Common dilemmas in Pregnancy

1. Common dilemmas in Pregnancy Andy Lindop

2. Chickenpox • Can cause problems for Mum to be and her unborn • Incidence 3 in 1000 • Situations commonly encountered in practice: • Contact no evidence yet (incubation is 10-21 days) • Developing classical rash

3. Why worry? Maternal Complications • Pneumonitis • Encephalitis • Hepatitis • Myocarditis • Glomerulonephritis • Appendicitis • Pancreatitis • Clotting disorders

4. Risks of complications for Mum are increased if • Smoker or have a lung condition, such as bronchitis or emphysema • Are taking steroids, or have taken steroids during the previous three months • Are more than 20 weeks pregnant. • Up to one in 10 pregnant women with chickenpox develop pneumonia (inflammation of the lungs).

5. How about risks to baby? • Foetal Varicella syndrome • Risks less than 1% in first 20 weeks • 0% after 28 weeks • Neonatal chickenpox • Neonatal chickenpox can be severe when the maternal rash appears between five days before delivery and two days after delivery. • Mortality may be as high as 30% without active treatment

6. What is Foetal Varicella Syndrome like? • Skin loss scarring limb hypoplasia/paresis • Microcephaly, hypotonia ophthalmological probs. • If ultrasound examination is suggestive of the syndrome then amniotic fluid can be tested for varicella zoster virus-DNA

7. Miscarriage? • There is no evidence that uncomplicated chickenpox in the mother significantly increases the likelihood of spontaneous abortion during the first 20 weeks of pregnancy • Women should be offered referral to a specialist centre for detailed ultrasound examination at around 5 weeks after her varicella infection to look for the specific anomalies of fetal varicella syndrome

8. What counts as contact? • Contact in the same room for 15 minutes or more, • Face-to-face contact • Contact in the setting of a large open ward with an individual with chickenpox or shingles

9. Management of Contact • Establish if immune • Assay varicella zoster antibodies if suspected exposure to chickenpox (or shingles) and uncertain if woman has had previous chickenpox • If not immune consider treatment-seek specialist advice re

10. Use of Immunoglobulin • Zoster immune globulin (VZIG) should be given for VZ antibody negative contacts exposed at any stage of pregnancy • VZ immune globulin does not prevent infection However it may attenuate disease even if given up to 10 days following exposure • The outcome in pregnant women is not adversely affected if there is a delay in administration of VZ immune globulin for up to 10 days after the initial contact whilst the VZ antibody status is determined

11. Management of well Mum with Chickenpox • Pregnant women with chickenpox may benefit from oral aciclovir • Caution advised before 20 weeks • VZ immune globulin has no place in treatment once chickenpox has developed

12. Management of ill Mum with overt Chickenpox • Admit to hospital (preferably somewhere with access to specialists in obstetrics, infectious diseases, and paediatrics) IF • Fever persists • The woman has chest symptoms, • Neurological symptoms other than headache, haemorrhagic rash or bleeding, • Severe disease (e.g. dense rash with or without numerous mucosal lesions), • or Significant immunosuppression.

13. UTI • Asymptomatic finding –should we treat? • Lower urinary tract -how long and with what? • Upper or Pyelonephritis-management?

14. Who should have iron? • Why not everyone? • May actually increase perinatal mortality and low birth weight is increased • Side effects risks to other children in house • Who then? • High risk of significant anaemia • Hb less than 10 in last trimester