Varicella in Pregnancy

Varicella-zoster virus

Varicella (chickenpox) is a highly contagious disease caused by primary infection with varicella-zoster virus (VZV)2 and may cause maternal mortality or serious morbidity

> Reactivation of latent infection, usually many years after the primary infection, may result in herpes zoster (shingles), a painful vesicular eruption in the distribution of sensory nerve roots2

> Both varicella (chickenpox) and zoster (shingles) are notifiable diseases. Notification must be made to the Communicable Disease Control Branch of SA Health as soon as possible and at least within three days of suspicion of diagnosis, by telephone or post.


Route of transmission

> Infection with chickenpox is transmitted through airborne / respiratory droplets and direct contact with vesicle fluid


Incubation period

> 10 to 21 days (may be up to 35 days in contacts given high titre zoster immunoglobulin, ZIG)


 Period of infectivity

> 48 hours before the onset of rash until crusting of all lesions (usually day 6 of rash)

> Infectious period may be prolonged in people with impaired immunity


Infection Control

> Non-immune staff should not care for the woman / baby infected with chickenpox

> Varicella (and herpes zoster) vesicles contain large numbers of virus particles. Ensure appropriate transmission based (standard, contact and airborne) precautions including:

> A negative pressure room with door shut (chickenpox and disseminated shingles)

> Immune staff in attendance

> Gloves, gown

> All dressing materials should be treated as medical waste

> Chickenpox and disseminated shingles use standard, contact and airborne precautions

> Localized shingles use contact precautions (only immune staff in attendance, single room, gloves, gown)

> In herpes zoster (shingles), transmission of infection usually requires contact with vesicle fluid; however, there is also evidence of respiratory spread. Localized shingles requires standard and contact precautions (not airborne precautions)


Susceptibility to varicella

> Women and babies susceptible to infection with VZV (may be severe or life-threatening) include:

> No history of varicella (chickenpox or shingles)

> Seronegative for varicella antibodies (VZV-IgG negative)

> No documented evidence of varicella vaccination 


Significant Exposure

> For the purpose of infection control and prophylaxis, significant exposure of a susceptible woman who is pregnant to varicella includes:

> Living in the same household as a person with active varicella or herpes zoster

OR

> Direct face to face contact with a person with varicella or herpes zoster for at least 5 minutes

OR

> Being in the same room for at least 1 hour

> Chickenpox cases are infectious from 2 days before rash until lesions crusted


Management of maternal exposure to varicella-zoster virus

History of previous chickenpox

> No action required

No or uncertain history of chickenpox

> Obtain serology for antibody status (VZV-IgG) (if practicable)

> ZIG if required should be given within 96 hours. Testing should only be done if ZIG would still be able to be given, if required, within this window


Within 96 hours from exposure

> Zoster immunoglobulin (ZIG) should be given to all seronegative women within 96 hours (see adult dose under ZIG dosage below)

> However there may be some limited effect out to as late as 10 days post exposure

> Advise to seek medical care immediately if chickenpox develops


More than 96 hours following exposure

> Oral aciclovir or valaciclovir (see dosage below) should be considered for women:

> In the second half of pregnancy

> With a history of an underlying lung disease

> Who are immuno-compromised

> Who are smokers

Note: Advise women to seek medical care immediately if chickenpox develops


Management of varicella-zoster in pregnancy

Less than 24 hours since appearance of rash

> Oral aciclovir 800 mg 5 times a day for 7 days OR oral valaciclovir 1 g three times a day for 7 days]

> Monitor at home

More than 24 hours since onset of rash

> No oral aciclovir / valaciclovir and monitor at home if:

> No underlying lung disease

> Not immunocompromised

> Non-smoker

> Monitor in hospital if any of the above risk factors

> Offer appropriate fetal medicine counselling


Complications

> Advise to seek medical attention for the following complications:

