update in vzv in preg

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UPDATE IN “CHICKENPOX IN PREGNANCY” Hashem Yaseen MD, 4 th year OG

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Page 1: Update in vzv in preg

UPDATE IN “CHICKENPOX IN PREGNANCY”Hashem Yaseen MD, 4th year OG

Page 2: Update in vzv in preg

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

Page 3: Update in vzv in preg

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?!

Page 4: Update in vzv in preg

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 .

Page 5: Update in vzv in preg

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

Page 6: Update in vzv in preg

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

Page 7: Update in vzv in preg

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

Page 8: Update in vzv in preg

Fetal Neonatal Varicella

Page 9: Update in vzv in preg

Congenital Varicella

Page 10: Update in vzv in preg

Hashem Yaseen MD, 4th year OG 31/10/2016

Again

1% 20%

Page 11: Update in vzv in preg

Hashem Yaseen MD, 4th year OG 31/10/2016

Page 12: Update in vzv in preg

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.

Page 13: Update in vzv in preg

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

Page 14: Update in vzv in preg

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

Page 15: Update in vzv in preg

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

Page 16: Update in vzv in preg

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

Page 17: Update in vzv in preg

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