Varicella-zoster virus: Prevention through vaccination

Widespread use of varicella vaccine in the United States has drastically changed the epidemiology of the disease. Although chickenpox is no longer a ubiquitous childhood infection, varicella-zoster virus continues to circulate in the community and nonimmune pregnant women remain at risk. Varicella can cause severe infection in pregnant women, often complicated by viral pneumonia. Maternal varicella occurring in the first half of pregnancy can cause the rare but devastating congenital varicella syndrome, whereas infection in the late stages of pregnancy may cause neonatal varicella. The best approach to avoiding the morbidity and mortality associated with chickenpox in pregnancy is to screen and vaccinate susceptible reproductive-age women.     

Varicella zoster virus infections in pregnancy]

Varicella in pregnancy are a rare event, but they may result in severe disease of child. During the first and second trimenon they may cause congenital defects, so-called congenital varicella syndrome. Primary infections with the varicella-zoster virus are also a risk shortly before or during delivery because of intrauterine transmission of the virus with subsequent connatal varicella. On the basis of own clinic-virological investigations there is reported on 27 women and their newborns affected with varicella during pregnancy. Measures for diagnosis, prophylaxis and therapy in the case of congenital varicella syndrome as well as connatal varicella are discussed.     

Varicella Infection in Pregnancy

Varicella (chickenpox) is a common childhood illness. Most adults are immune to the virus because of previous exposure. Pregnant women who contract varicella risk complications such as pneumonia. Varicella may be transmitted from mother to fetus and could cause congenital varicella syndrome or perinatal infection. Susceptibility to varicella should be determined before pregnancy. Varicella zoster immune globulin may be considered for the mother or newborn if exposure occurs. Acyclovir may decrease the risk of maternal complications from infection.     

Neonatal varicella.

Neonatal varicella is mostly caused by maternal chickenpox acquired during the last 3 weeks of pregnancy. Transplacentally transmitted infections occur in the first 10 to 12 days of life, whereas chickenpox after that time is most likely acquired by postnatal infection. If the mother develops rash between days 4 and 5 antepartum to day 2 postpartum, generalized neonatal varicella leading to death occurs in up to 20% of affected cases. Neonatal chickenpox within the first 4 days after birth has usually been found to be mild. A fatal outcome has been reported in 23% of cases if neonatal chickenpox occurs between 5 and 10 to 12 days of age. Serological methods have been widely used to confirm clinical diagnosis. For rapid virological diagnostics, amplification of viral DNA in skin swabs by polymerase chain reaction is the method of choice. To prevent severe neonatal chickenpox, passive immunization is indicated. If varicella occurs, acyclovir treatment has to be administered promptly.     

MANAGEMENT OF VARICELLA-ZOSTER VIRUS INFECTION DURING PREGNANCY AND THE PERIPARTUM

This paper reviews the important concepts about varicella-zoster virus (VZV) infection, varicella (chickenpox), and herpes zoster (shingles, zoster) during pregnancy and the peripartum period. The majority of the U.S. population has had chickenpox during childhood, leaving only about 10% of adults over the age of 15 susceptible to the virus. However, nonimmune adults, including pregnant women, are at greater risk for complications and mortality when they contrac varicella. The virus is also teratogenic. The implication of VZV infection during pregnancy and the perinatal period are presented. Risks such as varicella pneumonia and congenital defects can be serious even though the incidence during pregnancy is low, one to five per 10,000 pregnancies. Management and treatment plans are presented. Counseling and education aimed at prevention or modification of the infection in the mother and baby is outlined.     

Management of varicella-zoster virus infection during pregnancy and the peripartum.

This paper reviews the important concepts about varicella-zoster virus (VZV) infection, varicella (chickenpox), and herpes zoster (shingles, zoster) during pregnancy and the peripartum period. The majority of the U.S. population has had chickenpox during childhood, leaving only about 10% of adults over the age of 15 susceptible to the virus. However, nonimmune adults, including pregnant women, are at greater risk for complications and mortality when they contract varicella. The virus is also teratogenic. The implication of VZV infection during pregnancy and the perinatal period are presented. Risks such as varicella pneumonia and congenital defects can be serious even though the incidence during pregnancy is low, one to five per 10,000 pregnancies. Management and treatment plans are presented. Counseling and education aimed at prevention or modification of the infection in the mother and baby is outlined.     

