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MRCOG Part 2, MRCOG II

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MRCOG 2 Past Questions Tutorial: GROUP 3: Sat 16/11 from 10:00 - Statistics. Sun 17/11 from 10:00 - Oncology 1. Group 2: Sat 16/11 from 19:00 - Contraception & STI. See DISCUSSIONS below for details.

 

 

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Forum >> ESSAY 252 - Chickenpox in pregnancy
ESSAY 252 - Chickenpox in pregnancy Posted by PAUL A.
Tue Jan 8, 2008 04:05 am
You are the registrar on call and a local general practitioner asks for your advice about a healthy 30 year old pregnant school teacher who has been in contact with a pupil with chickenpox. (a) What additional information would you request from the general practitioner? [4 marks] (b) What are the management options in this case? [5 marks] (c) Four weeks later, you are telephoned again because the woman has now developed chickenpox at 18 weeks gestation. How would you advise the GP?[11 marks].
Posted by N S.
Tue Jan 8, 2008 02:38 pm
A) I would like to know about the duration of exposure with the chicken pox patient, also what stage of infection the person was .As the disease is infectious 48 hours before till the crust is appeared. Duration of pregnancy is important to assess further plan in case of non immune maternal status. I would like ask the GP about her previous history chicken pox infection as 90% population is immune to varicella infection once they have been exposed to chicken pox in past.
B) If patient is immune that is IgG present in serum then no need to worry. How ever if the patient does not give history of previous varicella zoster infection then check for antibodies. VZIG should be given as soon as possible. Advice the patient to avoid contact with other pregnant patient till the result are available. Also inform the GP and midwife in case any rash develop. I will also inform the patient the risk of developing fetal vericella syndrome is very low.

C) Avoid contact with the vulnerable group of people that is pregnant women, young children. Oral Acylovir should be started to reduce the severity of t he symptom, with caution before 20 weeks. Patient should be informed about the risk and benefit of acyclovir .VZIG is of no benefit once the infection has developed. Patient should be advised that in case of any worsening symptom to contact her due to the risk of developing pneumonia, encephalitis and meningitis with significant mortality rate. If suspected then patient should be referred to the hospital.MDT team involving the chest physician, obstetrician should review if the mother has chest symptom along with history of use of corticosteroid and COPD. Detail anomaly scan at specialist fetal centre should be arranged for this patient. Though there is very low risk of fetal anomalies. Offer amniocentesis to exclude the infection affecting the fetus. Discuss risk and benefits .even if vzv seropostive risk of fetal infection is low. Continue with ANC as planned. Aim for the normal vaginal birth. Newborn should be reviewed for any sign of ophthalmic infection. Send newborn baby sample to check varicella antibodies. If the fetus delivered prematurely then VZIG should be given to baby.
Posted by hoping ..
Tue Jan 8, 2008 05:51 pm
I would enquire regarding woman\'s gestation, if any past history of her having chickenpox or herpes zoster or immunisation against varicella in last 20 years to determine her susceptibility. If she is susceptible ,duration of contact with infected pupil because higher risk if close contact, stage of rash in pupil to determine if it was in infectious period ( 2 days before onset of rash until lesions crust).
b)
if history suggestive of past infection reassure woman, otherwise check for varicella antibody in serum- if IgG positive it indicates immunity and thus reassure woman that there is no risk to her or fetus.If IgG negative than she is susceptible to infection. If exposure was significant advice VZIG as it reduces risk and severity of infection, caution should be advised as it increases incubation period from 7-21 to 7-28 days. woman should be advised against contact with susceptible pregnant patients and neonates therfore should avoid attending maternity unit in this period. She should be advised to contact GP or midwife if rash occurs.
c) Chicken pox in pregnancy has 5 fold risk of severity than nonpregnant adults, patient should have hospital assesment in unit with facilities for seeing infectious diseases especially in pregnancy because of increased risk of maternal hepatitis, encephalitis and pneumonia. VZIG has no role now.Aciclovir if given within 24 hours reduces severity with caution as she is 18 weeks pregnant. woman should be advised that there is theoretical risk of teratogenesis although it has not been reported so far. She should be advised to avoid contact with susceptible individuals. If signs and symptoms suggest severe infection- bleeding , haemorrhagic rash, neurological symptoms, chest symptoms she will require inpatient management by multidisciplinary team involving obstetrician, virologist, chest physician, high dependancy team. In extreme cases termination of pregnancy may be required ti improve maternal ventilaion. After recovery patient should be seen by Obstetrician / fetal medicine specialist for discussion of implications on fetus, risk of fetal varicella syndrome(FVS) is rare.Detailed ultrasound five weeks following infection can identify microcephaly, hydrocephalus, limb deformities. Negative findings indicate low risk of FVS which can be further reduced if repeat scan is negative as well. Serial growth scans to identify growth restriciton may be indicated. Amniocentesis to diagnose FVS is not routinely performed , if joint descision is made , negative antibodies in amnitic fluid reliably indicate that fetus is not infectedand doesnot need further investigations, if it is positive then infection is present but risk of FVS is low.Paediatricians should be alerted as baby will need carefull assesment after delivery, mother may want to discuss implications antenataly.Diagnosis of FVS can be ground for termination , therefore detailed counselling should be available alongwith psychological support if it is required.
Posted by Anna A.
Tue Jan 8, 2008 06:40 pm
a)Chicken pox is contagious 2 days before the onset of rashes until the skin lesion has crusted over. Thus, the GP should tell the stage of the skin lesion of the pupil in her school. Information of personal history of chickenpox or varicella vaccination is important to determine the susceptibility of the patient. Varicella serology if any is useful information. The significant of contact should be obtained; direct contact to contagious lesion is a significant exposure. In door contact of more than 15 minutes is also significant. Personal history of chronic smoker or if she is immune compromised has a value information for adverse maternal outcome.
b)If she is very certain of previous history of chickenpox or vaccinated before, she can be reassured. If she has no history of chickenpox and she has a significant exposure, she should be given Varicellas Zoster immunoglobulin G (VZIG) immediately. VZIG is still effective if given up to 10 days from the onset of rashes. If the status of immunity is uncertain, the administration of VZIG can be delayed until the serology result available. She should received VZIG if she is sero-negative and reassured if the varicela serology result is positive. She should notify her GP should she develop any rashes. She should avoid contact with susceptible pregnant mother and neonate within 8 to 21 days.
c)Advice the GP to prescribed oral aciclovir 800mg 5 times perday for 7 days. Consent for administration of aciclovir should be taken by the GP as her pregnancy is less than 20 weeks with theoretical risk of fetal teratogenesis. She should be informed regarding the benefit of aciclovir include reduction course of disease if given within 24hours from the onset of rashes. She should be prescribed symptomatic treatment and should encourage good hygiene to avoid secondary skin infection. Administration of VZIG once the rashes develop is not useful. She should avoid contact with susceptible pregnant mother or neonate until the skin lesion crusted over. Arranged detail scan after 5 weeks of chickenpox infection at tertiary centre to look for features of congenital varicella syndrome. Serial scan to look for intrauterine growth restriction should be arranged as well. Admission to the ward should be arranged if she develop chest symptom, hepatitis or encephalitis. Careful measure should be taken to susceptible medical staff who in contact with this patient. Ophthalmic assessment should be arranged during neonatal period. Further follow up and leaflet information should be given to the patient.
Posted by Azza S.
Tue Jan 8, 2008 09:32 pm
It is important to ask about previous infection as most of the population are sero-positive It is also important to ask about gestational age. It is important to ask about type of contact and for how long and when was that. We should ask if she is booked and if there is saved serum from her booking investigations
The management should start with reassurance as 90% of the population are sero- positive . The risk is only 2% to develop congenital varicella syndrome if she contracted the disease in the first 20 weeks of gestation. A detailed ultrasound anomaly scan should be offered .In the second half of the pregnancy the risk to the fetus is mainly occurs if the mother developed the disease one week before delivery, as a severe infection is likely to develop with no passive immune antibodies from the mother as they are likely not developed yet. The chicken pox in pregnant women is likely to be severe disease specially if they developed chest symptoms. The save serum from booking investigations should be tested for Varicella IGG antibodies and if negative immunoglobulin should be given within 96 hours from contact, If positive then she can be assured that there no risk to her or her fetus. In late pregnancy labour should be delayed if possible for few days.
The GP should be advice to refer her if she developed severe or prolonged disease or chest symptoms. Acyclovir can be used. A detailed anomaly scan can be offered at 22weeks gestational age, and termination of pregnancy can be offered if the child is affected. She should be advised to stay away from other pregnant women.
Posted by Srivas  P.
Tue Jan 8, 2008 09:51 pm
(a)Menstrual history to assess gestational age, her chicken pox immune status should be asked-any prior infection or vaccination against chickenpox. Nature of contact with chicken pox patient-ask for time of exposure whether during the period of infectivity (which is 48 hrs prior to appearance of rash until it crusts over) , closeness of contact?face to face , same room etc and duration of contact-all this can help assess her risks if she is non-immune.

History of smoking, any chronic chest infections like bronchitis, asthma, taking immunosuppressive like corticosteroids?these affect severity of infection if she does get chicken pox.

(b)Prior chicken pox infection or positive serum VZV IgG indicates she is most likely protected from infection and can be reassured. If she has negative history of chicken pox infection and VZV IgG is negative and she has significant exposure, she should have VZIG given I/V or I/M within 7-10 days. She should also avoid meeting susceptible contacts and pregnant women for 28 days following a VZIG injection as she could be in the incubation period and be infective.

She should be asked to report to her GP if she gets a rash and receive acyclovir within 24hrs of rash. Though the risks of FVS syndrome are very low if she gets Chicken pox , she should be referred to Fetal medicine unit for detailed fetal scan for possible Fetal Varicella syndrome and she should be offered TOP if fetus is infected.

Chicken Pox in adults is likely to be more severe with likelihood of Hepatitis, Encephalitis, Pnemonia and even death. She should be referred to hospital if she develops chest complications, neurological symptoms or hemorrhagic rash. If she has chronic lung diseases or or she smokes she should have hospital review.

She is not at risk of miscarriage and her rest of pregnancy is likely to be uneventful and she can be reassured.

(c)He should put her on oral acyclovir within 24 hrs of getting rashes after discussing possible but rare possibility of teratogenesis with acyclovir when taken before 20 weeks pregnancy and discussing risks versus benefits to her. He should advice woman not to scratch and cause secondary infections. Chicken pox has greater morbidity in adults and she can have complications and he should refer her to hospital if she develops chest complications, bleeding rash and neurological symptoms. If she has history of chronic lung infections or recent steroid intake, even without complications she should be referred to hospital.

