NHS FORTH VALLEY Date of First Issue 01/04/2006 Approved 05/05/2012 Current Issue Date 18/09/2012 Review Date 18/09/2016 Version 1.2 EQIA Yes 01/04/2012 Author / Contact Group Committee Final Approval Debbie Forbes Unit Clinical Governance This document can, on request, be made available in alternative formats Version 1.2 18 th September 2012 Page 1 of 6
Consultation and Change Record Contributing Authors: Consultation Process: Debbie Forbes Circulation to all Midwives, Obstetricians, Supervisors Of Midwives, Team Leaders, Clinical Shift Co-ordinators, Department Managers,, Unit Service Manager and Head of Midwifery, GP Stakeholders Distribution: Midwives, Obstetricians, Supervisors Of Midwives, Team Leaders, Clinical Shift Co-ordinators, Department Managers, and Head of Midwifery Change Record Date Author Change Version 16.06.2016 KM Review date changed to September 2016. 1.2 Version updated to 1.2 Version 1.2 18 th September 2012 Page 2 of 6
Women & Children s Unit 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. 90% of the UK adult population is immune but non-immune pregnant women should be given VZIG prophylaxis Who is infectious? Following the primary infection, the virus remains dormant in a nerve but can be reactivated to cause a rash known 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. Screening Contacts without definite history of previous chickenpox should be screened for antibodies. 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 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. Neonates whose mothers develop varicella infection within 7 days before and 7 days after delivery. Neonates whose mothers have no history of varicella and/or a negative immune status. 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. Pregnant women, who have been exposed to chickenpox, should not be sent to the maternity services to receive VZIG because of risk of spreading infection to other patients and should 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. Version 1.1 18 th September 2012 Page 3 of 6
Women & Children s Unit 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 acyclovir (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 on-call public health consultant should always be contacted to be notified of a non-immune pregnant women s exposure to chicken pox. 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 01324 559740. The pharmacy department will deliver it to GP practice as soon as possible. The practice nurse can then administer the vaccine 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 1.1 18 th September 2012 Page 4 of 6
Women & Children s Unit 3 Hospital referral in severe cases Women in late pregnancy are at an additionally increased risk of severe morbidity from pneumonia. 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 Fetal infection is more common (<24% of pregnancies in the first 28 weeks of gestation) and is associated with low birth weight & preterm labour. 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). September 2012 Review September 2014 or Sooner Debbie Forbes Version 1.1 18 th September 2012 Page 5 of 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 01786 434784. For other formats contact 01324 590886, text 07990 690605, fax 01324 590867 or e-mail - fv-uhb.nhsfv-alternativeformats@nhs.net Version 1.1 18 th September 2012 Page 6 of 6