Severe life events and impaired fetal growth: a nation-wide study with complete follow-up

BACKGROUND: To estimate the association between severe maternal life events and infants small for gestational age at different gestational ages at birth. METHODS: From 1980 to 1992 all women exposed to severe life events such as death or first hospitalization for cancer or acute myocardial infarction in partners or children during pregnancy or up to 485 days before were identified through national registers. We included all 3,402 exposed pregnancies and 19,551 unexposed pregnancies randomly selected to the control cohort and performed adjusted stratified Cox proportional hazards regression analyses with time-dependent covariates. RESULTS: These life events were not associated with SGA in general, but exposed infants born before 32 weeks of gestation had twice the risk for being born with a birth weight相似文献   

Use of acyclovir for varicella pneumonia during pregnancy

Twenty-one cases (five new and 16 literature) of varicella pneumonia of pregnancy were retrospectively reviewed to evaluate the benefits and risks of intravenous acyclovir on maternal and fetal outcomes. All women were in their second (12 cases) or third (nine cases) trimester. Mean gestational ages at the onset of pneumonia and time of delivery were 27 and 36 weeks, respectively. Twelve patients required mechanical ventilation. The mean duration of treatment was 7 days. No definite adverse drug effects were noted. Three women (14%) died of uncontrolled infection or complications. Two infants died (whose mothers also died): One was stillborn at 34 weeks' gestation, and the other died from prematurity shortly after birth at 26 weeks. No child was born with features of congenital varicella syndrome, and none developed active perinatal varicella infection. Onset of pneumonia during the third trimester was a risk factor associated with fatal maternal outcome. Intravenous acyclovir may reduce maternal morbidity and mortality associated with varicella pneumonia occurring during pregnancy, and appears to be safe for the developing fetus when given during the latter trimesters.     

Fetal Outcome and Amniocentesis Results in Pregnancies Complicated by Varicella Infection

ObjectiveTo evaluate the outcome of infants born to mothers with varicella zoster virus (VZV) infection in pregnancy who had second trimester amniocentesis for detection of placental transfer.MethodsWe interviewed women who had had VZV infection in pregnancy and who underwent diagnostic amniocentesis to detect transplacental infection using both polymerase chain reaction (PCR) and cell culture methods to characterize their children’s clinical and psychomotor development.ResultsTwenty women who had a diagnosis of primary VZV during pregnancy were available for interview. The mean gestational age at which primary VZV was acquired was 11±3.5 weeks. One infant had hypospadias and developmental delay. He was born to an epileptic mother who had been treated during pregnancy with sodium valproate and clonazepam. Another infant had abnormal brainstem auditory-evoked potentials. All other infants were reported to have normal clinical and psychomotor development.ConclusionIn cases of varicella infection during pregnancy, negative studies of amniotic fluid using PCR may contribute to decision making.     

Use of glucocorticoids in pregnancies complicated by severe hypertension and proteinuria

Summary. During a 2-year period, 56 infants of 34 weeks gestation were delivered from 53 pregnancies complicated by severe hypertension and proteinuria. In the first part of the study 32 infants were delivered whose mothers did not receive antepartum glucocorticoids; subsequently 24 infants were born whose mothers did receive antepartum glucocorticoids. The severity of maternal disease, gestational age at delivery, birthweight and obstetric management was similar in both groups. In the group receiving glucocorticoids 88% of the infants were discharged live from the neonatal unit compared with 72% in the group who did not receive corti-costeroids. It is concluded that in pregnancies complicated by severe hypertension and proteinuria requiring delivery before 34 completed weeks of pregnancy, the administration of antepartum glucocorticoids to the mother does not carry an increased risk to the fetus, and may be of benefit by reducing the risk of idiopathic respiratory distress syndrome and subsequent intraventricular haemorrhage.     

Use of glucocorticoids in pregnancies complicated by severe hypertension and proteinuria

During a 2-year period, 56 infants of less than 34 weeks gestation were delivered from 53 pregnancies complicated by severe hypertension and proteinuria. In the first part of the study 32 infants were delivered whose mothers did not receive antepartum glucocorticoids; subsequently 24 infants were born whose mothers did receive antepartum glucocorticoids. The severity of maternal disease, gestational age at delivery, birthweight and obstetric management was similar in both groups. In the group receiving glucocorticoids 88% of the infants were discharged live from the neonatal unit compared with 72% in the group who did not receive corticosteroids. It is concluded that in pregnancies complicated by severe hypertension and proteinuria requiring delivery before 34 completed weeks of pregnancy, the administration of antepartum glucocorticoids to the mother does not carry an increased risk to the fetus, and may be of benefit by reducing the risk of idiopathic respiratory distress syndrome and subsequent intraventricular haemorrhage.     

Virus detection in the fetal tissue of a premature delivery with a congenital varicella syndrome. A case report

Cases of congenital varicella syndrome have been published, to date, a single case reports. Isolation attempts of Varicella-Zoster virus from fetal tissues have, thus far, been unsuccessful. This is a first report of detection of Varicella-Zoster virus in fetal tissue by means of DNA hybridization technique in a typical case of congenital varicella syndrome in a premature delivery of the 27th gestational week. The case is documented anamnestically, sonographically, pathologically and virologically. In women with primary varicella infection during pregnancy good sonographical controls are recommended. In cases with sonographically characteristical signs prenatal diagnosis with puncture of the umbilical vein cord and placentocentesis may be considered. The varicella DNA detection should be supplemented, however, by the polymerase chain reaction.     