Risks of Fetal varicella syndrome are very rare at between 0.5-1% in mothers with chicken pox. She must have detailed scan in Fetal Medicine unit at 16-20 weeks or 5 weeks after maternal infection to look for features of Fetal varicella syndrome. She can be assured if repeated USG appears normal. If USG looks suspect she may need referral to obstetric consultant for possibility of amniocentesis to confirm fetal infection and discuss possible TOP.

If fetus appears normal and she recovers completely, rest of pregnancy and labor are likely to be uneventful and her antenatal visits can be as per schedule with usual monitoring and antenatal care and she can deliver in mid-wife led units.
Posted by SAIMA A.
Tue Jan 8, 2008 11:53 pm
The additional information which I need to know is how many weeks pregnant she is and secondly whether she had history of chicken pox infection in the past.If she doesnot remember previous exposure or unsure about it then duration of contact with the pupil and infectious state of pupil is important as infectious state is 48 hours before eruption of rash till vesicle crusts off.
If there is significant contact and to cofirm immunity ,varicella IgG in maternal serum should be checked.If she is IgG positive she can be reassured about immunity as 90% of pregnant females are varicella immune.If her IgG comes negative ,she should be advised to avoid contact with other pregnant ladies and neonates upto 4 weeks after contact and can be offered immunoglobulins witin 24 hours of exposure(effective upto 10 days) .IgM should be checked after 3 weeks of exposure to detect seroconversion or infection.She should be advised to contact GP in case of rash or pyrexia or other symptoms.
She should be given oral acyclovir to reduce the severity of symptoms after proper counselling as acyclovir before 20 week gestation is associated with theoretical risk of teratogenicity.she should be given symptomatic treatment in form of antipyretics,antihistamines with hygiene advice to prevent superadded bacterial infection. Varicella infection is associated with maternal mortality of upto 6% in pregnant females mainly due to complication of pneumonia,encephalitis and hepatitis.History of smoking ,chronic obstructive lung disease or corticosteroid treatment in past 3 months need assessment in hospital as these lead to increased risk of complicating pneumonia which sometimes need ventilation.She should be advised to contact hospital immediately if she develops cough ,neurological symptoms or haemorrhagic rash as any of these needs immediate admission in isolation and intravenous acyclovir treatment under multidisciplinary care of chest physician,virologist ,obstetrician and ITU physician. She should be advised to avoid contact with other pregnant women and neonates till vesicle crusts off.She should be informed about 1% risk of fetal congenital varicella syndrome before 28 weeks gestation and associated with skin scarring ,limb hypoplasia,cataract and microcepahly.There is no role of immunoglobulin once rash appeared.She should be offered detailed anomaly scan at 23 weeks gestation (5 weeks after infection).Amniocentesis for detection of viral DNA is associated with miscarriage rate of 1% above background and this should be balanced against 1% risk of congenital varicella syndrome and proper counselling needed. Once infectious state is over ,she can be managed as normal pregnancy and routine antenatal care given and .After delivery neonate ophthalmic examination should be done.
Posted by maha G.
Tue Jan 8, 2008 11:56 pm
You are the registrar on call and a local general practitioner asks for your advice about a healthy 30 year old pregnant school teacher who has been in contact with a pupil with chickenpox. (a) What additional information would you request from the general practitioner? [4 marks] (b) What are the management options in this case? [5 marks] (c) Four weeks later, you are telephoned again because the woman has now developed chickenpox at 18 weeks gestation. How would you advise the GP?[11 marks].

ADDITIONAL INFORMATION;
Chicken pox is due to varicella zoster virus which is herpes virus group infection is by droplet infection or direct contact with with the rash the incubation period is about 14 to 21 days period of infectivity is 2 days before appearance of rash till crustation of rash i.e.about 5 days of eruption.
INtially,I will ask about gestational age and if early dating scan done or not.
The time of exposure is requested for further management,is it less than or more than 10 days in case of prescribing VZIG if patient is non immune and VZIG not detected and exposure within 10 days.
The duration of exposure for how long ?is it in open or closed place? exposure for 15 minutes is significant.
The history of previous chicken pox,if positive history just reassurance is warrented.
If negative history or woman not sure ,further investigation is requested.
Past medical history ,if taking any medication especially corticosteriods.
Enquiry about smoking any chest problemas chicken pox may be complicated with pneumonia which will be associated with maternal morbidity and mortality.
2.Mangement option;
Mangement will depend on previous assessment,if woman gave history of chicken pox before I would reassure her.
If no history of chicken or not sure ,I would check her VZIG status,IF positive reassure her,if negative give VZIG if exposure within 10 days after proper counselling as it is a blood product however the risk of infection with blood products transfion is markedly reduced ,also I would tell her that incubation period after VZIG will be prolonged 21to 28 days vs.14 to 21 days.
Reduced risk of transmission of infection to other pregnant women or non immune persons at risk of infection as medical staff ,avoid antenatal visits in maternity units ,in case of need to hospital referal should be in infection isolation unit.
Women to be advised to report any symptoms suggestive of chicken pox as flue like symptos,fever ,rashwhich will be vesicular rash on an erythematous base.
3.Devolped chicken pox ,
I would advise the G.P.to counsell the women properly regarding risk of varicella zoster syndrome {limb hypoplasia,skin scarring,dysfunction of bladder and bowel sphincters,eye effectsas microophthalmia and also CNS FEATURES AS MICROCEPHALLY AND CERebral atrophy}which affect 1 to 2% so patient should be booked for detailed anomaly scan at 22 weeks gestationor 5 weeks after devolping chicken pox.
Acyclovir can be used for treatment of chicken pox,however ,with caution as still 18 weeks pregnant and usually it is used after 20 weeks also not licensed for use in pregnancyand after proper counselling.
Hospital referal,if patient devolped haemorragic rash ,any neurological symptoms,chest symptoms,smooker or on corticosteriod therapy as risk of pneumonia will increase which associated with high morbidity and mortality.
Avoid contact with other pregnant women,
the period of infectivity is 2 days before eruption of rash and 5 days after i.e. after crustation.
Proper conselling , documentation nd communication with patient so she can easily contact her G.p.
Back up with information leaflet.
Termination of pregnancy is not advised as VZS affect only 1 to 2% however patient wishes should be considered.
Multidisciplinary team G.P.obstetrician ,midwive,chest physcian.
Posted by Sahathevan S.
Wed Jan 9, 2008 01:45 am
(a) What additional information would you request from the general practitioner? [4 marks]
Varicella (VZV) in pregnancy may cause maternal mortality or serious morbidity .it may also cause fetal varicella syndrome. I would ask the Gp more information to assess the risk of of her potential varicella exposure, firstly weather she had significant contact (Contact in the same room 15 min or more or face to face contact) with infected individual.Varicella can infect even 2 days before rash develop therefore information of the period of infectiousness (48 hrs before rash until vesicle crust over) is vital. Also I would ask details of exposure including the timing of exposure , type of VZV. Gestation of pregnancy is important for futher management and risk assessment.; previous history of chicken pox (varicella) is a valuable information .I would also inquire any h history of smoking and chronic obstructive airway disease.and state of immunsupressed (steroid treatment)

b) What are the management options in this case? [5 marks]
Management optionsdepends on varicella immunity sate of the patient.
if this lady had chicken pox in the past and ,Blood test for Varicella IgG and confirm immunity ( over 90% of antenatal population are seropositive for varicell zoster IgG.)She can be reassured and no further investigations needed..Once Varicella IgG negative varicella immunoglobulin is recommended which is effective if it is given 10 days of after contact. She should be managed potentially infectious even 8- 28 days after Varicella Ig G administration Also she should report to Gp once she delelop rash even if she had IgG. contact with . Susceptible individual (Pregnant mothers and neonates) should be avoided.
If she is going to have seroconversion or develop chicken pox the risk of congenital varicella syndrome is 1% if she is is < 28 wks gestation and very rare after 28 weeks She should have proper counselling need referral for detailed Uss at 16-20 wks or 5wks after infection.

(c) Four weeks later, you are telephoned again because the woman has now developed chickenpox at 18 weeks gestation. How would you advise the GP?[11 marks].
Aim of the management of chicken pox to prevent complications and to avoid infection to susceptible individuals
Patient should be managed at home unless any potential complications relate to varicella or if she is high risk for varicella pneumonia . (Smoking, immunosupressed, COPD)
Hospital admission and assessment should be considered if she has any risk factors to develop complications. As supportive measures symptomatic treatment such as analgesics and antipyretics can be prescribed. Personal hygiene is important to prevent secondary bacterial infections.
Varicella Ig G has no benefit as she has developed chickenpox.
Oral acyclovir reduces the fever and symptoms of VZV infection in immunocompetent adults.
Acyclovir should be cautiously used before 20 wks gestation if she present within 24 hrs onset of rash.She should be informed benefit and risk of acyclovir if it is prescribed. However as she is 18 wks, there is no risk for tetratogenesis and Acyclovir doesn?t cause fetal anomalies.
Excess morbidity associated with varicella infection in adults including pneumonia , hepatitis and encephalitis.
She should be warned regarding Symptoms of complications of VZV infection , Immediate to hospital referral needed if she develop chest symptoms, neurological symptoms haemorrhagic rash or bleeding .Once she hospitalised for either high risk or managing complications of VZV she should be isolated from potential susceptible individuals (pregnant mothers, neonates and non immune staff) until vesicles crust over.
Mannegent would be multi disciplinary settings. Involving Respiratory physician, Obstetrician, Virologist and neonatologist.
Information leaflets and contact details of support group should be given.Counselling should be arranged regarding the risk for the baby fetal varicella syndrome which is 1%risk .Amniocentesis is not routinely adviced because the fetal varcella syndrome is so low even when amniotic fluid positive for VZV DNA. Referral to fetal medicine specialist can be arranged Prenatal diagnosis possible using detailed USS 5wks afterprimary infection ( at 23 wks)when findinggs such as microchephaly, Hydrocephalus , soft tissue calcification and IUGR identified.Counselling should be backed up by written information and support group details.



Posted by M M A.
Wed Jan 9, 2008 02:03 am
A] we ask the GP if she had previous infection as she will be considered immunized.
We also ask if she is vaccinated before because vaccination can give protection up to 20 years post vaccination.

We inquire about significance of contact, 15 minutes in same room or face to face contact, however, the UK advisory Group of chicken pox consider any contact as being significant. We also ask about duration since contact because the incubation period is about 1-3 weeks and she may already report her exposure after that time without evidence of infection.

B] If she gives certain history of previous infection or immunization , we consider her immunized and she will need only reassurance. If she is not sure , we advise for serum immunoglobulin. If IgG is positive, we consider her immunized also and reassure her.
If IgM is positive , this mean she got the infection and should be treated with antiviral drugs according to her gestational age.
If both of them are negative it means that she is susceptible and she should receive VZIG and IgM titer should be repeated after 3 weeks to detect the disease.

