Acrobat
MS WordPerinatologist Corner - C.E.U/C.M.E. Modules
Varicella in Pregnancy
6. Management Strategies
Case Scenario #3
TA is a 28 y/o G3P2 at 39 weeks gestation whose grandmother, who lives in her
home, was diagnosed with shingles today. She inquires if this could pose any
risk to her unborn baby.
Management
For the pregnant woman who has had a significant exposure (see above) less
than 4 days previously, susceptibility should be ascertained by history and ELISA
testing. If the patient was nonimmune, VZIG was administered in the past.
Unfortunately, the manufacturer has discontinued production, so the availability
of VZIG is rapidly declining, since the only manufacturer of this product has
ceased production.
The CDC has recommended the use of “VariZIG”, a purified lyophilized human
immune globulin preparation prepared from plasma with high levels of anti-
varicella antibodies. It is only available however under an “investigational new
drug application expanded access protocol” from the sole U.S. distributor. And
informed consent must be obtained prior to use. Turn around time for your
laboratory is obviously critical to stay within the 4-day window.
How readily available is VariZIG at your service unit?
Where will you obtain it ad how quickly can it arrive?
Infection may not be prevented with VariZIG, but it will certainly be ameliorated.
Here are some indications for VariZIG
-Neonates whose mothers have signs and symptoms of varicella around the time
of delivery (i.e., 5 days before to 2 days after)
-Premature infants born at >28 weeks of gestation who are exposed during the
neonatal period and whose mothers do not have evidence of immunity.
-Premature infants born at <28 weeks of gestation or who weigh <1,000 g at birth
and were exposed during the neonatal period, regardless of maternal history of
varicella disease or vaccination.
-Pregnant women
For more specific VariZIG information, e. g., dose, administration, 24 hour hotline
contact information please go to the March 3, 2006 MMWR
Once active varicella is diagnosed in the mother, VariZIG is of no use. In the
presence of severe systemic symptoms, and certainly if the patient has
pneumonitis or encephalitis, acyclovir 10 to 15 mg/kg IV q8h x 7 days is
appropriate. There is no known effective treatment for fetal infection and there is
no evidence that acyclovir is helpful in this situation. If the mother is nonimmune
and presents in the 4 day window however, VariZIG can be given to try to
prevent fetal infection. Newborns with the congenital varicella syndrome are not
infectious and need not be isolated. If a newborn is born to a mother who was
infected between 5 days before birth and 2 days after birth, VariZIG is indicated
for the infant, but outside this time frame it is ineffective. Intravenous acyclovir
should definitely be used for the infected neonate.
See also: What about the varicella vaccine (Varivax)?