> Respiratory symptoms

> Haemorrhagic rash or bleeding

> New pocks developing after 6 days

> Persistent fever

> 6 days

> Neurological symptoms

> Give aciclovir 10 mg / kg every 8 hours for 7 to 10 days (IV followed by oral [see dosage below]) and administer supportive therapy

Consider caesarean section if:

> Signs of significant fetal compromise

> Evidence of maternal respiratory failure exacerbated by advanced


Risk of fetal varicella syndrome (FVS) after maternal VZV

Timing of maternal infection:

>Less than 12 weeks gestation-  0.55%

>12-28 weeks gestation- 1.4%

>More than 28 weeks gestation- No cases of FVS reported


Refer to maternal fetal specialist for prenatal diagnosis and counselling

> Detailed fetal ultrasound for anomalies is recommended at least five weeks after primary infection

> Repeat ultrasounds until delivery. If abnormal may consider fetal MRI

> VZV fetal serology is unhelpful

> Amniocentesis not routinely advised if ultrasound normal, because risks of FVS low but negative VZV PCR may be reassuring


Management of infants exposed to maternal varicella zoster

Maternal chickenpox > 7 days before delivery

> No zoster immunoglobulin (ZIG) required

> No isolation required

> Encourage breastfeeding

> No other interventions even if baby has chickenpox at or very soon after birth unless preterm < 28 weeks gestation or low birth weight < 1,000 g > Very preterm infants (≤ 28 weeks gestation) born with chickenpox should receive intravenous aciclovir 20 mg / kg / dose every 8 hours as a slow infusion (1-2 hours)

 

Thank you to Christine DeFranco PGY-4 EM Resident for this review of VZV in pregnancy!

Case of the Week #2 – I can’t pee!!

CC: Urinary retention

HPI: 44 yo F presents with suprapubic abdominal pain since this AM. She also complains of dysuria and denies fever, chills, hematuria, vaginal bleeding or discharge, flank pain, N/V/D, CP, SOB or any other symptoms. This is her third visit to the ED in the past 3 days for urinary retention. On patient’s initial visit, she c/o pelvic pain, dysuria and urinary retention for 12 hours.  A straight urinary catheter was placed, and 2 liters of urine was drained and the pt was d/c’d home and told to follow up with her PMD. Yesterday, pt returned once again to the ED c/o urinary retention during which a Foley catheter was placed and 900 cc of urine was collected. No UTI was documented. Today, pt still c/o a sense of fullness and has been unable to urinate since 4 am despite having the Foley catheter in place and emptying the bag. Pt called her PMD last night during which he prescribed her Ciprofloxacin for a presumed UTI.

PMH/PSH: None

Meds/Allergies: None

Social: Denies

Physical Exam: Vitals: BP 130/84 P 144 RR 17 O2 sat 100% RA Temp 98.2F

General: Awake, alert, in no acute distress, comfortable
Cardiac: RRR , S1 S2, no murmurs
Lungs: CTAB, no rales, no rhonchi, no wheezing
Abd: Soft, with mild tenderness in suprapubic area. No distention. No rebound or guarding
Back: No CVA tenderness
GU: Foley catheter in place with empty bag
Extremities: No edema or rashes. Able to move all extremities
Neuro: AAO x 3

Labs

WBC: 10. 5
Hg/Hct: 13.3/40
Platelet: 215

Na: 141
K+4.6
CL –: 102
CO2: 26
BUN: 9
Cr: 0.83

Urine HCG: Negative

Urinalysis:
Ketones: Small
Blood: Small
Nitrite Urine: NEG
Leukocyte Esterase: Moderate
RBC: 0-3
WBC: 11-20
Bacteria: Rare

Imaging: 

DDX: Vaginal Mass vs Urinary Retention vs UTI

ED Course: 

Upon evaluation, the Foley catheter’s leg bag straps were fitted incorrectly causing a drainage bag obstruction. In the ED, the obstruction was resolved and catheter was successful draining urine.

