First, a broad spectrum of abnormalities can result from varicella infection in utero. In addition, attempts at recovering virus from the affected fetus or neonate have been unsuccessful. Immunologic data also have been difficult to obtain. Fetal IgM has been detected in blood samples obtained by cordocentesis. Varicella zoster virus DNA has been identified in the amniotic fluid and in fetal tissue using PCR techniques .The risk of congenital varicella syndrome in exposed pregnancies is roughly equivalent to the rates of pregnancy loss associated with the performance of invasive testing , Additionally, identification of the virus in chorionic villi, amniotic fluid, or fetal blood does not predict the severity and effect of fetal infection
References World Health Organization (WHO). Who expert consultation on rabies, 5-8 October 2004. Technical Report Series 931 – First Report. Switzerland: WHO Press; 2004 Nadin-Davis SA. Molecular epidemiology. In: Jackson AC, Wunner WH, eds. Rabies. 2nd edn. London: Elsevier Academic Press ; 2007:69-122 3. Bleck TP, Rupprecht CE. Rhabdoviruses. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases . 6th edn. Philadelphia: Churchill Livingstone Inc.; 2005:2047-56 4. Centers for Disease Control and Prevention (CDC). Rabies. http://www.cdc.gov/rabies/bats.html . Accessed March 2, 2009
References World Health Organization (WHO). RABNET. Rabies, countries or areas at risk. 23 Feb 2009. http://gamapserver.who.int/mapLibrary/Files/Maps/Global_Rabies_ITHRiskMap.png. Acce ssed March 2, 2009
Dog is one of best human friends but can spread Rabies if not vaccinated
References 1. World Health Organization (WHO). Who expert consultation on rabies, 5-8 October 2004. Technical Report Series 931 – First Report. Switzerland: WHO Press; 2004 2. World Health Organization (WHO). Rabies vaccines. WHO position paper . Wkly Epidemiol Rec 2007;82:425–35
References 1. World Health Organization (WHO). Who expert consultation on rabies, 5-8 October 2004. Technical Report Series 931 – First Report. Switzerland: WHO Press; 2004 2. World Health Organization (WHO). Rabies vaccines. WHO position paper . Wkly Epidemiol Rec 2007;82:425–35 References 1. World Health Organization (WHO). Who expert consultation on rabies, 5-8 October 2004. Technical Report Series 931 – First Report. Switzerland: WHO Press; 2004 2. World Health Organization (WHO). Rabies vaccines. WHO position paper . Wkly Epidemiol Rec 2007;82:425–35
Evidence based treatment of
Chicken pox in pregnancy
Dr. Jyoti Agarwal
Dew drops on a rose petal
A highly contagious viral illness that causes an itchy rash
and is followed by a vesicular eruption on the skin
What causes chicken pox ?
• Varicella zoster virus ,
a DNA virus and is a
member of the herpes
• Primary infection
causes chicken pox .
results in herpes
Humans are the only known reservoir
What is chicken pox
• Also known as varicella
• A highly contagious
viral illness that causes an
itchy rash and is followed
by a vesicular eruption on
• Spreads by direct contact
or via respiratory droplets
• Incubation period is 2 to 3
How long is the disease
Disease is most infectious 48 hrs before
the rash appears
Continues to be infectious until the last
vesicle crust over.
This usually takes 7 days from beginning to
The scabs formed are NOT
Chicken pox in pregnancy
• More than 90% of antenatal population are
• Primary VZV infection is uncommon.
• Chickenpox complicates 3 in every 1000
5 times greater morbidity than
• Varicella pneumonia ( 20 % ) with high mortality of 15 %.
Severity of these complications increases
with increase in gestation period .
Organisation for teratology
information service (OTIS )
• 0.5 – 1 % in the first trimester
• 2 % from 13 – 20 weeks
• 25 – 30 % if chicken pox occurs within 5
days before delivery to 2 days after
Risk to the foetus depends on the
timing of the pregnancy
• Results from transplacental
infection during pregnancy .
• Risk appears to be small
(2 % )
• Atrophy of extremity with skin
scarring , low weight , eye
and neurological problems.
Maternal infection - near term
Causes neonatal varicella
• If maternal infection occurs 1-4 weeks
before delivery up to 50% of babies are
infected and 23% of these develop clinical
• High risk for disseminated varicella
• Mortality rates as high as 30%
• Prognosis much better if lesions develop
greater than 5 days after delivery
Risk of spontaneous
miscarriage does NOT
increase if chicken
pox occurs in the first
Should be made aware of
• Potential adverse maternal and foetal sequelae
• Risk of transmission to the foetus
• Options available for prenatal diagnosis.