C] We Tell the GP to advice her to avoid contact with our susceptible persons like pregnant ladies or neonates.
We advice him to prescribe supportive measures and give advice about hygiene to prevent secondary bacterial infection.
We tell the GP that acyclovir is given to patient more than 20 weeks gestation if present within 24 hours from developing the rash, however, it can be prescribed earlier after counseling the patient about benefits and risks of it, aciclovir is given orally 800 mg X 5 for 7 days, it can reduce severity and duration of fever.
However, there is theoretical risk of teratogenisity if it is given early in pregnancy.
We advice the GP to refer her for inpatient management if she had chest symptoms as there is 10 % risk of varicella pneumonia which can be serious and fatal.
Admission is required also if she is smoker, if she had neurological symptoms or if her rash is dense and heamorrhagic, because there is risk of thrombocytopenia.
We advice also that this patient should have a multidisciplinary team work care including virologist, fetal medicine specialist, neonatologist, senior obstetrician and anaesthetist.
The risk of developing fetal varicella syndrome is 1%, so we advice the GP to refer her for detailed scan at 22 weeks gestation to detect limb hypoplasia or neurological defects like microcephaly, cortical atrophy or fetal calcifications, although this is unlikely because FVS is usually result from reactivation of the virus and not at the initial infection.
We advice also for serial growth scan from 28 weeks gestation, fortnightly to detect intrauterine fetal growth restriction.
The patient should get verbal and written information about the disease and its consequences and get arrangement for follow up appointment.
Posted by S M.
Wed Jan 9, 2008 04:42 am


a) I would ask when and how long was she in contact with the pupil. Also, was she in direct physical contact with him. Did she have chickenpox in the past or was she vaccinated against it. I would also like to know her gestational age.

b) If this lady has had chickenpox in the past or received a vaccine against it, then nothing needs to be done, since she would have antibidies against the varicella zoster virus, the causative organism of chickenpox.
If she does not have a history of chicklenpox, then she should have a blood test for the presence of varicella zoster virus immunoglobulin antibodies. If there are no antibodies, then she should be given the varicella zoster virus vaccine. If the test shows antibodies, then she does not need the vaccine.

c) Chickenpox is very contagious and harmful to other pregnant women and their fetuses. Therefore, this lady should not be around pregnant women or children. She should not attend the antenatal clinic. If ward admission is needed she should be cared for in an isolated room. Chickenpox can cause both maternal and fetal morbidity. Therefore, it should be treated immediately with acyclovir. There is a risk that the mother may develop pneumonia and any symptoms of pneumonia such as cough and difficulty breathing should be reported immediately. Hospitalisation and a course of antibiotics would be required. She should also be aware that she is at risk of hepatitis and encephalitis.
During the pregnancy , serial ultrasound scans should be done to identify growth restriction and microcephaly which can be caused by chickenpox. A normal delivery can be performed. Postnatally, the neonate will be reviewed by the neonatologist. There is a small chance that the infant may develop fetal varicella syndrome.
Posted by Hala T.
Wed Jan 9, 2008 07:15 am
a)I\'d like to ask him about the details of contact and previous history of chickenpox
with particular respect to the certainty of infection , infectiousness , and degree of exposure.
An important question , must be the time of exposure to the infected child. The pupil is infectious 48 hrs before appearance of rash until vesicles crust over.
The susceptibility of the teacher should be determined . If there is a definite past history of
Chickenpox , it is an indicator of her immunity.
If there is uncertainty or no previous history of chickenpox , she is at risk of catching the infection.
b) If the teacher has had chickenpox in the past , serum should be checked for IgG to confirm the immunity. The pregnancy is allowed to continue without any further intervention.
If IgG is negative ,she should be given VZ immunoglobulin ( VZIG) as soon as possible . It is effective if given up to 10 days after contact. A second dose of VZIG should be as administered ,if further exposure reported and three weeks had passed after the last dose.
The woman should be asked to notify her Doctor early if rash develops. VZV IgM should be checked 3 weeks after exposure to detect seroconverion. If she develops rash , fever , malaise ,she should immediately to contact her Doctor. c) She should be advised to avoid contact with other susceptible individuals , such as other pregnant women and neonates, until the five days after the onset of rash or the lesions have crusted over. Symptomatic treatment and hygiene should be advised to prevent secondary bacterial infection of the lesions. Oral Aciclovir if she presents within 24 hrs of the onset of the rash. Dose of Aciclovir is 800 mg( 5 times a day)for 7 days. Informed consent should be obtained from the patient .There is no associated fetal anomalies,although there is therotical risk of teratogenicity in the first trimester. Aciclovir reduces the duration of fever and symptoms of varicella. The woman should be counselled about the risk of fetal varicella syndrome 1%,and informed about the implications . FV Syndrome consists of skin scarring , limb hypoplasia ,eye defects and neurological abnormalities.
The woman should be referred immediately to the hospital if she developed chest symptoms , neurological symptoms , haemorrhagic rash , dense rash with or without mucosal bleeding . Intravenous acyclovir ( 10 mg /kg b.wt tds) should be used if varicella pneumonitis develops or evidence of disease progression.Appropriate treatment should be decided by obstetrician , virologist and neonatologist, and respiratory physician.
She should be nursed in isolation from the pregnant women and neonates .Detailed ultrasound examination should be considered five weeks after infection. Neonatal ophthalmic examination should be organized after birth.
Posted by Farina A.
Wed Jan 9, 2008 11:08 pm
a) Past history of chicken pox is important as majority of such patients have immunity against VZV and are not at increase risk. Duration and extent of contact is important as contact within the same room for 15 minutes and face to face contact is significant for transmission. History of varicella zoster vaccination should be obtained as it may prevent development of maternal and fetal varicella. The GP should also be inquired about a serum examination for IGG and IGM antibodies for varicella.

b) Management depends upon the immune status of the patient. If the patient is immune reassurance should be provided and the woman should be advised to avoid contact with other pregnant woman. If the patient is susceptible she should be given VZIG within 10 days of exposure. However the rate of prevention of fetal varicella syndrome is unknown as the incidence itself is very low. Inspite of giving VZIG some women do develop primary chicken pox and are infectious for 8-28 days after administration. Patient should avoid contact with other pregnant women and should contact immediately with health care staff once the rash develops. A second dose of VZIG may be required after 3 weeks.

c) The GP should be advised about the higher complication rates of chicken pox in pregnancy like pneumonia, hepatitis and encephalitis. The patient who are smokers have chronic obstructive lung disease, are on corticosteroids and are immunocompromised, and are in the late stage of pregnancy have higher chances of developing complications of chicken pox so they should be referred earlier for hospital care.
A detailed ultrasound after 5 weeks of infection is recommended to detect fetal varicella syndrome.
The woman is infectious from 48 hours before the appearance of rash and upto 5 days (scab formation) so she should avoid contact with other pregnant women.
Treatment with acyclovir is given within 24 hours of onset of rash.
Acyclovir should be given with caution before 20 weeks.
Symptomatic treatment with analgesics and antipyretics and advice for general hygiene and prevention of secondary infection should be given.
Woman should be reassured that varicella infection does not increase the risk of miscarriage.
Woman should be informed that the prenatal diagnosis of fetal varicella syndrome is possible through ultrasound and amniocenteces however it is not recommended ad routine due to lower incidence (1%) of FVS.
Pt should be provided with written information.
Posted by Idris O.
Thu Jan 10, 2008 12:46 am
a)I would ask if the woman remembered having chicken pox in the past because she may be immune . If unknown I would find out the interval between exposure and presentation to the GP since the incubation period of the virus is 1-3weeks.
I would ask about the type of varicella zoster infection as this may be a primary VZV infection in the pupil. The timing of the exposure would determine if this exposure may be associated with the period of high infectivity . This is the period from 48h before the rash appears and up to 5days later when vesicles are crusting over. The closeness and the duration of contact as contact in the same room for 15minutes or more, or face-to-face contact increases the risk of infection. I would also ask the gestational age of the pregnancy. There is a risk of fetal varicella syndrome if infection occurs in the first 28 weeks of pregnancy or varicella infection of the newborn if infected at term. I would also find out if the patient is from overseas as as she is more likely to be non immune.

b)If the patient has had a previous infection, I would re-assure she is immune . She?s more likely to have an uncomplicated pregnancy.
If there was no previous infection, I would check her VZVIgG antibody from her booking blood and if this is positive, it show?s she?s immune. I would reassure her.
If her VZVIgG is negative, suggesting she?s not immune and she has had significant exposure, I would offer her VZIG. This prevents or attenuates the disease in pregnancy . It is effective when given up to 10days after contact. I would manage her as potentially infectious until 28days after VZIG. I would advice her to notify her GP or midwife early if she develops a rash. She may be offered a second dose of VZIG if a further exposure is reported and 3weeks have elapsed since the last dose.

d)She requires multidisciplinary care involving the GP, midwife, obstetrician and fetal medicine specialist. She should promptly be seen by the GP or midwife and avoid contact with other susceptible individuals like pregnant women and neonates until the lesions has crusted over. This takes about 5days after the onset of the rash. The GP should offer her symptomatic treatment and advice on hygiene to prevent secondary bacterial infection of the lesions. Oral acyclovir is not recommended for use below 20weeks because of the small risk of teratogenesis in the first trimester.
She should be referred to the hospital if develop signs of complications like chest or neurological symptoms, haemorrhagic rash or bleeding. If admitted, she should be nursed in an isolation ward from babies, or potentially susceptible pregnant women or non-immune staff.
The patient should be informed there is no increased risk of spontaneous miscarriage. There is a small risk of fetal varicella syndrome and this can be diagnosed prenatally. She would require referral to a fetal medicine specialist for discussion and a detailed anomaly scan about 5weeks post infection. The mother should be aware that if the fetus is not affected at this stage, she can be reassured the fetus most likely would be normal. The fetus would also be protected from the passively acquired antibody from the the mother.
Posted by PAUL A.
Thu Jan 10, 2008 01:01 am
A) I would like to know about the duration of exposure do you mean length of time since exposure or the length of time the woman spent with the infected pupil? with the chicken pox patient, also what stage of infection the person was .As the disease is infectious 48 hours before till the crust is appeared ? meaning?? Until lesions crust over . Duration of pregnancy (1) gestation age is important to assess further plan in case of non immune maternal status. I would like ask the GP about her previous history chicken pox infection as 90% population is immune to varicella infection once they have been exposed to chicken pox in past How do you know people who have been EXPOSED as opposed to infected? If you have chickenpox, then immunity is life-long .
B) If patient is immune that is IgG present how will the GP know this? in serum then no need to worry. How ever if the patient does not give history of previous varicella zoster infection then check for antibodies (1) . VZIG should be given as soon as possible ?? irrespective of IgG status?? . Advice the patient to avoid contact with other pregnant patient till the result are available. Also inform the GP and midwife in case any rash develop. I will also inform the patient the risk of developing fetal vericella syndrome is very low ? for all women or thise who are IgG neg?? .

