Download Common dilemmas in Pregnancy

Common dilemmas in
Pregnancy
Andy Lindop
Chickenpox
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Can cause problems for Mum to be and
her unborn
Incidence 3 in 1000
Situations commonly encountered in
practice:
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Contact no evidence yet (incubation is 10-21
days)
Developing classical rash
Why worry?
Maternal Complications
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Pneumonitis
Encephalitis
Hepatitis
Myocarditis
Glomerulonephritis
Appendicitis
Pancreatitis
Clotting disorders
Risks of complications for Mum are
increased if
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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).
How about risks to baby?
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Foetal Varicella syndrome
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Risks less than 1% in first 20 weeks
0% after 28 weeks
Neonatal chickenpox
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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
What is Foetal Varicella Syndrome
like?
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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
Miscarriage?
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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
What counts as contact?
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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
Management of Contact
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Establish if immune
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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
Use of Immunoglobulin
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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
Management of well Mum with
Chickenpox
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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
Management of ill Mum with overt
Chickenpox
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Admit to hospital (preferably somewhere
with access to specialists in obstetrics,
infectious diseases, and paediatrics) IF
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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.
UTI
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Asymptomatic finding –should we treat?
Lower urinary tract -how long and with
what?
Upper or Pyelonephritis-management?
Who should have iron?
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Why not everyone?
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May actually increase perinatal mortality and
low birth weight is increased
Side effects risks to other children in house
Who then?
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High risk of significant anaemia
Hb less than 10 in last trimester