NHS FORTH VALLEY. Chickenpox in Pregnancy

Transcription

1 NHS FORTH VALLEY Date of First Issue 13/12/2016 Approved 01/12/2016 Current Issue Date 13/12/2016 Review Date 01/10/2018 Version 1.0 EQIA Yes 13/12/2016 Author / Contact Dr N Miller/Kirsty MacInnes Group Committee Final Approval Unit Clinical Governance Meeting This document can, on request, be made available in alternative formats Version th December 2016 Page 1 of 6

2 Consultation and Change Record for ALL documents Contributing Authors: Consultation Process: Distribution: Dr N Miller/Kirsty MacInnes Circulation to all Midwives, Obstetricians, Supervisors Of Midwives, Team Leaders, Clinical Shift Co-ordinators, Department Managers, Unit Service Manager and Head of Midwifery Midwives, Obstetricians, Supervisors Of Midwives, Team Leaders, Clinical Shift Co-ordinators, Department Managers, Unit Service Manager and Head of Midwifery Change Record Date Author Change Version 13/12/2016 NM/KMacI This protocol is an amalgamation of the following protocols/guidelines: Administration of VZIG in close contact with Chickenpox or shingles in a pregnant woman Varicella care pathway for GP s Varicella aide memoir 13/12/2016 NM/KMacI All other changes highlighted in blue Version th December 2016 Page 2 of 6

3 NHS Forth Valley Women, Children s and Sexual Health Directorate 1 The primary infection with herpes varicella zoster virus (VZV), in pregnancy may cause maternal mortality or serious morbidity. It may also cause fetal varicella syndrome (FVS) and varicella infection of the newborn. Screening Women booking for antenatal care should be asked about previous chickenpox/shingles infection. Pregnant women with an uncertain or no previous history of chickenpox, or who come from tropical or subtropical countries, who have been exposed to infection should have a blood test to determine VZV immunity or non-immunity. This can be done on saved booking blood if this is available. If antibodies to VZV are detectable then VZIG is not needed. There is still time to test for VZ antibody even when the woman presents relatively late after contact Who is infectious? Following the primary infection, the virus remains dormant in a nerve but can be reactivated to cause a rash known herpes zoster, also called zoster or shingles. The risk of acquiring infection is remote. However, shingles or zoster (such as ophthalmic) in any individual or localised zoster in an immunocompromised patient should be considered infectious. Significant contact with chickenpox is defined as: Contact in the same room for 15 minutes or more Face-to-face contact Contact in the setting of a large open ward Period of infectivity 48 hours before the appearance of rash until the vesicles crust over Therapeutic indication for use of VZIG Pregnant women with negative VZV immune status if she has had significant exposure VZIG should be offered as soon as possible or <10 days from exposure Neonates whose mothers develop varicella infection within 7 days before and 7 days after delivery. Premature infants <28 weeks of gestation or new born with low birth weight (birth weight<1kg) who has sibling with chickenpox Contraindication to the use of VZIG Hypersensitivity to any of the components. Hypersensitivity to human immunoglobulin s. Pregnant women who develop the rash of chickenpox should immediately contact their GP. The diagnosis can be made clinically in most instances and advice should be given to avoid contact with other pregnant women and neonates, until the lesions have crusted over. This is usually about 5 days after the onset of the rash. Symptomatic treatment and hygiene is advised to prevent secondary bacterial infection of the lesions Version th December 2016 Page 3 of 6