C) Avoid contact with the vulnerable group of people that is pregnant women, young children (1) . Oral Acylovir should be started to reduce the severity of t he symptom, with caution before 20 weeks what does ?caution? mean as far as the GP is concerned? . Patient should be informed about the risk and benefit of acyclovir what are the risks / benefits? You are telling the GP what to do / tell the patient. The GP does not know what the risks / benefits are .VZIG is of no benefit once the infection has developed. Patient should be advised that in case of any worsening symptom to contact her due to the risk of developing pneumonia, encephalitis and meningitis (1) with significant mortality rate. If if what is suspected? suspected then patient should be referred to the hospital.MDT team involving the chest physician, obstetrician should review if the mother has chest symptom along with history of use of corticosteroid and COPD read the question ? HEALTHY woman . Detail anomaly scan at specialist fetal centre should be arranged for this patient (1) when?. Though there is very low risk of fetal anomalies. Offer amniocentesis to exclude the infection affecting the fetus not indicated (-1) . Discuss risk and benefits of what? . even if vzv seropostive risk of fetal infection is low ? meaning . Continue with ANC as planned. Aim for the normal vaginal birth. Newborn should be reviewed for any sign of ophthalmic infection. Send newborn baby sample to check varicella antibodies. If the fetus delivered prematurely then VZIG should be given to baby will the GP be responsible for this? Why are you giving him this advice?

You have not demonstrated a clear understanding of the investigation & management of a woman exposed to chickenpox during pregnancy
.
Posted by PAUL A.
Thu Jan 10, 2008 01:23 am
I would enquire regarding woman\'s gestation You mean gestation age? , if any past history of her having chickenpox or herpes zoster (1) or immunisation against varicella in last 20 years (-1) why 20 years? Is there a time limit to immunity following infection? to determine her susceptibility. If she is susceptible ,duration of contact with infected pupil because higher risk if close contact, stage of rash in pupil to determine if it was in infectious period ( 2 days before onset of rash until lesions crust). this is not a complete sentence and is meaningless
b)
if history suggestive of past infection reassure woman RCOG guidelines suggest it is good practice to confirm immunity by testing for IgG , otherwise check for varicella antibody in serum- if IgG positive it indicates immunity and thus reassure woman that there is no risk to her or fetus (1) .If IgG negative than she is susceptible to infection. If exposure was significant advice VZIG as it reduces risk and severity of infection (1) woman should be counselled about value / risks of VZIG , caution should be advised as it increases incubation period from 7-21 to 7-28 days. woman should be advised against contact with susceptible pregnant patients and neonates (1) therfore should avoid attending maternity unit in this period. She should be advised to contact GP or midwife if rash occurs.
c) Chicken pox in pregnancy has 5 fold risk of severity ? meaning?? Do you mean 5 fold risk of severe disease? than nonpregnant adults, patient should have hospital assesment not necessarily in unit with facilities for seeing infectious diseases especially in pregnancy because of increased risk of maternal hepatitis, encephalitis and pneumonia (1) . VZIG has no role now.Aciclovir if given within 24 hours reduces severity with caution How do you give a drug with caution? You are giving the GP advice. What should they do? as she is 18 weeks pregnant. woman should be advised that there is theoretical risk of teratogenesis will you expect terratogenesis at 18 weeks? although it has not been reported so far. She should be advised to avoid contact with susceptible individuals (1) . If signs and symptoms suggest severe infection- bleeding , haemorrhagic rash, neurological symptoms, chest symptoms she will require inpatient management (1) by multidisciplinary team involving obstetrician, virologist, chest physician, high dependancy team. In extreme cases termination of pregnancy may be required ti improve maternal ventilation why are you telling the GP this? . After recovery how long after? patient should be seen by Obstetrician / fetal medicine specialist for discussion of implications on fetus, risk of fetal varicella syndrome(FVS) is rare what is the risk? .Detailed ultrasound five weeks following infection (1) can identify microcephaly, hydrocephalus, limb deformities. Negative findings indicate low risk of FVS which can be further reduced if repeat scan is negative as well. Serial growth scans to identify growth restriciton may be indicated why MAY? It is either indicated or it is not . Amniocentesis to diagnose FVS amniocentesis does NOT diagnose FVS ? it will detect fetal infection but not every infected fetus develops the syndrome (-1) is not routinely performed , if joint descision ? meaning is made , negative antibodies in amnitic fluid reliably indicate that fetus is not infectedand doesnot need further investigations, if it is positive then infection is present but risk of FVS is low.Paediatricians should be alerted as baby will need carefull assesment after delivery, mother may want to discuss implications antenataly.Diagnosis of FVS can be ground for termination , therefore detailed counselling should be available alongwith psychological support if it is required.

You were not asked about the management of chickenpox in pregnancy. You were asked about how you will advise a GP who had a pregnant woman with chicken pox. There is no point telling the GP about amniocentesis / paediatricians
Posted by PAUL A.
Thu Jan 10, 2008 03:21 am
a)Chicken pox is contagious 2 days before the onset of rashes until the skin lesion has crusted over. Thus, the GP should tell the stage of the skin lesion of the pupil in her school (1) . Information of personal history of chickenpox or varicella vaccination is important to determine the susceptibility of the patient (1) . Varicella serology if any is useful information. The significant of contact should be obtained; direct contact to contagious lesion is a significant exposure. In door contact of more than 15 minutes is also significant (1) . Personal history of chronic smoker or if she is immune compromised healthy has a value information for adverse maternal outcome.
b)If she is very certain of previous history of chickenpox or vaccinated before, she can be reassured guidelines suggest good practice to confirm by testing for antibodies . If she has no history of chickenpox and she has a significant exposure, she should be given Varicellas Zoster immunoglobulin G (VZIG) NO ? test for immunity ? 85% will be immune immediately. VZIG is still effective if given up to 10 days from the onset of rashes. If the status of immunity is uncertain, the administration of VZIG can be delayed until the serology result available. She should received VZIG if she is sero-negative and reassured if the varicela serology result is positive. She should notify her GP should she develop any rashes. She should avoid contact with susceptible pregnant mother and neonate (1) within 8 to 21 days.
c) Advice the GP to prescribed oral aciclovir 800mg 5 times perday for 7 days (1) need discussion with consultant in infectious diseases / obstetrician . Consent for administration of aciclovir should be taken ? meaning?? Should she sign a consent form? by the GP as her pregnancy is less than 20 weeks with theoretical risk of fetal teratogenesis will you expect terratogenesis at 18 weeks? . She should be informed regarding the benefit of aciclovir include reduction course of disease if given within 24hours from the onset of rashes. She should be prescribed symptomatic treatment and should encourage good hygiene to avoid secondary skin infection (1) . Administration of VZIG once the rashes develop is not useful. She should avoid contact with susceptible pregnant mother or neonate until the skin lesion crusted over (1) . Arranged detail scan after 5 weeks of chickenpox infection at tertiary centre to look for features of congenital varicella syndrome (1) . Serial scan to look for intrauterine growth restriction should be arranged as well ? value . Admission to the ward ? antenatal ward? should be arranged if she develop chest symptom, hepatitis or encephalitis (1) . Careful measure should be taken to susceptible medical staff who in contact with this patient. Ophthalmic assessment should be arranged during neonatal period. Further follow up and leaflet information should be given to the patient.
Posted by PAUL A.
Thu Jan 10, 2008 03:33 am
It is important to ask about previous infection as most of the population are sero-positive (1) It is also important to ask about gestational age (1) . It is important to ask about type of contact and for how long (1) and when was that (1) . We should ask if she is booked and if there is saved serum from her booking investigations
The management should start with reassurance as 90% of the population are sero- positive you cannot just reassure her irrespective of history of previous infection . The risk is only 2% to develop congenital varicella syndrome if she contracted the disease in the first 20 weeks of gestation. A detailed ultrasound anomaly scan should be offered .In the second half of the pregnancy the risk to the fetus is mainly occurs if the mother developed the disease one week before delivery, as a severe infection is likely to develop with no passive immune antibodies from the mother as they are likely not developed yet. The chicken pox in pregnant women is likely to be severe disease specially if they developed chest symptoms. The save serum from booking investigations should be tested for Varicella IGG antibodies and if negative varicella zoster immune globulin ? different drug from immunoglobulin immunoglobulin should be given within 96 hours from contact, If positive then she can be assured that there no risk to her or her fetus (1) . In late pregnancy labour should be delayed if possible for few days. if previous infection, reassure but confirm by testing for VZ IgG.If no previous infection / uncertain, test. IgG positive ? reassure. IgG neg ? counsel and offer VZIG
The GP should be advice to refer her if she developed severe or prolonged disease or chest symptoms what will you tell the GP are the signs / symptoms of severs disease? . Acyclovir can be used CAN? How will the GP know if / when to use it? . A detailed anomaly scan can be offered at 22weeks gestational age You are supposed to tell the GP what to do, not what can be done , and termination of pregnancy can be offered if the child is affected. She should be advised to stay away from other pregnant women.

See NOTES > INFECTION IN PREGNANCY > VARICELLA
Posted by PAUL A.
Thu Jan 10, 2008 04:13 am
(a)Menstrual history to assess gestational age, her chicken pox immune status should be asked-any prior infection or vaccination against chickenpox you need to write in simple grammatically correct sentences addressing single issues. The examiner is not just looking for key words or phrases . Nature of contact with chicken pox patient-ask for time of exposure whether during the period of infectivity (which is 48 hrs prior to appearance of rash until it crusts over) , closeness of contact?face to face , same room etc and duration of contact-all this can help assess her risks if she is non-immune (1) .

History of smoking, any chronic chest infections like bronchitis, asthma, taking immunosuppressive like corticosteroids READ THE QUESTION ? HEALTHY WOMAN ?these affect severity of infection if she does get chicken pox.

(b)Prior chicken pox infection or positive serum VZV IgG indicates she is most likely protected what does most likely mean? from infection and can be reassured. If she has negative history of chicken pox infection and VZV IgG is negative and she has significant exposure (1) , she should have VZIG given I/V or I/M within 7-10 days will you do this irrespective of gestation age? . She should also avoid meeting susceptible contacts and pregnant women (1) for 28 days following a VZIG injection as she could be in the incubation period and be infective.

She should be asked to report to her GP if she gets a rash and receive acyclovir within 24hrs of rash. Though the risks of FVS syndrome are very low if she gets Chicken pox , she should be referred to Fetal medicine unit for detailed fetal scan for possible Fetal Varicella syndrome and she should be offered TOP if fetus is infected.

Chicken Pox in adults is likely to be more severe with likelihood of Hepatitis, Encephalitis, Pnemonia and even death. She should be referred to hospital if she develops chest complications, neurological symptoms or hemorrhagic rash. If she has chronic lung diseases or or she smokes she should have hospital review.