The reading of the CT abd/pelvis was: CT Abd/Pelvis W/ and w/o Contrast: There is a 9.9 x 9.4 x 9.9 cm vaginal mass, which displaces the uterus cephalad, and likely the cervix and the bladder anteriorly which is quite effaced. The mass is likely centered in the mid and posterior vagina, which is worrisome for a vaginal or possibly a cervical malignancy although could be of other etiology and warrants a follow up MRI. The most worrisome component is anteriorly to the left where there is either a lymph node measuring 3.7 x 2.5 x 4.7 cm or extrusion of the mass. A left ovary is likely seen with an involuting cyst measuring 2.1 x 1.6 x 1.7 cm quite cephalad to the lesion

OB/GYN was consulted. They came down to evaluate the patient and perform a vaginal speculum exam, which revealed a small amount of malodorous thick discharge similar to pus and a palpable mass in left vaginal wall. OB-GYN recommended patient continues to take Ciprofloxacin as prescribed by her PMD and return to the Emergency Dept. in 3-4 days for re-evaluation and admission to the hospital for a Diagnostic laparoscopy

Pt returned to the ED 4 days later, during which she was admitted and underwent a diagnostic laparoscopy, Left salpingo-oophorectomy and resection of vaginal mass. Foley Catheter was inserted in operating room and pt was d/c home from Same day Surgery.

Discussion:

• Acute Urinary Retention (AUR) in women is rare. It is estimated that are 3 cases of AUR per 100,000 women per year.

• The female to male incidence ration is 1:13

• The most common cause of AUR is obstruction. In women, it is usually secondary to anatomic distortion, including pelvic organ prolapse, pelvic masses, or less likely urethral diverticulum.

• Other less common etiologies include neurogenic causes (MS, Cauda equine syndrome, metastatic spinal cord lesion, neuropathy) and infectious causes (cystitis, Herpes simplex (genital), local abscess, PID).

• Evaluation should include: UA with urine cultures, Chemistry, CBC if you suspect infection or massive hematuria, and a bedside ultrasound to verify retention. Then bladder decompression by inserting Foley catheter. Incomplete retention is PVR > 50mL and > 100mL in patients > 65 years of age

• Pearls: Urinary retention in women is rare. Think of a pelvic mass as a cause, especially if urine is clean. Have a low threshold for obtaining a CT Abd/pelvis to confirm diagnosis.

Post by: Dr. Yenis Paez-Perez, DO

 

Digoxin abortion gone awry….or did it?

Emergency medicine has to be one of the most diverse fields of medicine out there.  Each day is a whirlwind of activity and patients, ranging from cardiac arrests down to the broken fingernail.  Not only are we responsible for the most critically ill, the walking wounded and the patients that have nowhere else to go, but also are faced with the complications encountered in the outpatient setting.  This could be a patient fresh from the chiropractor that is having neck pain, can’t move their arm and now have a carotid dissection; or a patient from a outpatient surgi-center that had local anesthesia but is now seizing; or in the case below a patient that underwent an elective abortion and now is hypotensive and bradycardic.

A 19-year-old female at 20 weeks gestation who had just underwent part 1 of a two day late term elective abortion presents with a syncopal event about 2 hours after the procedure.  Her vital signs at the time were BP: 60/palp, HR: 40bpm, RR: 16, O2: 100% RA and T: 98.7.  After a liter of normal saline her blood pressure and heart rate both normalized (BP:120/70, HR:70s)

So what happened?  Since 2013 one of the day 1 medications of late term abortions is trans-vaginal Digoxin that is delivered either intrafetally or intraplacentally.  The dose is typically 1-3 mg and in this case the patient received a dose of 2 mg.  Initially they drew a dig level, so let’s think about this. You have a post procedural syncope, with a patient still in the clinic 2 hours after the treatment.  You would have to believe that they were concerned about sending her home, she is hypotensive and bradycardic.  Digoxin is used to increase inotropy, thus improving cardiac output. It is doubtful this young healthy female patient, would present with hypotension in this setting. Also the dig level was drawn within first 3 hours of administration and had a level of 5. As you know Dig has a large volume of distribution and levels should be drawn after 6 hours of administration. Also her symptoms improved with IVF, and the only thing they reported were questionable T-wave inversions in lateral leads as the only EKG abnormality, this is after her symptoms resolved. Dig toxicity can present with multiple EKG abnormalities: T-wave changes, short QT, St-scooping, AV blocking, VT, VF, and most commonly PVC’s, and various conduction abnormalities. The center did not transmit EKG.

