This document discusses evidence-based treatment of chickenpox during pregnancy. It notes that chickenpox is caused by the varicella zoster virus and is highly contagious. While most pregnant women are immune, primary infection can complicate around 3 in 1000 pregnancies. Risks to the mother increase with gestational age and include pneumonia, encephalitis, and death. Risks to the fetus depend on the timing of infection and can include congenital abnormalities. Oral acyclovir treatment is recommended starting within 24 hours of rash onset for pregnant women after 20 weeks. Delivery should be delayed if possible if chickenpox develops near term to reduce transmission risk.

1. Evidence based treatment of
Chicken pox in pregnancy
Dr. Jyoti Agarwal

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Indications for hospitalisation
Maternal complications like
• Pneumonia
• Neurological symptoms
• Haemrragic rash or bleeding
• Dense rash with mucosal lesions
• Immunosuppressed or women taking
corticosteroids

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. 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. 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. 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. 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. Optimum Method of
Anaesthesia

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. 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. 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. 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. • 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. 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. 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
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
India carries highest disease burden - WHO
2009
20,000 deaths occur in india every year

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. The rabies virus ( Rhabdos = Road )cdc
2007
Bullet-shaped
Has knob like spikes
single-strand, negative sense
RNA

35. 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

36. Risk of developing rabies
Depends upon….
•Type of exposure
•Location of the bite
•The biting animal

38. 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

39. 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

40. It is anIt is an
emergency andemergency and
as a generalas a general
rule should notrule should not
be delayed orbe delayed or
deferreddeferred

41. WHO CRITERIA

42. WHAT IS A
SIGNIFICANT
EXPOSURE?

43. There has been NO indentified associations
between rabies vaccination and foetal
abnormalities .

44. WHO Approved Vaccines
• Purified chick embryo cell
vaccine (PCECV)
Rabipur
• Human diploid cell
vaccine (HDCV)
Rabivac
• Purified vero cell vaccine
(PVCV) Verorab,

45. 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

46. 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)

47. 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

48. 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.

49. 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.

50. • 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

51. • 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

52. 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

54. Thank you