Evidence based treatment of chicken poc in pregnancy


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  • 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 poc in pregnancy

    1. 1. Evidence based treatment of Chicken pox in pregnancy Dr. Jyoti Agarwal
    2. 2. 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
    3. 3. What causes chicken pox ? • Varicella zoster virus , a DNA virus and is a member of the herpes virus group • Primary infection causes chicken pox . Recurrent infection results in herpes zoster (shingles). Humans are the only known reservoir
    4. 4. 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 the skin • Spreads by direct contact or via respiratory droplets or secretions • Incubation period is 2 to 3 weeks
    5. 5. How long is the disease contagious ? 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 end . The scabs formed are NOT infectious.
    6. 6. Chicken pox in pregnancy • More than 90% of antenatal population are seropositive. • Primary VZV infection is uncommon. • Chickenpox complicates 3 in every 1000 pregnancies.
    7. 7. Maternal risks 5 times greater morbidity than nonpregnant patients • Varicella pneumonia ( 20 % ) with high mortality of 15 %. • Encephalitis • Myocarditis • Hepatitis • Glomerulonephritis • Thrombocytopenia Severity of these complications increases with increase in gestation period .
    8. 8. 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 delivery Risk to the foetus depends on the timing of the pregnancy
    9. 9. Congenital varicella syndrome • Results from transplacental infection during pregnancy . • Risk appears to be small (2 % ) • Atrophy of extremity with skin scarring , low weight , eye and neurological problems.
    10. 10. 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 varicella. • High risk for disseminated varicella • Mortality rates as high as 30% • Prognosis much better if lesions develop greater than 5 days after delivery
    11. 11. Reassure that Risk of spontaneous miscarriage does NOT increase if chicken pox occurs in the first trimester. Should be made aware of • Potential adverse maternal and foetal sequelae • Risk of transmission to the foetus • Options available for prenatal diagnosis.
    12. 12. Women who develop rash • Should report to the doctor immediately • Should avoid contact with susceptible individuals • 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
    13. 13. Acyclovir therapy in pregnancy Oral acyclovir 800 mgm 5 times a day for 7 days OR Valacyclovir (valcivir) 1 gm 3 times a day for 57days. No adverse fetal or neonatal effects have been reported with the use of acyclovir. VZIG has no therapeutic benefit once chicken pox has developed Acyclovir should be used with caution before 20 weeks of gestation (RCOG Green Top guidelines 2007
    14. 14. VARICELLA IN PREGNANCY-The Evidence • no evidence to suggest that maternal acyclovir prevents fetal infection • no evidence of teratogenic effect of acyclovir at therapeutic doses • Acyclovir is NOT recommended for post exposure prophlaxsis
    15. 15. Report to the hospital • If fever rises above 102 degree F • Lesions which become very red , warm , tender , and leaking pus. • Lethargy • Difficulty in walking • Stiff neck • Severe vomiting • Difficulty in breathing and cough
    16. 16. Indications for hospitalisation Maternal complications like • Pneumonia • Neurological symptoms • Haemrragic rash or bleeding • Dense rash with mucosal lesions • Immunosuppressed or women taking corticosteroids
    17. 17. 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 hrly
    18. 18. Symtomatic treatment • 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
    19. 19. If maternal infection occurs at term If possible delivery should be delayed by 5 days after onset of illness. If delivery within 5 days of infection - VZIG is 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 with acyclovir.
    20. 20. Prenatal diagnosis • 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 advised. Positive results do not indicate FVS
    21. 21. Timing and mode of delivery must be individualised Delivery during the viremic period is extremely dangerous. Maternal risk during delivery includes bleeding , thrombocytopenia , DIC and hepatitis. Chances of neonatal varicella are high
    22. 22. Optimum Method of Anaesthesia
    23. 23. 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 as possible significant contact is defined as contact in the same room for 15 minutes or more or face to face contact
    24. 24. 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.
    25. 25. Indications of VZIG to the baby • If mother is not immune , VZIG to baby if – 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
    26. 26. Varicella prevention • 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 months
    27. 27. • 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 period • (Report of the Canadian task force on preventive health care ).
    28. 28. VARICELLA VACCINE: Side Effects • fever (12%) • pain at site (2%) • rash at injection site (1.5%) • generalized rash (1.5%) • transmission of vaccine virus – higher if immunocompromised
    29. 29. VARICELLA VACCINE : Efficacy • 96-100 % seroconversion within 4-6 weeks post vaccination • Antibodies titre is more than 90% even after 20 years . • Less than 2% breakthrough of varicella in 2 year
    30. 30. 30 Rabies is one of the oldest and most feared diseases reported in medical text Painting of a rabid dog biting a man Arabic A.D. 1224 Baghdad school, by Abdallah ibn al- Fadl Picture courtesy Smithonian Institution, It infects both domestic and wild animals.
    31. 31. 31 India carries highest disease burden - WHO 2009 20,000 deaths occur in india every year
    32. 32. Most human deaths follow a bite from an infected dog. Dog is one of best human friends but can spread Rabies if not vaccinated
    33. 33. The rabies virus ( Rhabdos = Road )cdc 2007 Bullet-shaped Has knob like spikes single-strand, negative sense RNA
    34. 34. Incubation period • 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 nerve supply
    35. 35. Risk of developing rabies Depends upon…. •Type of exposure •Location of the bite •The biting animal
    36. 36. GLOBAL STANDARDS ofGLOBAL STANDARDS of Management Post exposure Prophylaxis : 3 steps Wound care Passive immunisation Antirabies vaccination The good news is that if post exposure treatment is given correctly and in time , it is 100 % effective in preventing rabies
    37. 37. 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 stitches • Do not bandage the wound • Seek professional medical help
    38. 38. It is anIt is an emergency andemergency and as a generalas a general rule should notrule should not be delayed orbe delayed or deferreddeferred
    39. 39. WHO CRITERIA
    41. 41. There has been NO indentified associations between rabies vaccination and foetal abnormalities .
    42. 42. WHO Approved Vaccines • Purified chick embryo cell vaccine (PCECV) Rabipur • Human diploid cell vaccine (HDCV) Rabivac • Purified vero cell vaccine (PVCV) Verorab,
    43. 43. 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 efficacy Choice is YOURS Claims of superiority of any one over the others are NOT TRUE
    44. 44. Post-exposure prophylaxis IM administration: Essen regimen 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 deltoid (adults) or into anterolateral area of thigh (children)
    45. 45. Patients previously vaccinated with a cell-culture rabies vaccine x1 x1 Day 0 3 Should get two doses of rabies vaccine on 0 and 3 rd day . Rabies immunogloubulin is NOT needed
    46. 46. 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.
    47. 47. Rabies immunoglobulins for- PET • 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 inoculation . • 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 thorough infiltration • RIGs should never be administered intravenously because of the potential for serious reactions.
    48. 48. • 20IU/ kg for Human RIG - maximum of 2000 IU • 40 IU/ kg of Equine RIG - maximum of 40000IU • 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
    49. 49. • Pregnancy is NOT an contraindication • No harmful effect on the foetus or neonate has been noted. • 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 LACTATIONLACTATION
    50. 50. To conclude • 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
    51. 51. Thank you