She is not at risk of miscarriage and her rest of pregnancy is likely to be uneventful and she can be reassured.

(c)He should put her on oral acyclovir within 24 hrs of getting rashes after discussing possible but rare possibility of teratogenesis with acyclovir when taken before 20 weeks will you expect terratogenesis at 18 weeks?? pregnancy and discussing risks versus benefits to her what should he tell her are the risks / benefits? . He should advice woman not to scratch and cause secondary infections. Chicken pox has greater morbidity in adults worse still in pregnancy and she can have complications and he should refer her to hospital if she develops chest complications, bleeding rash and neurological symptoms (1) . If she has history of chronic lung infections or recent steroid intake read the question ? healthy. You have written this information in part (b). If you had written an answer plan, you would have detected this duplication. You will not be asked the same thing twice in the same exam , even without complications she should be referred to hospital.

Risks of Fetal varicella syndrome are very rare at between 0.5-1% in mothers with chicken pox (1) . She must have detailed scan in Fetal Medicine unit at 16-20 weeks you have been asked a specific question and she is 18 weeks. Writing 16-20 weeks simply tells the examiner you have not read the question or 5 weeks after maternal infection to look for features of Fetal varicella syndrome. She can be assured if repeated USG appears normal. If USG looks suspect she may need referral to obstetric consultant so who is going to do the initial scan if she is referred to a consultant only after an initial abnormal scan??? for possibility of amniocentesis to confirm fetal infection and discuss possible TOP.

If fetus appears normal and she recovers completely, rest of pregnancy and labor are likely to be uneventful and her antenatal visits can be as per schedule with usual monitoring and antenatal care and she can deliver in mid-wife led units.

You need to read every word in the question and answer the question as asked.
Posted by Shankaralingaia N.
Thu Jan 10, 2008 09:40 am
I would like to know the gestational age of the patient,how long ago was she in contact and the duration?Would also like to know if she had chicken pox in the past or if she has developed any rash?Obtain history of smoking and chronic cough or lung disease is paramount?
If the women has had chickenpox in the past then she is immune and she needs no further interventions.Emphasis on reporting if any rash develops.
If not immune or not sure then take bloods for varicella zoster antibodies within 24-48hrs.If susceptible varicella Zoster immunoglobulins needs administering within 10 days after liasing with the virologist .Advice on avoiding contact with other pregnant women and neonates for 4 weeks.
If any rash develops and is <28 weeks gestation she needs referral to the fetal medicine unit after 5 weeks.She should be counselled about risk of fetal varicella syndrome.She needs detailed anamoly scan,fetal VZ DNA after counselling.
If >28 weeks then risk of fetal varicella syndrome is small.
If rash develops within 4 weeks of delivery and 7 days after delivery there is >50% risk of neonatal varicella syndrome.Baby needs varicella immunoglobulins and serum for antibodies at birth and at 7 months of age.
If she develops chest infections(pneumonitis),she need admission in the hospital for intravenous acyclovir and defer delivery for atleast 7 days to reduce the viral transmission.
She should be advised to avoid further contact as she is a teacher,she is more susceptible and should liaise with the occupational health.
As she is 18 weeks she should be counselled about the fetal varicella syndrome and referrral to the fetal medicine unit at 23 weeks for detailed scan for detailed anamoly scan.The risk is small if the anamoly scan is normal.Fetal VZ DNA may not be essential if the scan is normal and should discuss the risk of miscarriage associated with amniocentesis.
The fetal varicella syndrome involves skin scarring,microophthalmia,cataract,microcephaly and hypo plasia of limbs.The risk of miscarriage is not increased
She should be started on 800 mgs 5 times daily oral acyclovir after discussing with the virologist.she should be adviced about avoiding contact for 5 days(until the vesicles crust) and report if any chest infection or neurological signs develops.

Posted by Dr seema jain J.
Thu Jan 10, 2008 04:04 pm
a). The risk of the ?varicella syndrome? to the fetus depends on the weeks of pregnancy when the mother was exposed to chicken pox so I would inquire as to how many weeks of gestation is she. It is important to know whether the mother had chickenpox in childhood so as to know her susceptibility status . I would want to know the exact timing of contact ? whether it was before the vesicles erupted or after.It is important to find out whether the mother is a chronic smoker since this may imply that the woman may hospitalization to prevent complications like pneumonia, hepatitis or hematological sequelae. I would inquire whether this was the first exposure in pregnancy to chickenpox and if she had taken VZIG for the same. (VZIG may need to be repeated if it was taken more than 3 weeks before).

b). If the mother is immune to varicella (positive VZIG antibodies) then she can be reassured that she and her baby are safe. If the mother is susceptible and presents before she has developed chickenpox then VZIG should be given. It can be given upto 10 days after contact and the mother should be treated as potentially infectious for the next 8-28 days. The mother should be referred to fetal medicine specialist for detailed ultrasound at 16-20 weeks(or 5 weeks after the exposure) to check for varicella syndrome. If there was a previous exposure to chickenpox for which VZIG was taken 3 weeks back, then VZIG may need to be repeated.
If the immunity status of the mother is not known, then it is reasonable to await the serology result (shout be available in 24-48 hours) and manage accordingl to the serology report. Oral acyclovir in the dose of 800 mg five times a day can be given to the mother (after counseling) if she has contracted chickenpox after 20 weeks of gestation and if she presents within 24 hours of exposure.Intravenous acyclovir and hospitalization is indicated if the mother develops chest pain, jaundice, haemorrhagic rash, etc.
Hospitalization is also indicated if she is a chronic smoker. If chickenpox is contracted at term, delivery should be delayed for 5-7 days to prevent neonatal complications. Appropriate treatment should be decided in consultation with fetal medicine specialist, neurologist and neonotologist.
c) The woman should be advised to remain away from potential susceptible contacts especially other pregnant women and neonates. Varicella in pregnancy is associated with increased maternal complications like pneumonia, hepatitis and hematological problems and hence the mother should report immediately if she develops chest pain, jaundice, or a hemorrhagic rash. If the mother has been a chronic smoker she should be hospitalized. VZIG is also not recommended since she has already contracted chickenpox..I would advise the GP to notify this case to the registry.
The mother needs to be reassured that though the risk of ?varicella syndrome? in the baby is highest if chickenpox is contracted before 20 weeks of gestation,it is actually only about 0.9-1%. The mother should be referred to a fetal medicine specialist for detailed anomaly scan after five weeks of the infection.MRI Brain to detect neurological complications may be helpful. Amniocentesis for PCR for VZV DNA can be offered,but the presence of VZV DNA does not mean that the baby will have varicella syndrome.A normal ultrasound and a negative amniotic fluid VZV DNA indicates a very low risk of intrauterine infection.Oral acyclovir is not recommended in this case since its risks to the baby before 20 weeks are not known. Management should be undertaken in consultation with a fetal medicine specialist, urologist and neonotologist.
Posted by Dr seema jain J.
Thu Jan 10, 2008 04:05 pm
a). The risk of the ?varicella syndrome? to the fetus depends on the weeks of pregnancy when the mother was exposed to chicken pox so I would inquire as to how many weeks of gestation is she. It is important to know whether the mother had chickenpox in childhood so as to know her susceptibility status . I would want to know the exact timing of contact ? whether it was before the vesicles erupted or after.It is important to find out whether the mother is a chronic smoker since this may imply that the woman may hospitalization to prevent complications like pneumonia, hepatitis or hematological sequelae. I would inquire whether this was the first exposure in pregnancy to chickenpox and if she had taken VZIG for the same. (VZIG may need to be repeated if it was taken more than 3 weeks before).

