What are the recommendations for a pregnant individual to decrease the risk of contracting varicella (chickenpox) if their partner has herpes zoster (shingles)?

Risk Reduction for Pregnant Individual Exposed to Partner with Herpes Zoster

The pregnant individual should immediately avoid direct contact with the partner's shingles lesions, ensure the lesions remain completely covered until dry and crusted, and urgently confirm her varicella immunity status through serology—if seronegative, she must receive varicella-zoster immune globulin (VZIG) within 96 hours of exposure. 1, 2

Immediate Assessment and Action

Determine Immunity Status

• The first critical step is to immediately obtain varicella serology to confirm whether the pregnant individual has immunity to varicella-zoster virus 1
• If the pregnant woman has a clear history of chickenpox or herpes zoster herself, she can be reassured of her protection and no further intervention is needed 3
• If immunity history is uncertain or unknown, serologic testing must be performed urgently given the time-sensitive nature of prophylaxis 1, 3

Post-Exposure Prophylaxis for Seronegative Pregnant Women

• If seronegative and exposed, VZIG must be administered within 96 hours of exposure to prevent severe maternal complications 1
• The 96-hour window is absolutely critical—VZIG effectiveness diminishes significantly after this timeframe, making prompt action essential 1
• If VZIG is unavailable or the exposure occurred more than 96 hours ago, oral acyclovir prophylaxis can be considered as an alternative 1
• VZIG may prolong the incubation period by up to one week (extending monitoring from 21 to 28 days post-exposure), which requires extended surveillance 1

Infection Control Measures in the Household

Lesion Management and Contact Precautions

• The partner with herpes zoster must keep all lesions completely covered until they are dry and crusted, which typically takes 4-7 days after rash onset 2
• The pregnant individual should avoid any direct contact with the lesions, as transmission occurs through direct contact with lesions or inhalation of aerosols from vesicular fluid 2
• For localized herpes zoster in an immunocompetent partner, complete covering of the lesions with standard precautions is required 2

Duration of Precautions

• Precautions must be maintained until all lesions are completely dry and crusted—not just improved, but fully crusted 2
• A common pitfall is discontinuing precautions too early before complete crusting has occurred 2

Monitoring and Follow-Up

Surveillance Period

• The pregnant individual should be monitored for development of varicella symptoms during days 8-21 after exposure (or up to day 28 if VZIG was administered) 1
• Monitor daily for fever, skin lesions, and systemic symptoms during this period 2

If Varicella Develops Despite Prophylaxis

• Pregnant women who develop varicella despite preventive measures are at higher risk for severe disease and complications compared to non-pregnant adults 1
• Oral acyclovir treatment should be initiated within 24 hours of rash onset for maximum effectiveness 1
• Acyclovir is FDA Category B in pregnancy with strong safety data showing no increased rate of birth defects in 596 infants exposed during first trimester 1

Critical Pitfalls to Avoid

• Failing to act within the 96-hour window for VZIG administration in seronegative pregnant women is the most critical error 1
• Not maintaining contact precautions until all lesions are completely dry and crusted 2
• Overlooking the potential for transmission to the pregnant individual, who is at higher risk for severe complications 2
• Assuming immunity without confirmation when history is uncertain 3

Important Context About Herpes Zoster vs. Primary Varicella

• While herpes zoster in the pregnant woman herself poses minimal fetal risk, the concern here is transmission of varicella-zoster virus to a susceptible (non-immune) pregnant individual, which would result in primary varicella infection 4
• Primary varicella infection in pregnancy carries significant maternal morbidity risk and potential fetal complications depending on gestational age 5
• This is why confirming immunity and providing timely prophylaxis is paramount 1