Chickenpox in Pregnancy UHL Obstetric Guideline - Library
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Chickenpox in Pregnancy UHL
Obstetric Guideline C16/2015
1. Introduction and Who Guideline applies to
This guideline is intended for the use by all UHL staff involved in the care of pregnant patients
who have been exposed to or have acquired chickenpox.
Background:
Chickenpox is caused by the varicella zoster virus. This is a common childhood disease and over
90% over 15yrs are immune to varicella. This virus is highly contagious and transmitted by
respiratory droplets and direct personal contact. The incubation period is between 1-3 weeks and
the disease is infectious 48 hours before the rash appears and continues to be until the vesicles
crust over (which is usually 5 days). The virus can remain dormant in sensory nerve root ganglia
which can then be reactivated to cause a vesicular erythematous skin rash in a dermatomal
distribution known as herpes zoster (shingles).
The vast majority of pregnant women are immune to varicella and infection with varicella zoster
virus (VZV) is uncommon in pregnancy. It is estimated that VZV infection complicates about 3 in
1000 pregnancies. Varicella infection in pregnancy can lead to maternal mortality or serious
morbidity. About 10-20% of infected pregnant women develop varicella pneumonia which can
lead to severe sepsis, disseminated intravascular coagulopathy or acute respiratory failure and
death. Maternal VZV infection can also cause fetal varicella syndrome (FVS) or varicella infection
of the newborn. It can cause a multi-system disorder in the fetus and may lead to skin lesions,
neurological and cardiovascular abnormalities, limb and muscle hypoplasia, mental retardation
as well as abnormalities of the genitourinary and gastrointestinal systems. The risk of
embryopathy with maternal varicella infection is highest between 13-20 weeks gestation and is
estimated to be around 2%. The risk of embryopathy before 13 weeks gestation is around 0.4%.
2. Guideline Standards and Procedures
Recommendations
1. Women who give a history of significant exposure to chickenpox or shingles should have a
careful history to confirm significance of the contact and susceptibility of the patient.
2. Women with significant, exposure should be treated appropriately
3. Women who develop chickenpox should be isolated from other pregnant women , if attends
for medical assessment
4. Women should be counselled about the risks of chickenpox to herself and her baby
5. Delivery needs to be considered on an individual basis
6. Women who are found to be VZV IgG negative should consider varicella vaccination pre
pregnancy or postpartum
Recommendation One:
Women who give a history of significant exposure to chickenpox or shingles should have a
careful history to confirm significance of the contact and susceptibility of the patient.
Significant exposure is defined as contact in the same room for 15mins or more or face to face
contact.
Page 1 of 5
Title: Chickenpox in Pregnancy UHL Obstetric Guideline
V: 2 Next Review: May 2023
Approved by: Guidelines and Maternity Service Governance
Trust Ref No: C16/2015
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library. It should be determined if woman has had previous infection with chickenpox or immunisation.
If she is unsure, test for VZV IgG to determine immunity (see appendix A).
If the woman is sure she has had chickenpox, no further action is required.
Recommendation Two:
Women with significant exposure should be treated appropriately.
Treatment should only be administered when the woman's VZV IgG status is known. If
immune she should be reassured but asked to notify her doctor if a rash develops. For details
of how to test for Varicella Immunity in pregnancy see Appendix 1.
If she is non-immune and has had significant exposure, she should be given VZIG within 10
days of exposure or within 10 days of development of rash in the index case in case of
ongoing exposure.
Non-immune pregnant women who have been exposed to chickenpox should be managed as
potentially infectious from 8–28 days after exposure if they receive VZIG and from 8–21 days
after exposure if they do not receive VZIG.
VZIG is not indicated after rash has developed.
Intravenous immunoglobulin should be given to all women with severe chickenpox.
A second dose of VZIG may be required if a further exposure is reported and three (3) weeks
have elapsed since the last dose
Recommendation Three:
Women who develop chickenpox should be isolated from other pregnant women if they attend for
medical assessment.
If women attend for assessment they should be isolated from other potentially susceptible
pregnant women, babies and non-immune staff.