b). If the mother is immune to varicella (positive VZIG antibodies) then she can be reassured that she and her baby are safe. If the mother is susceptible and presents before she has developed chickenpox then VZIG should be given. It can be given upto 10 days after contact and the mother should be treated as potentially infectious for the next 8-28 days. The mother should be referred to fetal medicine specialist for detailed ultrasound at 16-20 weeks(or 5 weeks after the exposure) to check for varicella syndrome. If there was a previous exposure to chickenpox for which VZIG was taken 3 weeks back, then VZIG may need to be repeated.
If the immunity status of the mother is not known, then it is reasonable to await the serology result (shout be available in 24-48 hours) and manage accordingl to the serology report. Oral acyclovir in the dose of 800 mg five times a day can be given to the mother (after counseling) if she has contracted chickenpox after 20 weeks of gestation and if she presents within 24 hours of exposure.Intravenous acyclovir and hospitalization is indicated if the mother develops chest pain, jaundice, haemorrhagic rash, etc.
Hospitalization is also indicated if she is a chronic smoker. If chickenpox is contracted at term, delivery should be delayed for 5-7 days to prevent neonatal complications. Appropriate treatment should be decided in consultation with fetal medicine specialist, neurologist and neonotologist.
c) The woman should be advised to remain away from potential susceptible contacts especially other pregnant women and neonates. Varicella in pregnancy is associated with increased maternal complications like pneumonia, hepatitis and hematological problems and hence the mother should report immediately if she develops chest pain, jaundice, or a hemorrhagic rash. If the mother has been a chronic smoker she should be hospitalized. VZIG is also not recommended since she has already contracted chickenpox..I would advise the GP to notify this case to the registry.
The mother needs to be reassured that though the risk of ?varicella syndrome? in the baby is highest if chickenpox is contracted before 20 weeks of gestation,it is actually only about 0.9-1%. The mother should be referred to a fetal medicine specialist for detailed anomaly scan after five weeks of the infection.MRI Brain to detect neurological complications may be helpful. Amniocentesis for PCR for VZV DNA can be offered,but the presence of VZV DNA does not mean that the baby will have varicella syndrome.A normal ultrasound and a negative amniotic fluid VZV DNA indicates a very low risk of intrauterine infection.Oral acyclovir is not recommended in this case since its risks to the baby before 20 weeks are not known. Management should be undertaken in consultation with a fetal medicine specialist, urologist and neonotologist.
Posted by PAUL A.
Thu Jan 10, 2008 09:55 pm
The additional information which I need to know is how many weeks pregnant she is (1) and secondly whether she had history of chicken pox infection in the past (1) .If she doesnot remember previous exposure or unsure about it then duration of contact (1) and nature of contact with the pupil and infectious state of pupil is important (1) as infectious state is 48 hours before eruption of rash till vesicle crusts off.
If there is significant contact and to cofirm immunity ,varicella IgG in maternal serum should be checked.If she is IgG positive she can be reassured (1) about immunity as 90% of pregnant females are varicella immune.If her IgG comes negative ,she should be advised to avoid contact with other pregnant ladies and neonates (1) upto 4 weeks after contact and can be offered immunoglobulins ? VZIG? Immunoglobulin is a different drug witin 24 hours of exposure(effective upto 10 days) .IgM should be checked after 3 weeks of exposure to detect seroconversion (1) or infection.She should be advised to contact GP in case of rash or pyrexia or other symptoms.
She should be given oral acyclovir should be discussed with consultant in infectious diseases / obstetrician to reduce the severity of symptoms after proper counselling as acyclovir before 20 week gestation is associated with theoretical risk of teratogenicity the risk is only in the first trimester .she should be given symptomatic treatment in form of antipyretics,antihistamines with hygiene advice to prevent superadded bacterial infection (1) . Varicella infection is associated with maternal mortality of upto 6% in pregnant females mainly due to complication of pneumonia,encephalitis and hepatitis (1) .History of smoking , chronic obstructive lung disease or corticosteroid treatment read the question ? HEALTHY woman in past 3 months need assessment in hospital as these lead to increased risk of complicating pneumonia which sometimes need ventilation.She should be advised to contact hospital immediately if she develops cough ,neurological symptoms or haemorrhagic rash (1) Are you advising the GP or the patient? as any of these needs immediate admission in isolation and intravenous acyclovir treatment under multidisciplinary care of chest physician,virologist ,obstetrician and ITU physician. She should be advised to avoid contact with other pregnant women and neonates till vesicle crusts off (1) .She should be informed about 1% risk of fetal congenital varicella syndrome before 28 weeks gestation (1) and associated with skin scarring ,limb hypoplasia,cataract and microcepahly.There is no role of immunoglobulin once rash appeared.She should be offered detailed anomaly scan at 23 weeks (1) gestation (5 weeks after infection). Amniocentesis for detection of viral DNA is associated with miscarriage rate of 1% above background and this should be balanced against 1% risk of congenital varicella syndrome and proper counselling needed does amniocentesis diagnose congenital varicella syndrome? Presence of virus (exposure) does not = infection which does not = affected . Once infectious state is over ,she can be managed as normal pregnancy and routine antenatal care given and .After delivery neonate ophthalmic examination should be done.
Posted by PAUL A.
Fri Jan 11, 2008 01:36 am
ADDITIONAL INFORMATION;
Chicken pox is due to varicella zoster virus which is herpes virus group infection is by droplet infection or direct contact with with the rash the incubation period is about 14 to 21 days period of infectivity is 2 days before appearance of rash till crustation of rash i.e.about 5 days of eruption. this is not answering the question
INtially,I will ask about gestational age (1) and if early dating scan done or not why? .
The time of exposure is requested (1) for further management, is it less than or more than 10 days in case of prescribing VZIG if patient is non immune and VZIG not detected and exposure within 10 days ? meaning?? Poor English .
The duration of exposure for how long poor English ?is it in open or closed place? what difference does it make? exposure for 15 minutes is significant. is contact with vesicles for less than 15 mins not significant?
The history of previous chicken pox (1) ,if begin new sentence with upper case letter positive history just reassurance is warrented.
If negative history or woman not sure ,further investigation is requested
you were asked about information, NOT what you will do with the information. You are almost certainly going to repeat yourself .
Past medical history , if taking any medication especially corticosteriods.
Enquiry about smoking any chest problemas
read the question - HEALTHY chicken pox may be complicated with pneumonia which will be associated with maternal morbidity and mortality.
2.Mangement option;
Mangement will depend on previous assessment,if woman gave history of chicken pox before I would reassure her CONFIRM BY TESTING FOR IgG .
If no history of chicken or not sure ,I would check her VZIG VZIG = varicella zoster immune globulin; it is NOT varicella zoster IgG status,IF positive reassure her (1) ,if negative give VZIG if exposure within 10 days after proper counselling as it is a blood product (1) however the risk of infection with blood products transfion is markedly reduced ,also I would tell her that incubation period after VZIG will be prolonged 21to 28 days vs.14 to 21 days.
Reduced risk of transmission of infection to other pregnant women or non immune persons at risk of infection as medical staff ,avoid antenatal visits in maternity units ,in case of need to hospital referal should be in infection isolation unit poor English .
Women to be advised to report any symptoms suggestive of chicken pox as flue like symptos,fever ,rashwhich will be vesicular rash on an erythematous base.
3.Devolped chicken pox ,
I would advise the G.P.to counsell the women properly regarding risk of ? fetal varicella zoster syndrome {limb hypoplasia,skin scarring,dysfunction of bladder and bowel sphincters,eye effectsas microophthalmia and also CNS FEATURES AS MICROCEPHALLY AND CERebral atrophy}which affect 1 to 2% so patient should be booked for detailed anomaly scan at 22 weeks gestationor 5 weeks after devolping chicken pox (1) .
Acyclovir can be used for treatment of chicken pox,however ,with caution what does caution mean? Should the GP prescribe it?? as still 18 weeks pregnant and usually it is used after 20 weeks also not licensed for use in pregnancyand after proper counselling.
Hospital referal,if patient devolped haemorragic rash ,any neurological symptoms,chest symptoms (1) ,smooker (1) or on corticosteriod therapy healthy as risk of pneumonia will increase which associated with high morbidity and mortality.
Avoid contact with other pregnant women ? neonates ,
the period of infectivity is 2 days before eruption of rash and 5 days after i.e. after crustation.
Proper conselling , documentation nd communication with patient so she can easily contact her G.p.
Back up with information leaflet.
Termination of pregnancy is not advised as VZS affect only 1 to 2% however patient wishes should be considered.
Multidisciplinary team G.P.obstetrician ,midwive,chest physcian. this is not a sentence ? the examiner is not looking for key words or phrases

You need to improve your English and focus on the question asked
Posted by PAUL A.
Fri Jan 11, 2008 02:06 am
(a) What additional information would you request from the general practitioner? [4 marks]
Varicella (VZV) in pregnancy may cause maternal mortality or serious morbidity is this what you will ask the GP? .it may also cause fetal varicella syndrome. I would ask the Gp more information to assess the risk of of her potential varicella exposure, firstly weather she had significant contact (Contact in the same room 15 min or more or face to face contact) (1) with infected individual.Varicella can infect even 2 days before rash develop therefore information of the period of infectiousness (48 hrs before rash until vesicle crust over) is vital (1) . Also I would ask details of exposure including the timing of exposure (1) , type of VZV How many types are there? . Gestation gestation means pregnancy ? you want gestation age of pregnancy is important for futher management and risk assessment.; previous history of chicken pox (varicella) (1) is a valuable information .I would also inquire any h history of smoking and chronic obstructive airway disease.and state of immunsupressed (steroid treatment) HEALTHY woman

b) What are the management options in this case? [5 marks]
Management optionsdepends on varicella immunity sate of the patient.
if this lady had chicken pox in the past and ,Blood test for Varicella IgG and confirm immunity (1) ( over 90% of antenatal population are seropositive for varicell zoster IgG.)She can be reassured and no further investigations needed.. Once IF Varicella IgG negative varicella immunoglobulin is recommended which is effective if it is given 10 days of after contact poor English . She should be managed as potentially infectious even for 8- 28 days after Varicella Ig G administration Also she should report to Gp once if she delelop rash even if she had IgG. contact with . Susceptible individual (Pregnant mothers and neonates) should be avoided (1) .
If she is going to have seroconversion or develop chicken pox the risk of congenital varicella syndrome is 1% if she is is < 28 wks gestation and very rare after 28 weeks She should have proper counselling need referral for detailed Uss at 16-20 wks or 5wks after infection.

(c) Four weeks later, you are telephoned again because the woman has now developed chickenpox at 18 weeks gestation. How would you advise the GP?[11 marks].
Aim of the management of chicken pox to prevent complications and to avoid infection to susceptible individuals
Patient should be managed at home unless any potential complications relate to varicella or if she is high risk for varicella pneumonia . (Smoking, immunosupressed, COPD) healthy woman
Hospital admission and assessment should be considered if she has any risk factors to develop complications. As supportive measures symptomatic treatment such as analgesics and antipyretics can be prescribed. Personal hygiene is important to prevent secondary bacterial infections (1) .
Varicella Ig G has no benefit as she has developed chickenpox.
Oral acyclovir reduces the fever and symptoms of VZV infection in immunocompetent adults.
Acyclovir should be cautiously used before 20 wks gestation if she present within 24 hrs onset of rash.She should be informed benefit and risk of acyclovir if it is prescribed what does cautiously mean? Should the GP prescribe it or not? . However as she is 18 wks, there is no risk for tetratogenesis and Acyclovir doesn?t cause fetal anomalies.
Excess morbidity associated with varicella infection in adults including pneumonia , hepatitis and encephalitis (1) .
She should be warned regarding Symptoms of complications of VZV infection , Immediate to hospital referral needed if she develop chest symptoms, neurological symptoms haemorrhagic rash or bleeding .Once she hospitalised for either high risk or managing complications of VZV she should be isolated from potential susceptible individuals (pregnant mothers, neonates and non immune staff) until vesicles crust over your English is poor, making comprehension difficult .
Mannegent would be multi disciplinary settings. Involving Respiratory physician, Obstetrician, Virologist and neonatologist why are you telling the GP this?? .
Information leaflets and contact details of support group do you know any support groups? should be given.Counselling should be arranged regarding the risk for the baby fetal varicella syndrome what is this? which is 1%risk .Amniocentesis is not routinely adviced because the fetal varcella syndrome is so low even when amniotic fluid positive for VZV DNA. Referral to fetal medicine specialist can be should be arranged Prenatal diagnosis possible using detailed USS 5wks afterprimary infection ( at 23 wks) (1) when findinggs such as microchephaly, Hydrocephalus , soft tissue calcification and IUGR identified.Counselling should be backed up by written information and support group details.

You have lost at least 5 marks because or poor / careless language and a failure to focus on the question. You need to write in complete and grammatically correct sentences.
Posted by PAUL A.
Fri Jan 11, 2008 03:06 am
A] we ask the GP if she had previous infection (1) as she will be considered immunized.
We also ask if she is vaccinated before because vaccination can give protection up to 20 years post vaccination.

We inquire about significance of contact, 15 minutes in same room or face to face contact, however, the UK advisory Group of chicken pox consider any contact as being significant (1) . We also ask about duration since contact (1) because the incubation period is about 1-3 weeks and she may already report her exposure after that time without evidence of infection.

B] If she gives certain history of previous infection or immunization , we consider her immunized and she will need only reassurance good practice to test for IgG . If she is not sure , we advise for serum immunoglobulin what does this mean? Administer or test?? . If IgG is positive, we consider her immunized also and reassure her (1) .
If IgM is positive , this mean she got the infection and should be treated with antiviral drugs according to her gestational age.
If both of them are negative it means that she is susceptible and she should receive VZIG and IgM titer should be repeated after 3 weeks (1) to detect the disease.