Her Dig level before they gave her Digibind, was 1.3. The discussion consensus amongst the NYPCC toxicologists was clear on not giving Digibind in this setting; just observe the patient on tele, repeating EKG, and discharging the next morning.  The patient more likely was having anxiety around her procedure and suffered a vasovagal event, that improved with IVF. The patient was fine and went to clinic next day for termination of pregnancy.

There are plenty of complications that can occur after abortions, whether they are infections, retained products of conception, DIC, amniotic fluid embolisms and as described above, aberrant delivery of abortifacient medications.  Besides the historical use of mechanical means of fetal termination, there are pharmacologic medications as well; most commonly intracardiac KCl and intra-fetal/intra-amniotic digoxin.  As you might expect, delivery of these medications could inadvertently end up being maternally injected and will present as though they are hyperkalemic or having acute digoxin toxicity.  The management of both are the same as we typically would proceed with.  Just knowing that these are potential methods that are used for abortions may give you an extra consideration if one of these patients presents to your ED.

Post by: Dr. Daniel Poor, MD

BOGO on TOAs

Lower abdominal pain in women can be challenging diagnostic dilemma in the Emergency Department. We had a case of a 50-year-old woman that had been previously seen by her PMD 3 days prior and diagnosed with a “small kidney stone” without any imaging, but did get the ever-reliable percocet prescription. Needless to say, she came to the ED because her pain wasn’t getting any better and now she was having increasing lower abdominal pain with high fevers. In the ED she was febrile (T: 104.5) and tachycardic (HR: 120s), but her BP was normal. She ended up having a WBC: 17k/mm3, bands: 20% and a pretty nasty UTI. Her pain persisted and we ended up doing a CT abd/pelvis with contrast to see if she had anything brewing. From the images below you can see that she had bilateral tubo-ovarian abscesses causing bilateral hydronephrosis seen on CT and confirmed with ultrasound. She was started on ampicillin, clindamycin and gentamicin and her abscesses were drained with CT guidance, yielding 400cc of thick, brown, purulent fluid. Yum

Figure 1 Figure 2

Up to one half of all cases of tubo-ovarian abscesses occur in patients with a history of pelvic inflammatory disease (PID). The theoretical etiology of tubo-ovarian abscesses is thought to revolve around an ascending infection arising in the lower reproductive tract, into the uterus and subsequently the fallopian tubes and ovaries. While Neisseria gonorrhea and Chlamydia trachomatis are commonly associated with PID, TOAs are typically polymicrobial and rarely grow either chlamydia or gonorrhea when cultured. As with most pelvic pathology, ultrasound remains the initial diagnostic modality of choice for tubo-ovarian abscesses to best visualize the upper reproductive tract. Ultrasound remains very specific (86-98%), whereas the sensitivity ranges between 56-93%. There is evidence however that computed tomography of the pelvis with contrast may provide better sensitivity than ultrasound in evaluation of TOAs. In the Emergency Department, a triple coverage antibiotic regimen (i.e. ampicillin/clindamycin/gentamicin) should be initiated despite whether the patient is going to need surgical exploration, percutaneous abscess drainage or conservative management. If the patient’s clinical status has either worsened or not improved after 48-72 hours the gynecologist will likely proceed with minimally invasive drainage procedures that have become more readily available, similar to our case.

Post by: Terrance McGovern DO, MPH (@drtmcg13)