Women with chickenpox should be advised to avoid contact with other susceptible individuals
(other pregnant women and neonates) until lesions have crusted over, which is typically five
(5) days after the onset of rash.
Women with chickenpox should be advised regarding hygiene measures to avoid
superimposed bacterial infections.
Women who develop chickenpox should immediately contact their GP. Oral acyclovir should
be prescribed if they present within 24 hours of the onset of the rash and if they are 20 weeks
of gestation or beyond. However, acyclovir should also be considered prior to 20 weeks
gestation.
Intravenous Acyclovir should be given to all women with severe chickenpox.
VZIG has no therapeutic benefit once chickenpox has developed and should therefore not be
used in pregnant women who have developed a chickenpox rash.
Women who are thought to have signs and symptoms of severe chickenpox should have
hospital assessment and those who smoke cigarettes, have chronic lung disease, are
immunosuppressed or are in the second half of pregnancy should also be considered for
hospital assessment.
Note: Acyclovir is not licensed for use in pregnancy and the risks and benefits should be
discussed.
Page 2 of 5
Title: Chickenpox in Pregnancy UHL Obstetric Guideline
V: 2 Next Review: May 2023
Approved by: Guidelines and Maternity Service Governance
Trust Ref No: C16/2015
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.Recommendation Four:
Women should be counselled about the risks of chickenpox to herself and her baby.
Women should be advised about the signs and symptoms of chickenpox which include pruritic
rash, crops of vesicles, fever and malaise.
Chickenpox can have potentially life-threatening complications like pneumonia, hepatitis,
encephalitis, maternal death, fetal varicella syndrome and varicella infection of newborn.
Women should be advised that there is no apparent increase in miscarriage in first trimester if
chickenpox occurs during first trimester.
If a woman develops chickenpox in the first 28 weeks of pregnancy, she has a small risk of
developing fetal varicella syndrome and this should be discussed with her.
Women who develop chickenpox in pregnancy should be referred to a fetal medicine
specialist at 16-20 weeks or 5 weeks after infection for detailed ultrasound examination of the
fetus and discussion.
Women who develop chickenpox during pregnancy should be counselled about risks and
benefits of amniocentesis to detect varicella DNA in amniotic fluid; however amniocentesis
should only be performed once the skin lesions have completely healed.
Recommendation Five:
Delivery needs to be considered on an individual basis.
Delivery while the vesicles are still active maybe hazardous and poses a very high risk of
maternal morbidity and mortality and therefore should be avoided. There is also a high risk of
varicella infection of the newborn with significant morbidity and mortality.
Ideally, a minimum of 7 days should elapse between onset of rash and delivery providing
continuing the pregnancy does not pose any additional risk to mother or baby.
The newborn is at high risk of varicella infection which has significant morbidity and mortality.
The risk of acquiring this is highest if maternal infection occurs in the last 4 weeks of a
woman's pregnancy.
Women with chickenpox requiring delivery should be reviewed by the anaesthetist. There's
no evidence to inform decisions on the optimum method of anaesthesia. General anaesthesia
may exacerbate respiratory compromise and theoretically there is risk with spinal anaesthesia
transmitting the virus to the CNS. A site free of cutaneous lesions should be chosen for needle
placement.
A neonatologist should be informed of the birth of babies to women who developed
chickenpox at any gestation during pregnancy.
Women who had chickenpox can breastfeed unless otherwise contraindicated. If they are
active lesions close to the nipple they should express milk from the affected breast until the
lesions crust over. The expressed milk can be used if baby has received treatment with
acyclovir or VZIG.
Recommendation 6:
Women who are found to be VZV IgG negative should consider varicella vaccination pre
pregnancy or postpartum
Women who are found to be VZV IgG negative should consider varicella vaccination pre-
pregnancy or postpartum.
Page 3 of 5
Title: Chickenpox in Pregnancy UHL Obstetric Guideline
V: 2 Next Review: May 2023
Approved by: Guidelines and Maternity Service Governance
Trust Ref No: C16/2015
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library. If given pre-pregnancy, women should avoid getting pregnant for 4 weeks after completion of
the course of vaccine and also avoid contact with other pregnant women and neonates if a
rash occurs.