C] We Tell the GP to advice her to avoid contact with our susceptible persons like pregnant ladies or neonates (1) .
We advice him to prescribe supportive measures and give advice about hygiene to prevent secondary bacterial infection (1) .
We tell the GP that acyclovir is given to patient more than 20 weeks gestation if present within 24 hours from developing the rash, however, it can be prescribed earlier after counseling the patient about benefits and risks of it how will the GP know what the benefits and risks are? , aciclovir is given orally 800 mg X 5 for 7 days, it can reduce severity and duration of fever very long sentence .
However, there is theoretical risk of teratogenisity if it is given early in pregnancy ? relevance ? she is 18 weeks pregnant .
We advice the GP to refer her for inpatient management if she had chest symptoms as there is 10 % risk of varicella pneumonia which can be serious and fatal (1) .
Admission is required also if she is smoker (1) , if she had neurological symptoms or if her rash is dense and heamorrhagic (1) , because there is risk of thrombocytopenia.
We advice also that this patient should have a multidisciplinary team work care including virologist, fetal medicine specialist, neonatologist, senior obstetrician and anaesthetist.
The risk of developing fetal varicella syndrome is 1%, so we advice the GP to refer her for detailed scan at 22 weeks gestation (1) to detect limb hypoplasia or neurological defects like microcephaly, cortical atrophy or fetal calcifications, although this is unlikely because FVS is usually result from reactivation of the virus and not at the initial infection why does this make FVS unlikely? It is precisely for this reason that the scan is done 5 weeks later .
We advice also for serial growth scan from 28 weeks gestation ? why , fortnightly to detect intrauterine fetal growth restriction.
The patient should get verbal and written information about the disease and its consequences and get arrangement for follow up appointment.
Posted by PAUL A.
Fri Jan 11, 2008 03:17 am
a) I would ask when and how long was she in contact with the pupil. Also, was she in direct physical contact with him. Did she have chickenpox in the past (1) or was she vaccinated against it. I would also like to know her gestational age (1) .

b) If this lady has had chickenpox in the past or received a vaccine against it, then nothing needs to be done, since she would have antibidies against the varicella zoster virus, the causative organism of chickenpox guidelines suggest confirm by testing for IgG. Vaccination does not result in life-long immunity .
If she does not have a history of chicklenpox, then she should have a blood test for the presence of varicella zoster virus immunoglobulin antibodies (1) immunoglobulins are antibodies . If there are no antibodies, then she should be given the varicella zoster virus vaccine NO ? SHE SHOULD NOT BE VACCINATED (-2). She should be counselled and offered VZ immune globulin . If the test shows antibodies, then she does not need the vaccine.

c) Chickenpox is very contagious and harmful to other pregnant women and their fetuses. Therefore, this lady should not be around pregnant women or children (1) . She should not attend the antenatal clinic. If ward admission is needed she should be cared for in an isolated room. Chickenpox can cause both maternal and fetal morbidity. Therefore, it should be treated immediately with acyclovir discuss with consultant in infectious diseases / obstetrics . There is a risk that the mother may develop pneumonia and any symptoms of pneumonia such as cough and difficulty breathing should be reported immediately. Hospitalisation and a course of antibiotics would be required what is the value of antibiotics in a woman with a viral illness? . She should also be aware that she is at risk of hepatitis and encephalitis.
During the pregnancy , serial ultrasound scans should be done to identify growth restriction and microcephaly which can be caused by chickenpox. A normal delivery can be performed. Postnatally, the neonate will be reviewed by the neonatologist is this what you will tell the GP over the phone? . There is a small chance what is small? 0.001% or 10%? that the infant may develop fetal varicella syndrome.

See NOTES > INFECTIONS IN PREGNANCY > VARICELLA
Posted by PAUL A.
Fri Jan 11, 2008 04:06 am
a)I\'d like to ask him about the details which details? of contact and previous history of chickenpox
with particular respect to the certainty of infection , infectiousness it is not clear what you are asking the GP, and degree of exposure. ? meaning
An important question , must be the time of exposure to the infected child does this mean for how long or when? If you ask ambiguous questions, there is a potential for wrong decisions . The pupil is infectious 48 hrs before appearance of rash until vesicles crust over.
The susceptibility of the teacher should be determined . If there is a definite past history of
Chickenpox (1) , it is an indicator of her immunity.
If there is uncertainty or no previous history of chickenpox , she is at risk of catching the infection.
b) If the teacher has had chickenpox in the past , serum should be checked for IgG to confirm the immunity (1) . The pregnancy is allowed to continue without any further intervention.
If IgG is negative ,she should be given VZ immunoglobulin ( VZIG) as soon as possible should be counselled as value depends on gestation age . It is effective if given up to 10 days after contact. A second dose of VZIG should be as administered ,if further exposure reported and three weeks had passed after the last dose.
The woman should be asked to notify her Doctor early if rash develops. VZV IgM should be checked 3 weeks after exposure to detect seroconverion (1) . If she develops rash , fever , malaise ,she should immediately to contact her Doctor. c) She should be advised to avoid contact with other susceptible individuals , such as other pregnant women and neonates (1) , until the five days after the onset of rash or the lesions have crusted over. Symptomatic treatment and hygiene should be advised to prevent secondary bacterial infection of the lesions (1) . Oral Aciclovir if she presents within 24 hrs of the onset of the rash. Dose of Aciclovir is 800 mg( 5 times a day)for 7 days. Informed consent should be obtained from the patient ? meaning? Should she sign a consent form? .There is no associated fetal anomalies,although there is therotical risk of teratogenicity in the first trimester ? relevance ? she is 18 weeks . Aciclovir reduces the duration of fever and symptoms of varicella. The woman should be counselled about the risk of fetal varicella syndrome 1% (1) ,and informed about the implications . FV Syndrome consists of skin scarring , limb hypoplasia ,eye defects and neurological abnormalities.
The woman should be referred immediately to the hospital if she developed chest symptoms , neurological symptoms , haemorrhagic rash , dense rash with or without mucosal bleeding (1) . Intravenous acyclovir ( 10 mg /kg b.wt tds) should be used if varicella pneumonitis develops or evidence of disease progression.Appropriate treatment should be decided by obstetrician , virologist and neonatologist, and respiratory physician why are you telling this to the GP? .
She should be nursed in isolation from the pregnant women and neonates .Detailed ultrasound examination should be considered why considered? What are the circumstances when it should not be recommended? five weeks after infection. Neonatal ophthalmic examination should be organized after birth.

You were not asked about the management of chickenpox in pregnancy. You were asked to give advice to a GP over the phone.
Posted by Lekshmi B.
Fri Jan 11, 2008 04:19 pm
a) I will ask the GP whether she has a previous history of chickenpox infection,to know if she is susceptible.The timing of contact will be asked since the risk of infection is maximum within 2 days before the onset of rash and till the lesions have crusted over.The type of varicella infection will also be noted as varicella Zoster in unexposed area is unlikely to be infective.Duration and type of exposure is also important as face to face contact,contact more than 15 minutes are considered significant risk.Time since exposure will also be asked to plan management. b)If there is history of previous infection,she is likely to be immune hence reassured.If no history or uncertain historyblood serology is done for VZ antibodies. If negative for Ab and there is significant exposureVZ Immunoglobulin(Ig)has to be given provided less than 10 days have elapsed since exposure.The patient should be treated as potentially infective for 8- 28 days after treatment and advised to avoid contact with other susceptible pregnant women.Whether or not she has received IG she has to report at the earliest to the doctor or midwife if she develops rash. c)GP will be told that out patient management is sufficient in most cases.Aciclovir is better avoided at 18 weeks due to the theoretical of fetal damage.Developement of chest symptoms,neurological symptoms, haemorrhagic rash or bleeding or dense rash are indications for referral to hospital. Similarly history of smoking, COPDand steroid therapy also need assesment in hospital.The patient should also be told of the risk of Fetal varicella syndrome (FVS ) which is characterised by cutaneous scarring,limb hypoplasia,ocular and neurological manifestations.Prenatal diagnostic options are available.This would include a detailed ultrasound scan in fetal medicine unit for evidence oflimb and cerebral anomalies.Amniocentesis is another option but detection of VZ DNA does not imply FVS.Negative USS and negative Amniocentesis almost rules out FVS.Positive amniocentesis and positive USS findings increase the risk of FVS hence termination of pregnancy can be offerd.Positive amniocentesis with negative USS requires a follow up USS after 3-4 weeks and if still normal the risf of FVS is low.
Posted by PAUL A.
Sat Jan 12, 2008 04:49 am
a) Past history of chicken pox is important as majority what is majority? 52%? What about the rest who are not immune? of such patients have immunity against VZV and are not at increase risk. Duration and extent of contact is important as contact within the same room for 15 minutes and face to face contact is significant for transmission (1) . History of varicella zoster vaccination should be obtained as it may prevent development of maternal and fetal varicella. The GP should also be inquired about a serum examination for IGG and IGM antibodies for varicella.

b) Management depends upon the immune status how will you know her immune status? of the patient. If the patient is immune reassurance should be provided and the woman should be advised to avoid contact with other pregnant woman why? If she is immune, she cannot get the disease therefore cannot transmit it . If the patient is susceptible how will you know if she is susceptible? IgG negative she should be counselled given VZIG within 10 days of exposure. However the rate of prevention of fetal varicella syndrome is unknown as the incidence itself is very low. Inspite of giving VZIG some women do develop primary chicken pox ?? do you get secondary chickenpox? and are infectious for 8-28 days after administration. Patient should avoid contact with other pregnant women and should contact immediately with health care staff once the rash develops. A second dose of VZIG may be required after 3 weeks.

c) The GP should be advised about the higher complication rates of chicken pox in pregnancy like pneumonia, hepatitis and encephalitis (1) . The patient who are smokers have chronic obstructive lung disease, are on corticosteroids and are immunocompromised read the question - HEALTHY , and are in the late stage of pregnancy she is 18 weeks ? answer the question asked have higher chances of developing complications of chicken pox so they should be referred earlier for hospital care.
A detailed ultrasound after 5 weeks of infection she is not going to have the infection for 5 weeks is recommended to detect fetal varicella syndrome.
The woman is infectious from 48 hours before the appearance of rash and upto 5 days up to 5 days from when? (scab formation) so she should avoid contact with other pregnant women.
Treatment with acyclovir is given within 24 hours of onset of rash.
Acyclovir should be given with caution before 20 weeks what does this mean to the GP? .
Symptomatic treatment with analgesics and antipyretics and advice for general hygiene and prevention of secondary infection should be given (1) .
Woman should be reassured that varicella infection does not increase the risk of miscarriage.
Woman should be informed that the prenatal diagnosis of fetal varicella syndrome is possible through ultrasound and amniocenteces what is the role of amniocentesis? Exposure to virus does NOT = infected which does not = affected however it is not recommended ad routine due to lower incidence (1%) of FVS.
Pt should be provided with written information.
You need to answer the precise question asked rather than just present general information. More careful use of language will result in less ambiguous statements
Posted by PAUL A.
Sat Jan 12, 2008 05:08 am
a)I would ask if the woman remembered having chicken pox in the past because she may be immune (1) . If unknown I would find out the interval between exposure and presentation to the GP since the incubation period of the virus is 1-3weeks.
I would ask about the type of varicella zoster infection as this may be a primary VZV infection in the pupil the pupil has chickenpox ? this is always a primary infection . The timing of the exposure would determine if this exposure may be associated with the period of high infectivity . This is the period from 48h before the rash appears and up to 5days later when vesicles are crusting over (1) . The closeness and the duration of contact as contact in the same room for 15minutes or more, or face-to-face contact increases the risk of infection (1) . I would also ask the gestational age of the pregnancy (1) . There is a risk of fetal varicella syndrome if infection occurs in the first 28 weeks of pregnancy or varicella infection of the newborn if infected at term. I would also find out if the patient is from overseas as as she is more likely to be non immune.