Women who develop rash
• Should report to the doctor immediately
• Should avoid contact with susceptible
• Should receive oral acyclovir if they come
within 24 hrs of the onset of the rash and
are more than 20 weeks pregnant.
• Should maintain hygiene to prevent
secondary bacterial infection
Acyclovir therapy in pregnancy
Oral acyclovir 800 mgm 5 times a day for 7
Valacyclovir (valcivir) 1 gm 3 times a day for
No adverse fetal or neonatal effects have been
reported with the use of acyclovir.
VZIG has no therapeutic benefit once chicken pox has
Acyclovir should be used with caution before 20 weeks of
(RCOG Green Top guidelines 2007
• no evidence to suggest that
maternal acyclovir prevents fetal
• no evidence of teratogenic effect of
acyclovir at therapeutic doses
• Acyclovir is NOT recommended for
post exposure prophlaxsis
Report to the hospital
• If fever rises above 102 degree F
• Lesions which become very red , warm ,
tender , and leaking pus.
• Difficulty in walking
• Stiff neck
• Severe vomiting
• Difficulty in breathing and cough
Indications for hospitalisation
Maternal complications like
• Neurological symptoms
• Haemrragic rash or bleeding
• Dense rash with mucosal lesions
• Immunosuppressed or women taking
Chicken pox with complications
• High risk of Varicella of the newborn with
significant morbidity & mortality.
• IV Acyclovir is recommended
10 – 15 mgm / kg body weight every 8
• Antihistamines and calamine lotion
helps stop the itching
• Aspirin should be avoided
• Acetaminophen can be given
• Do not scratch
• Best way to stop scratching is to
keep finger nails clean and short.
• Loose fitting , smooth , cotton
fabrics will help stop the skin from
bocoming sore and irritant
If maternal infection occurs at
If possible delivery should be delayed by 5 days
after onset of illness.
If delivery within 5 days of infection -
to be given to the neonate.
VZIG does not prevent neonatal infection
but lowers mortality rate.
Monitor baby for signs of infection for 14-16 days.
If neonatal infection occurs, it should be treated
• Is difficult and invasive.
• Benefit/risk is low
• Noninvasive with ultrasound:
cranial calcifications, porencephalic cysts, hepatic
calcifications ,echogenic bowel, ascites,
hydrops, and polyhydramnios…
Amniocentesis is not routinely
Positive results do not indicate
Timing and mode of delivery
must be individualised
Delivery during the viremic period is
Maternal risk during delivery includes
bleeding , thrombocytopenia , DIC
Chances of neonatal varicella are high
Pregnant women with history of
contact with chicken pox
• Definite past H/O chickenpox - Reassure
• If she is not immune and has a significant
contact , she should be given VZIG as soon
significant contact is defined as contact in the
same room for 15 minutes or more or
face to face contact
Role of immunoglobulins
• (VZIG) is recommended within 96 hours of exposure
of a pregnant woman who is non-immune to VZV.
• VZIG is effective when given upto 10 days after contact.
• A second dose may be required if further exposure is
reported and 3 weeks has elapsed since the last dose
• VZIG is also recommended if it is not possible to obtain
antibody test results within 96 hours.
Indications of VZIG to the baby
• If mother is not immune , VZIG to baby
– Birth occurs within 7days of rash
– Rash appear within 7days of delivery
– Exposure of baby in first 7days of life
– Rash appear – VZIG is of no use .
-- if neonate delivered prematurely.
• Mother is immune- VZIG is not needed
• Adults who have no history of chickenpox and have
never been immunized against the disease, should
receive the vaccine.
• All non - immune or seronegative women should
receive vaccine before pregnancy or in the post
partum period .
Avoid pregnancy for three
• Exposure to the varicella vaccine is not an
indication for termination of pregnancy as
theroretical risk to the foetus is very small .
• Data from more than 300 deliveries indicate
no birth defects compatible with congenital
varicella syndrome .
Vaccination is safe during lactation
• (Report of the Canadian task force on preventive health care ).
• fever (12%)
• pain at site (2%)
• rash at injection site (1.5%)
• generalized rash (1.5%)
• transmission of vaccine virus
– higher if immunocompromised
VARICELLA VACCINE :
• 96-100 % seroconversion
within 4-6 weeks post
• Antibodies titre is more than
90% even after 20 years .
