What are the next steps in managing a pregnant woman at 21 weeks gestation with varicella (chicken pox) infection who has completed a 1-week course of acyclovir (antiviral medication)?

From the Guidelines

For a pregnant woman at 21 weeks gestation who has completed a 1-week course of acyclovir for varicella infection, the next steps include close monitoring for complications while providing supportive care. The patient should be monitored for signs of pneumonia, encephalitis, or other complications of varicella infection through regular clinical assessments 1. Supportive care should continue with acetaminophen for fever and discomfort, topical calamine lotion for itching, and maintaining good hydration and nutrition.

Key Considerations

• Fetal monitoring is essential, with a detailed ultrasound recommended at 18-22 weeks to assess fetal anatomy, and another at 28-32 weeks to evaluate for any signs of congenital varicella syndrome 1.
• The risk of congenital varicella syndrome is approximately 2% when infection occurs between 13-20 weeks gestation, and the risk decreases after 20 weeks.
• The patient should be counseled about this risk but reassured that it is relatively low at this gestational age.
• Additionally, the newborn should be monitored after birth for signs of neonatal varicella, although this is more concerning when maternal infection occurs within 5 days before to 2 days after delivery 1.

Antiviral Therapy

• No additional antiviral therapy is typically needed if the initial course of acyclovir has been completed and symptoms are resolving.
• However, antiviral therapy should be instituted immediately if signs or symptoms of varicella disease occur after the initial treatment course.

Varicella Zoster Immune Globulin (VZIG)

• VZIG might be considered for pregnant women without evidence of immunity who have been exposed to varicella, but its use is not recommended for routine prevention of congenital varicella syndrome or neonatal varicella 1.

From the FDA Drug Label

Chickenpox: Chickenpox in otherwise healthy children is usually a self-limited disease of mild to moderate severity. Adolescents and adults tend to have more severe disease Treatment was initiated within 24 hours of the typical chickenpox rash in the controlled studies, and there is no information regarding the effects of treatment begun later in the disease course.

The next steps in managing a pregnant woman at 21 weeks gestation with varicella (chicken pox) infection who has completed a 1-week course of acyclovir are not directly stated in the provided drug labels. However, considering the information available:

• Monitoring for complications such as pneumonia, hepatitis, and encephalitis is crucial.
• Fetal monitoring for potential effects of varicella infection, such as congenital varicella syndrome, especially if the infection occurs before 20 weeks of gestation.
• Supportive care to manage symptoms and prevent secondary infections.
• Consideration of post-exposure prophylaxis for close contacts who are at high risk of severe varicella, if applicable.

Given the lack of direct information on next steps after completing acyclovir treatment in the context of pregnancy, clinical judgment and guidelines from relevant medical societies should guide management decisions 2, 2, 2.

From the Research

Management of Varicella in Pregnancy

The management of varicella in pregnancy involves several key considerations, including the prevention of maternal infection, the reduction of risk to the fetus, and the treatment of complications.

• The risk of congenital varicella syndrome is estimated to be less than 1% if the maternal infection occurs during the first two trimesters 3.
• Maternal infection in the third trimester is not associated with congenital varicella syndrome, but the infant may develop herpes zoster during the first one or two years 3.
• The use of varicella-zoster immune globulin (VZIG) is recommended for pregnant women who are exposed to varicella and are not immune, ideally within 96 hours of exposure 4.
• Antiviral therapy, such as acyclovir, may be effective in reducing the severity of varicella infection in pregnant women and preventing complications such as maternal pneumonia 4, 5, 6.

Next Steps

Given that the pregnant woman has completed a 1-week course of acyclovir, the next steps in management would include:

• Close monitoring for any signs of complications, such as maternal pneumonia or fetal distress 4, 3.
• Consideration of VZIG administration to the newborn if the maternal rash appears 5 days prior to or 2 days after delivery 4.
• Education on the risks of varicella infection to the fetus and the importance of seeking medical attention immediately if any symptoms occur 7.
• Discussion of the potential for the infant to develop herpes zoster during the first one or two years of life 3.