Viral diseases in pregnancy: a review of rubella,chickenpox, measles,mumps and 5th disease

Approximately 10–15% of women of reproductive age are susceptible to Rubella. Such patients should be vaccinated immediately postpartum to prevent concern about congenital infection in future pregnancies. More than 90% of women of reproductive age are immune to varicella. Susceptible patients who are exposed to varicella should receive immunoprophylaxis with varicella zoster immune globulin. When mothers acquire chickenpox in the first 20 weeks of pregnancy, the overall risk of congenital varicella infection is ≤2%. Measles infection during pregnancy is not associated with an increased incidence of fetal malformations. However, infected mothers are at risk for serious complications such as otitis media, encephalitis, and pneumonia. Mumps infection during pregnancy rarely poses a serious risk of maternal or fetal morbidity. In contrast, maternal parvovirus infection during the first 20 weeks of gestation may be associated with a 5–10% risk of fetal hydrops. This complication can be treated successfully with intrauterine transfusion.     

Albumin binding of MADDS--a measure of bilirubin binding--in women during pregnancy and after delivery and in their infants

The purpose of this study was to investigate the binding potential of MADDS (monoacetyldiaminodiphenyl sulphone) to albumin, a measure for binding of unconjugated bilirubin, in healthy women during pregnancy, during and after delivery, and in their infants. The serum concentrations of unconjugated bilirubin, reserve albumin for binding of MADDS and total albumin were measured in: (a) 21 non-pregnant women; (b) 16 pregnant women in the 16th-24th, 28th-32nd, and 36th-38th gestational weeks, and at the time of delivery from both mother and infant; and (c) 15 women at the time of delivery, and 24 and 72 hours after delivery. The bilirubin concentrations did not change during pregnancy or at delivery and were very small compared with the concentrations of reserve albumin for binding of MADDS and total albumin. Therefore, the ratio of reserve albumin to total albumin was an expression of the binding potential of the albumin for MADDS in women. During pregnancy, the reserve albumin decreased equal to total albumin, so that the ratio was not significantly changed (p greater than 0.05). In contrast, at delivery the reserve albumin was significantly lower (p less than 0.01) than in the 36th-38th gestational weeks, without any significant difference in total albumin, i.e. the ratio was significantly lower than during pregnancy (p less than 0.01). During the first 3 days after delivery the reserve albumin increased significantly (p less than 0.05), also without any significant change in total albumin, so that the ratio increased significantly (p less than 0.05) and was normalized. The binding potential for MADDS to albumin in newborn infants was even lower than that of their mothers. Since the binding-potential is reduced in both mother and infant at delivery, a relation is suggested.     

Asthma in Pregnancy

Asthma is the most common respiratory disease encountered during pregnancy. The normal physiological changes of pregnancy cause mild hyperventilation and reduced lung volumes. Asthma may improve, deteriorate or remain unchanged during pregnancy. Exacerbations of asthma usually occur between the 29th and 36th weeks of gestation with improvement during the final four weeks. Pregnant women are at a slightly higher risk for pregnancy-induced hypertension, Caesarian section, and, if taking oral corticosteroids, gestational diabetes mellitus. The management of asthma in a pregnant patient should be similar to that of a non-pregnant patient. The goals of therapy are to control the asthmatic symptoms, prevent acute exacerbations, and minimize the use of rescue inhaled bronchodilators. Regular inhaled corticosteroids, with inhaled beta-agonists on an as needed basis are the mainstays of current asthma management. None of the current medications used in the treatment of asthma has been shown to have a teratogenic effect. Poorly controlled asthma poses a much greater threat to the mother and fetus than any theoretical side-effect from drugs used to treat asthma. Exacerbations of asthma during pregnancy should be treated promptly with inhaled beta-agonists and ipratropium. A short course of oral corticosteroids may be necessary if the exacerbation is severe or prolonged. Objective assessment of the degree of airflow obstruction is mandatory during any exacerbation. It is prudent to ensure that the pregnant asthma patient has an optimal respiratory status during labour and delivery. Patients taking oral corticosteroids or high dose inhaled corticosteroids prior to labour should receive intravenous corticosteroids during labour.     