• Less than 2% breakthrough
of varicella in 2 year
Rabies is one of the oldest and most
feared diseases reported in medical text
Painting of a rabid dog
biting a man
Baghdad school, by Abdallah ibn al-
It infects both
and wild animals.
India carries highest disease burden - WHO
20,000 deaths occur in india every year
Most human deaths follow a bite from an infected
Dog is one of best human friends but can
spread Rabies if not vaccinated
The rabies virus ( Rhabdos = Road )cdc
Has knob like spikes
single-strand, negative sense
• The exact time course of these events is
unknown , therefore incubation period may
take years .
• Incubation period 20- 90 days
• In more than 90 % of the cases it is less
than 1 yr.
• Rarely as long as 19 yrs.
• Bites on head and neck have shorter
incubation time because of rich peripheral
Risk of developing rabies
•Type of exposure
•Location of the bite
•The biting animal
GLOBAL STANDARDS ofGLOBAL STANDARDS of
Post exposure Prophylaxis : 3 steps
The good news is that if post
exposure treatment is given
correctly and in time , it is
100 % effective in preventing
LOCAL WOUND CARE
• Immediate washing
with soap and water for
15 minutes .
• Remove any foreign
objects from the wound
• Disinfection of the
wound, ethanol, Iodine
• Do not suture or put
• Do not bandage the
• Seek professional
It is anIt is an
emergency andemergency and
as a generalas a general
rule should notrule should not
be delayed orbe delayed or
There has been NO indentified associations
between rabies vaccination and foetal
WHO Approved Vaccines
• Purified chick embryo cell
• Human diploid cell
• Purified vero cell vaccine
Which of the Three ??
• WHO recommends any of the three
• All three produce good AB titres well above the
desired 0.5 IU/ml
• All three have equal long lasting
Choice is YOURS
Claims of superiority of any one
over the others are NOT TRUE
Post-exposure prophylaxis IM administration:
One IM dose of vaccine on Days 0, 3, 7, 14, and 28
RIG is always recommended for transdermal wounds
5 doses – 5 visits
WHO 2007 National Guidelines for Rabies Prophylaxis and Intra-dermal Administration of Cell Culture Rabies Vaccines,
1 mL (IM) into
area of thigh
Patients previously vaccinated with a
cell-culture rabies vaccine
Day 0 3
Should get two doses of rabies vaccine on
0 and 3 rd day .
Rabies immunogloubulin is NOT needed
Precautions Rabies PET –
IM - Vaccination
• Never into the Gluteal region
• Only into deltoid or Anterio-lateral thigh
• If injected into fat, no antibodies are formed.
• HRIG and HDCV: give in different anatomical sites
and never in the same syringe.
Rabies immunoglobulins for-
• Infiltrate into the depth of the wound and around
the wound . Any remainder should be injected
IM at a site distant from that of vaccine
• Should not exceed the total recommended dose
• If the calculated dose is insufficient sterile saline
may be used to dilute it 2 to 3 fold to permit
• RIGs should never be administered
intravenously because of the potential for serious
• 20IU/ kg for Human RIG - maximum of
• 40 IU/ kg of Equine RIG - maximum of
• The dose should not exceed the calculated recommended dose since
RIG may partially suppress active production of rabies antibody.
• RIG should be administered only once usually at the beginning of the
post-exposure regimen .
Beyond the 7th
day RIG is not indicated as it may interfere with
endogenous antibody response.
• Rabies immunoglobulin has a half-life of approximately 21 days.
DOSAGE AND ADMINISTRATIONDOSAGE AND ADMINISTRATION
• Pregnancy is NOT an contraindication
• No harmful effect on the foetus or neonate has been
• A study done on 202 women and their infants at Queen
Saovobha Memorial Institute, Bangkok, Thailand (WHO
collaborating center for Rabies) by Henry Wilde confirms
this finding (during 1987-1989 – 2 year study).
• Breastfeeding: No problems have been documented
in Humans. In fact Immunoglobulins are excreted into the
milk and may contribute to the transfer of protective
antibodies to the neonate.
RABIES IMMUNOGLOBULINS – PREGNANCY ANDRABIES IMMUNOGLOBULINS – PREGNANCY AND
• Wounds should be treated immediately.
• Start vaccine and serum therapy as soon as possible,
• Should not wait for the results of laboratory diagnosis
Or be delayed by dog observation
• pregnancy and infancy are never contraindications
• persons who present even months after having been
bitten need post exposure treatment