4 NHS Forth Valley Women, Children s and Sexual Health Directorate 2 Dosage and Treatment VZIG 15 IU/kg body weight as soon as possible or within 3 days up to 10 days maximum if non immune and no lesions present. Oral aciclovir (800 mg five times a day for 7 days) if presenting within 24 hours of rash and more than 20 weeks gestation use cautiously before 20 weeks of gestation If VZIG is administered, the pregnant women should be regarded as potentially infectious from 8-28 days after VZIG. If a second exposure to chickenpox occurs three weeks or more after the first dose of VZIG, a second dose is required. VZIG has no therapeutic benefit once chickenpox has developed. Method of administration Administered via the intramuscular route not, into a blood vessel (risk of shock). Injection sites include buttock, thigh or deltoid Volume >5 ml divide doses and administer in different sites If IM contraindicated (bleeding disorders) injection can be administered subcutaneously Document in woman s hand held record and prescription chart ensure the name and batch number of the product are recorded Place for administration The woman with exposure to chickenpox or shingles should visit her GP. The GP practice should fax a signed request for VZIG to pharmacy store at Forth Valley Royal Hospital fax The pharmacy department will deliver it to GP practice as soon as possible. The practice nurse can then administer the vaccine Pregnant women who have been exposed to chickenpox should not be sent to the maternity unit to receive the VZIG because of risk of spreading the infection At weekends, or on a public holiday, arrangements should be made through the Out of Hours service, in liaison with the hospital pharmacist for the VZIG to be supplied and administered in an appropriate Out of Hours department. (Or on call pharmacist if out-with pharmacy hours). The VZIG should be prescribed by the GP or obstetric doctor. Side Effects Hypersensitivity, anaphylactic shock Headache Tachycardia Hypotension Nausea, vomiting Arthralgia Fever, malaise, chill At injection site: swelling, pain, erythema, induration, warmth, pruritus, rash, itching Version th December 2016 Page 4 of 6

5 NHS Forth Valley Women, Children s and Sexual Health Directorate 3 Hospital referral in severe cases Pneumonia, encephalitis and hepatitis are more common in adults with chickenpox. Women in late pregnancy are at an additionally increased risk of severe morbidity and death. Other risks include bleeding, DIC and thrombocytopaenia. Appropriate treatment should be decided in consultation with a multidisciplinary team: obstetrician or fetal medicine specialist, virologist and neonatologist. Immediate hospital referral if: Chest symptoms Neurological symptoms Haemorrhagic rash or bleeding A dense rash with or without mucosal lesions Women with significant immunosuppression Consider hospital referral if the woman smokes, is taking corticosteroids, or is in the latter half of pregnancy Obstetric management Refer to Dr Holmes/ Dr Miller between 16 & 20 weeks or 5 weeks after infection for detailed ultrasound scanning & counselling. Avoid delivery within 7 days of developing rash Notify Paediatrician/ANNP of any woman who has had chickenpox in pregnancy If a sibling has chickenpox in the first 7 days of life VZIG should be administered to the baby if: The mother is non-immune The baby was born before 28 weeks or the birthweight was <1kg. Fetal Varicella Syndrome (FVS) Occurs in <1% of women who develop chickenpox before 20 weeks gestation and is extremely rare between 20 & 28 weeks, signs and symptoms include: Skin Lesions Limb hypoplasia Neurological abnormalities Eye disorders Varicella infection of the newborn Significant risk to the newborn if maternal infection occurs in the last 4 weeks of pregnancy. A planned delivery should be avoided for at least 7 days after onset of maternal rash to allow for passive transfer of antibodies from mother to child, provided that continuing the pregnancy does not create additional risks to the mother or baby Staff exposure to chickenpox or shingles Chickenpox- non-immune staff should be reallocated to minimise patient contact and referred to Occupational Health Exposed Shingles- staff with shingles should be referred to Occupational health (Fully covered lesions are not an infection risk). Reference RCOG. Green-top Guideline No.13 ; January 2015 October 2016 Review October 2018 or Sooner Dr N Miller/Kirsty MacInnes This version Version th will remain valid until replaced December 2016 Page 5 of 6

6 Publications in Alternative Formats NHS Forth Valley is happy to consider requests for publications in other language or formats such as large print. To request another language for a patient, please contact For other formats contact , text , fax or - fv-uhb.nhsfv-alternativeformats@nhs.net Version th December 2016 Page 6 of 6