condition.

VZV-IgG and IgM class antibodies (ELISA, Enzygnost;Dade Behring, Germany) were identified in the blood serumon the 9th and 29th days of illness. VZV-IgG concentrationwas 0.135 and 2.142; VZV-IgM 0.038 and 0.704 (pos. > 0.200OD).

She was born at the gestational age of 36 weeks. The deliv-ery was completed by caesarean section. A backbone injurywas identified for the newborn, and she was subjected toartificial lung ventilation.

The mother had a moderate case of varicella during the26th week of pregnancy.

CASE 2A girl, 10 months of age, was hospitalized on the 6th dayof illness because of restlessness, fever and a rash on theright chest. A maculovesicular rash developed on the 5th

day. On the same day the temperature was 38.5◦C. The pa-tient was feverish for 2 days. On physical examination thepatient appeared well. Vesicular skin lesions were observedon the right thorax along T6-7 dermatomes. Peripheral bloodanalysis was normal. The patient received symptomatictreatment for 6 days and was discharged in satisfactorycondition.

The concentration of VZV antibodies was established onthe 8th and 22nd day of illness. VZV-IgG concentration was0.200 and 2.462; VZV-IgM -0.122 and 0.412 (pos. > 0.200OD).

The mother had a mild case of varicella during the 15thweek of pregnancy.

CASE 3A 6-day-old male was hospitalized on the first day of illnessdue to maculovesicular rash of the skin of the face and back.The temperature was normal. The newborn weighed 3960 g.On the second day haemorrhagic fluid was observed in someof the vesicles, and pustules with infiltration and necrosis ofthe surrounding tissues on the 5th day of the illness. On the4th day the patient’s temperature rose to 38◦C. The patient’sworst condition was on the 6th day when the temperaturerose to 39◦C, the patient lost appetite and his weight droppedto 3440 g. The breathing was not restricted, and there wereno lung rales. On the 7th day of the illness chest radiogra-phy showed fine bilateral foci with a minor reaction of inter-lobular pleura in the right side suggestive of varicella pneu-monitis. Peripheral blood analysis on the 1st, 5th and 11thdays of illness was within normal limits. On the 2nd day thepatient received intravenously 2 ml (50 IU) of human vari-cella zoster immunoglobuline (VZIG; Varitect, Germany).On days 5–9, he was administered cephalosporins. On the12th day of illness, the patient was discharged in satisfactorycondition.

The mother had varicella 5 days before delivery. The in-cubation period for the newborn was 11 days.

C©2007 The Author/Journal Compilation C©2007 Foundation Acta Pædiatrica/Acta Pædiatrica 2007 96, pp. 1099–1104 1099

Consequences of varicella in pregnancy Narkeviciute

CASE 4A 2-day-old newborn was hospitalized on the first day ofillness due to a maculovesicular rash of body skin. Onphysical examination the newborn was afebrile and gen-erally appeared well, the number of rash elements wasonly 20 or so. Peripheral blood analysis was normal. Thepatient was discharged on the 4th day in satisfactorycondition.

The mother had varicella 12 days before delivery. The in-cubation period for the newborn was 14 days.

DISCUSSIONVaricella during the first and second trimesters may lead tofoetal (previously known as congenital) varicella syndrome(FVS). At least 112 infants born with FVS were describedprior to 2000 (3). The risk for congenital abnormalities isin 0.4–2% of all mothers who contract varicella during thefirst two trimesters of pregnancy (4–7). According to Brunell(8), maternal varicella at any period during pregnancy maycause herpes zoster in early childhood.

Two of the patients treated by us contracted typical her-pes zoster at an age of 10 and 13.5 months. The first infant’smother contracted varicella during the 15th and the secondinfant’s during the 26th week of pregnancy. Early manifesta-tion of herpes zoster may be explained by the immature cell-mediated immune response in young children and/or thedecrease of maternally derived antibodies (1). The hypoth-esis was confirmed by our two clinical cases. No VZV-IgGantibodies were identified for either of them at the begin-ning of the illness. High titres of VZV-IgG and IgM anti-bodies in their blood serum were discovered only 3–4 weekslater.

Clinical manifestations of neonatal varicella varied frommild to severe including serious disseminated infections withvisceral involvement (9). A fatal outcome has been reportedin 23% of cases if neonatal varicella occurs between 5 and10–12 days of age (10). Twenty-six newborns, aged 6–27days, described by the authors recovered (11). However, theyoften had complications (sepsis, pyodermia, pneumonia andhepatitis). Neonatal varicella within the first 4 days afterbirth has usually been found to be comparatively mild withan uncomplicated course (10). This is also confirmed by ourclinical case. A 2-day-old newborn whose mother had vari-cella 12 days before delivery had a very mild case of thedisease, as it had got maternal VZV-IgG antibodies throughthe placenta.

The newborn in our study, whose mother contracted vari-cella 5 days before delivery, had a severe, complicated caseof varicella. Intravenous VZIG injection was administeredwith a delay due to organizational snags. Intravenous VZIGthat should be administered immediately after delivery isrecommended for varicella prevention in newborns whosemothers contract the disease between 5 days before and 2

days after delivery. It was established that VZIG may reducethe severity of disease, but not always prevent neonatal in-fection (5,9,12). Therefore, intravenous acyclovir is recom-mended for severely affected neonates (5,13–15).

If a non-pregnant woman is seronegative, it is recom-mended to immunize her with varicella vaccine (16). As theseronegative pregnant woman has been exposed she shouldbe given V21G as soon as possible (5,14,15).

Although the risk of foetal abnormalities, herpes zosterin early childhood or neonatal varicella following maternalvaricella is small, the outcome for the affected infant may bevery serious. Active immunization before pregnancy of vari-cella seronegative women is the best prevention of maternalvaricella.

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11. Singalavanija S, Limpongsanurak W, Horpoapan S,Ratrisawadi V. Neonatal varicella: a report of 26 cases. J MedAssoc Thai 1999; 82: 957–62.

12. Hanngren K, Grandien M, Granstrom G. Effect of zosterimmunoglobulin for varicella prophylaxis in the newborn.Scand J Infect Dis 1985; 17: 343–7.

13. Corbeel L. Congenital varicella syndrome. Eur J Pediatr 2004;163: 345–6.

14. Royal College of Obstetricians and Gynecologists.Chickenpox in pregnancy. Guideline No.13. 2001.

15. The management of varicella-zoster virus exposure andinfection in pregnancy and the newborn period. MJA 2001;174: 288–92.

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