Treatment of Severe Pre-Eclampsia by Plasma Exchange

Summary: Three women with pre-existing renal disease developed severe preeclampsia with renal failure during the midtrimester of pregnancy. Plasma exchange was commenced at 23, 26 and 29 weeks of gestation and continued, initially daily then second daily, until delivery at 32, 29 and 32 weeks, respectively. During this period, signs of pre-eclampsia regressed and renal function stabilised or improved. One baby with severe hyaline membrane disease died at 6 days; the other 2, now aged 7 months and 4 months, are in good health. Plasma exchange may offer an alternative to termination of pregnancy in the management of patients with severe pre-eclampsia when fetal maturity is insufficient for viability.     

Chemotherapy for ovarian mucinous cystadenocarcinoma during pregnancy: a case report

There is limited experience in the treatment of epithelial ovarian malignancy with chemotherapy during pregnancy. We present the case of a 36-year-old women with ovarian mucinous cystadenocarcinoma during pregnancy, on whom exploratory laparotomy was performed at the gestational age of 16 weeks. Afterwards chemotherapy with cyclophosphamide (500 mg/m2) and cisplatin (50 mg/m2) was administered beginning at the second trimester of pregnancy due to surgical Stage Ic. Although preterm labor and a prematurely ruptured membrane occurred at the gestational age of 29 weeks before the fourth course of chemotherapy, there was still a satisfactory outcome for mother and fetus after an emergency cesarean section due to breech presentation at the gestational age of 30 weeks.     

The impact of pregnancy-prolonging management on maternal and neonatal morbidity in HELLP syndrome]

OBJECTIVE: Until recently, delivery immediately after diagnosing HELLP syndrome was recommended due to the life-threatening risk to mother and child. Prolongation at least until lung maturation is being increasingly considered because of the high rate of premature births characterized by extreme immaturity. We investigated the influence of the time of delivery on maternal and neonatal morbidity at a gestational age of less than 34 + 0 weeks of pregnancy. - MATERIAL AND METHODS: The disease course was reevaluated in 37 patients who developed HELLP syndrome (thrombocytes < 100 000/microl, transaminase > 70 U/l, haptoglobin < 0.5 g/l) between 1994 and 1999. An attempt was made to stabilize the mother's condition under therapeutic volume expansion. Pregnancy was terminated with the onset of a renewed HELLP episode. -RESULTS: HELLP syndrome occurred with an incidence of 1 : 310 births. There were no maternal or neonatal deaths or any severe complications. Prolonging pregnancy until completing drug-induced lung maturity was successful in 16 of 25 patients before the 34(th) week of pregnancy. In the case of immediate delivery with inadequate stabilization, 5 of 9 patients had postpartum complications. A severe RDS occurred in 3 premature babies without drug-induced maturity. - CONCLUSION: If there is no life-threatening risk to the fetus or mother in patients with HELLP syndrome, the objective is the prolongation of pregnancy in a perinatal center until lung maturation. Stabilization is successful in a high percentage of patients under therapeutic volume expansion with optimal monitoring of mother and child.     

Thyroid disorders and pregnancy.

During pregnancy physiologic changes in thyroid function occur which should not be misinterpreted as pathological. Thyroid disorders may complicate pregnancy and need thorough investigation and treatment in order to ensure a favourable pregnancy outcome. The incidence of hyperthyroidism in pregnant women has been reported to be approximately 0.2%. The leading cause is Graves' disease. Treatment of hyperthyroidism includes antithyroid drugs or surgery to avoid adverse effects on the neonate such as prematurity, intrauterine growth retardation and fetal or neonatal thyrotoxicosis. Use of radioactive iodine is contraindicated. Hypothyroidism during pregnancy is associated with gestational hypertension and low birth weight. Women on thyroid replacement therapy before pregnancy may require an increase in dosage during pregnancy. Pregnant women with chronic autoimmune thyroiditis have a higher incidence of spontaneous miscarriage. Nodular disease demands meticulous investigation to rule out a toxic adenoma or malignancy. Surgery in the case of cancer can be postponed under certain circumstances. Within one year following delivery, about 5-10% of women may exhibit postpartum autoimmune thyroid dysfunction, which may result in hypothyroidism.     

Varicella and the pregnant woman: prevention and management

Infection with varicella zoster virus (VZV) is often considered a childhood 'right of passage'; however, primary infection occurring in women of child-bearing age can have significant adverse consequences both for the mother and for her fetus. During the first trimester, primary VZV infection may result in stillbirth or a baby born with the stigmata of the congenital varicella syndrome, while infection in the peripartum period can result in neonatal varicella, which carries a significant mortality rate despite appropriate antiviral therapy. Varicella in pregnant women can progress to pneumonitis and other severe sequelae that may also compromise the viability of the fetus. Exposure to VZV most commonly occurs in the community or from children in the household, but occasionally, exposure may occur in the hospital environment. Determining a woman's serostatus prior to pregnancy is advised, as effective vaccines are now available and should be administered to non-pregnant seronegative women of child-bearing age. Clinical practice guidelines for management of a pregnant woman exposed to VZV are presented.