If the vaccine is administered postpartum, women can be reassured that it is safe to
breastfeed.
3. Education and Training
None
4. Monitoring Compliance
What will be measured to How will compliance be Monitoring Reporting
Frequency
monitor compliance monitored Lead arrangements
5. Supporting References
Chicken Pox in Pregnancy RCOG 2015
6. Key Words
Chicken pox in pregnancy, varicella, VZIG
__________________________________________________________
The Trust recognises the diversity of the local community it serves. Our aim therefore is to
provide a safe environment free from discrimination and treat all individuals fairly with
dignity and appropriately according to their needs.
As part of its development, this policy and its impact on equality have been reviewed and
no detriment was identified.
DEVELOPMENT AND APPROVAL RECORD FOR THIS DOCUMENT
Author / Lead N Archer, B Trivedi, S Agarwal and N Clark Job Title: Obstetricians and
Officer: Midwife
Reviewed by: Dr Rakhee Saxena and N Archer
Approved by: Guidelines and Maternity Service Governance Meeting Date Approved: 15.07.15
21/05/20
REVIEW RECORD
Date Issue Reviewed By Description Of Changes (If Any)
Number
April 2017 V1 N Archer and H No need to ring Collingdale, can ring LRI so flow chart
Ulyett amended
May 2020 V2 Dr Rakhee Saxena Flow chart amended to include updated contact details
and N Archer updated from NUH to UHL. General Update.
DISTRIBUTION RECORD:
Date Name Dept Received
7.15 All Obstetricians and Midwives Maternity
April 2017 All Obstetricians and Midwives Maternity
May 2020 All Obstetricians and Midwives Maternity
Page 4 of 5
Title: Chickenpox in Pregnancy UHL Obstetric Guideline
V: 2 Next Review: May 2023
Approved by: Guidelines and Maternity Service Governance
Trust Ref No: C16/2015
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.Appendix 1
Process from women booked at the University Hospitals of Leicester NHS Trust who are
exposed to Varicella (Chickenpox/Shingles) infection in pregnancy
Relevant Contact:
24-48 hours prior to
Women seen by GP/Midwife re contact with chickenpox/Shingles within appearance of rash
the last 10 days who has not had chickenpox and has had a relevant (chickenpox only)
contact (see yellow box) Fresh vesicular
rash/new lesions
appearing
Not Relevant contact:
GP/midwife to contact UHL laboratory on ext 6522 Scabbed lesions/no fresh
Request testing for varicella immunity on the stored ‘booking’ sample lesions within 48 hours
Submit an empath antenatal request form to the lab as a follow up to the
telephone request for VZV IgG antibody testing on the stored sample.
Be specific about the indication for testing and who to contact with
the results
Varicella IgG positive Varicella IgG NEGATIVE
Microbiology Microbiology lab telephones Microbiology informs
communicates results to results to GP/Midwife. If antenatal clinic of lab
GP/Named Midwife midwife contacted, she must results
inform GP immediately by
telephone to arrange VZIG.
VZIG prophylaxis (**) is recommended throughout
No further action pregnancy
** 1g = 4x250mg per vial IM injection
Monday – Sunday and bank holidays;
VZIG is available from UHL microbiology Dept. Needs to be sanctioned by the on-call
Consultant Virologist/Microbiologist over the phone.
Patient or elected representative MUST collect VZIG from microbiology Dept, Level 6,
Sandringham Building, LRI
Tel via switchboard or 01162586643/6638 (9-5 weekdays)
VZIG MUST BE ADMINISTERED IM WITHIN 10 DAYS OF CONTACT – midwives are
not licenced to give immunoglobulin – woman needs to attend GP surgery or urgent
care.
GP surgery responsible from
ensuring administration of VZIG to
woman has occurred within the
required 10 days post
Page 5 of 5
Title: Chickenpox in Pregnancy UHL Obstetric Guideline
V: 2 Next Review: May 2023
Approved by: Guidelines and Maternity Service Governance
Trust Ref No: C16/2015
NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guidelines library.You can also read
