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Chickenpox - Management
How should I manage a pregnant woman with chickenpox?

  • Urgently seek specialist advice regarding the need for diagnostic tests, counselling regarding the risk of fetal varicella syndrome, antiviral treatment, and follow up.
    • Only prescribe an antiviral drug in primary care (with the informed consent of the woman) on the advice of a specialist.
  • Offer symptomatic treatment.
  • Give advice about contact with other people and when to seek medical advice.
  • Monitor the woman closely (review daily, or earlier if her condition deteriorates).
  • Refer for urgent hospital assessment if fever persists, or cropping of the rash continues after 6 days.
  • Admit to hospital (preferably somewhere with access to specialists in obstetrics, infectious diseases, and paediatrics) if 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.
  • Seek specialist advice from the local obstetric unit (even in the absence of complications) if monitoring will be difficult; the woman is in the latter half of pregnancy; or the woman has a complicated obstetric history, history of smoking, chronic lung disease, or poor social circumstances, or is taking steroids.
  • Notify the relevant authorities if in Scotland or Northern Ireland (chickenpox is not a notifiable disease in England or Wales).
  • For more information on managing a pregnant woman who has been in contact with but not yet developed chickenpox, see Pregnant woman.
Basis for recommendation
  • The recommendations for primary healthcare professionals on what to advise the woman, symptomatic treatment, and when to refer for specialist care are based on a guideline from the Royal College of Obstetricians and Gynaecologists (RCOG) on chickenpox in pregnancy [RCOG, 2007], guidance from the Health Protection Agency on the management of rash illness and exposure to rash illness in pregnancy [HPA, 2007a], and an article in the Drug and Therapeutics Bulletin [DTB, 2005a].
  • The recommendation on reporting cases of chickenpox is from the Department of Health and the Health Protection Agency [DH, 2006; HPA, 2006].
  • Basis for seeking urgent specialist advice:
    • Pregnant women are more at risk of serious complications of varicella (e.g. fulminating varicella pneumonia). This risk is greatest in the second, and early in the third, trimester [DH, 2006].
    • There are prescribing and drug licensing issues in pregnancy, and a potential need for intervention and follow up. The Royal College of Obstetricians and Gynaecologists' guideline on chickenpox in pregnancy [RCOG, 2007] advises that the pregnant woman needs to be informed of the small risk of fetal varicella syndrome and its implications, if she develops varicella or shows serological conversion in the first 28 weeks of pregnancy. The guideline recommends considering referral to a specialist centre for detailed ultrasonography at 16–20 weeks of gestation or 5 weeks after infection (if specialist advice has been sought, this is likely to be arranged by secondary care).
  • Basis for antiviral treatment:
    • Only limited data on the treatment of chickenpox in pregnancy are available [DTB, 2005a], and advice differs between organizations on which antiviral to use and at what stage of pregnancy, therefore CKS recommend seeking specialist advice.
      • Guidance on the management of rash illness in pregnancy from the Health Protection Agency recommends offering a 7-day course of oral aciclovir or valaciclovir (with informed consent) if the woman presents within 24 hours of the onset of the rash (gestation not specified). The Health Protection Agency does not recommend antivirals after this time because evidence is lacking that they alter the natural history of the disease in an uncomplicated case [HPA, 2007a].
      • The RCOG guidelines on chickenpox in pregnancy suggest a recommendation from the UK Advisory Group on Chickenpox to prescribe oral aciclovir (with informed consent) for pregnant women with chickenpox who are at more than 20 weeks of gestation and present within 24 hours of the onset of the rash. The RCOG state that aciclovir should be used cautiously before 20 weeks of gestation [RCOG, 2007].
    • In one study of a group of immunocompetent adults, oral aciclovir taken within 24 hours of the rash onset reduced the duration of fever and symptoms of varicella infection when compared with placebo. The study was not sufficiently powered to detect any impact of early aciclovir on the serious complications of chickenpox [Wallace et al, 1992; RCOG, 2007].
    • The RCOG guideline found data to suggest no increase in the risk of fetal malformation with aciclovir in pregnancy, although there is a theoretical risk of teratogenesis in the first trimester [RCOG, 2007].
    • Varicella-zoster immunoglobulin has no benefit once chickenpox has developed [RCOG, 2007].

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