b)If the patient has had a previous infection, I would re-assure she is immune confirm by testing for antibodies . She?s more likely to have an uncomplicated pregnancy does exposure to chickenpox make it more likely that she will have an uncomplicated pregnancy??? .
If there was no previous infection, I would check her VZVIgG antibody from her booking blood and if this is positive, it show?s she?s immune. I would reassure her (1) .
If her VZVIgG is negative, suggesting she?s not immune and she has had significant exposure, I would counsel offer her VZIG. This prevents or attenuates the disease in pregnancy . It is effective when given up to 10days after contact. I would manage her as potentially infectious until 28days after VZIG so what will you do differently? . I would advice her to notify her GP or midwife early if she develops a rash. She may be offered a second dose of VZIG if a further exposure is reported and 3weeks have elapsed since the last dose.

d)She requires multidisciplinary care involving the GP, midwife, obstetrician and fetal medicine specialist. She should promptly be seen by the GP or midwife and avoid contact with other susceptible individuals like pregnant women and neonates until the lesions has crusted over (1) . This takes about 5days after the onset of the rash. The GP should offer her symptomatic treatment and advice on hygiene to prevent secondary bacterial infection of the lesions (1) . Oral acyclovir is not recommended for use below 20weeks because of the small risk of teratogenesis in the first trimester she is 18 weeks .
She should be referred to the hospital if develop signs of complications like chest or neurological symptoms, haemorrhagic rash or bleeding (1) . If admitted, she should be nursed in an isolation ward from babies, or potentially susceptible pregnant women or non-immune staff why are you telling the GP? .
The patient should be informed there is no increased risk of spontaneous miscarriage. There is a small risk of fetal varicella syndrome what is small? 0.001%? and this can be diagnosed prenatally. She would require referral to a fetal medicine specialist for discussion and a detailed anomaly scan about 5weeks post infection (1) . The mother should be aware that if the fetus is not affected at this stage, she can be reassured the fetus most likely would be normal. The fetus would also be protected from the passively acquired antibody from the the mother.
Posted by PAUL A.
Sat Jan 12, 2008 05:43 am
I would like to know the gestational age of the patient (1) ,how long ago was she in contact and the duration?Would also like to know if she had chicken pox in the past (1) or if she has developed any rash?Obtain history of smoking and chronic cough or lung disease is paramount? healthy. Why the (?) at the end of the sentence? It is not a question.
presume this is part (b) If the women has had chickenpox in the past then she is immune and she needs no further interventions. Emphasis on reporting if any rash develops why should she develop a rash if she is immune? .
If not immune or not sure then take bloods for varicella zoster antibodies within 24-48hrs. If susceptible which result will indicate susceptibility? varicella Zoster immunoglobulins needs administering within 10 days after liasing with the virologist counsel and offer .Advice on avoiding contact with other pregnant women and neonates for 4 weeks (1) .
If any rash develops and is <28 weeks gestation she needs referral to the fetal medicine unit after 5 weeks.She should be counselled about risk of fetal varicella syndrome.She needs detailed anamoly scan, fetal VZ DNA WHY? Not necessary after counselling.
If >28 weeks then risk of fetal varicella syndrome is small how small? There is no risk after 28 weeks .
If rash develops within 4 weeks of delivery and 7 days after delivery there is >50% risk of neonatal varicella syndrome.Baby needs varicella immunoglobulins and serum for antibodies at birth and at 7 months of age.
If she develops chest infections(pneumonitis),she need admission in the hospital for intravenous acyclovir and defer delivery for atleast 7 days to reduce the viral transmission.
Presume this is part (c ) She should be advised to avoid further contact with who as she is a teacher, she is more susceptible ? meaning and should liaise with the occupational health.
As she is 18 weeks she should be counselled about the fetal varicella syndrome and referrral to the fetal medicine unit at 23 weeks for detailed scan for detailed anamoly scan (1) .The risk is small if the anamoly scan is normal.Fetal VZ DNA may not be essential if the scan is normal and should discuss the risk of miscarriage associated with amniocentesis.
The fetal varicella syndrome involves skin scarring,microophthalmia,cataract,microcephaly and hypo plasia of limbs.The risk of miscarriage is not increased
She should be started on 800 mgs 5 times daily oral acyclovir after discussing with the virologist.she should be adviced about avoiding contact contact with what / who?? for 5 days(until the vesicles crust) and report if any chest infection or neurological signs develops.

It is not clear where the different parts of your answer start / stop. You were asked specific questions but you have made little attempt to address these questions.
Posted by Paul T.
Sat Jan 12, 2008 03:20 pm
a). The risk of the ?varicella syndrome? to the fetus depends on the weeks of pregnancy when the mother was exposed to chicken pox so I would inquire as to how many weeks of gestation is she (1) . It is important to know whether the mother had chickenpox in childhood what if she had chickenpox as an adult? so as to know her susceptibility status . I would want to know the exact timing of contact ? whether it was before the vesicles erupted or after how does this matter? The disease is infectious before and after vesicles have errupted .It is important to find out whether the mother is a chronic smoker since this may imply that the woman may hospitalization to prevent complications like pneumonia, hepatitis or hematological sequelae. I would inquire whether this was the first exposure in pregnancy to chickenpox and if she had taken VZIG for the same. (VZIG may need to be repeated if it was taken more than 3 weeks before).

b). If the mother is immune to varicella (positive VZIG antibodies) VZIG is a drug ? varicella zoster immune globulin then she can be reassured that she and her baby are safe. If the mother is susceptible how will the examiner know that you know which antibody profile indicates susceptibility? and presents before she has developed chickenpox then VZIG should be given correct - see comment above Re: VZIG . It can be given upto 10 days after contact and the mother should be treated as potentially infectious for the next 8-28 days. The mother should be referred to fetal medicine specialist for detailed ultrasound at 16-20 weeks(or 5 weeks after the exposure) to check for varicella syndrome. If there was a previous exposure to chickenpox for which VZIG was taken 3 weeks back, then VZIG may need to be repeated. you have written this before
If the immunity status of the mother is not known, then it is reasonable to await the serology result you have not written anywhere that you will do any test (shout be available in 24-48 hours) and manage accordingl to the serology report. Oral acyclovir in the dose of 800 mg five times a day can be given to the mother (after counseling) if she has contracted chickenpox after 20 weeks of gestation and if she presents within 24 hours of exposure.Intravenous acyclovir and hospitalization is indicated if the mother develops chest pain, jaundice, haemorrhagic rash, etc.
Hospitalization is also indicated if she is a chronic smoker. If chickenpox is contracted at term, delivery should be delayed for 5-7 days to prevent neonatal complications. Appropriate treatment should be decided in consultation with fetal medicine specialist, neurologist and neonotologist
you were not asked about the management of a woman with chickenpox. You were asked about management option in a woman who has been in contact with chickenpox. You will be writing most of this again in (c ). If you had written an answer plan, you will have recognised the duplication .
c) The woman should be advised to remain away from potential susceptible contacts especially other pregnant women and neonates (1) . Varicella in pregnancy is associated with increased maternal complications like pneumonia, hepatitis and hematological problems and hence the mother should report immediately if she develops chest pain, jaundice, or a hemorrhagic rash (1) . If the mother has been a chronic smoker she should be hospitalized (1) . VZIG is also not recommended since she has already contracted chickenpox..I would advise the GP to notify this case to the registry which registry?? .
The mother needs to be reassured that though the risk of ?varicella syndrome? in the baby is highest if chickenpox is contracted before 20 weeks of gestation,it is actually only about 0.9-1% (1) . The mother should be referred to a fetal medicine specialist for detailed anomaly scan after five weeks of the infection five weeks after infection. She is not going to have the infection for five weeks . MRI Brain to detect neurological complications may be helpful why / how? . Amniocentesis for PCR for VZV DNA can be offered,but the presence of VZV DNA does not mean that the baby will have varicella syndrome. so what is the point in offering an invasive test that you know is of little use? (-1) A normal ultrasound and a negative amniotic fluid VZV DNA indicates a very low risk of intrauterine infection. Oral acyclovir is not recommended in this case since its risks to the baby before 20 weeks are not known are there any documented cases of adverse outcome? What about potential benefits? . Management should be undertaken in consultation with a fetal medicine specialist, urologist why?? and neonotologist.
Posted by Paul T.
Sat Jan 12, 2008 03:36 pm
a) I will ask the GP whether she has a previous history of chickenpox infection,to know if she is susceptible (1) .The timing of contact will be asked since the risk of infection is maximum within 2 days before the onset of rash and till the lesions have crusted over (1) . The type of varicella infection will also be noted as varicella Zoster in unexposed area is unlikely to be infective if a child has chickenpox, will the lesions be confined to specific parts of the body? .Duration and type of exposure is also important as face to face contact,contact more than 15 minutes are considered significant risk.Time since exposure will also be asked to plan management (1) . b)If there is history of previous infection,she is likely to be immune hence reassured confirm by testing for IgG .If no history or uncertain historyblood serology is done for VZ antibodies. If negative what if she is IgG positive? for Ab and there is significant exposureVZ Immunoglobulin(Ig) has to be given counsel and offer ? it does not have to be given provided less than 10 days have elapsed since exposure.The patient should be treated as potentially infective for 8- 28 days after treatment and advised to avoid contact with other susceptible pregnant women (1) .Whether or not she has received IG she has to report at the earliest to the doctor or midwife if she develops rash. c)GP will be told that out patient management is sufficient in most cases.Aciclovir is better avoided at 18 weeks due to the theoretical of fetal damage what could be damaged? .Developement of chest symptoms,neurological symptoms, haemorrhagic rash or bleeding or dense rash are indications for referral to hospital (1) . Similarly history of smoking, COPDand steroid therapy HEALTHY woman also need assesment in hospital.The patient should also be told of the risk of Fetal varicella syndrome (FVS ) which is characterised by cutaneous scarring,limb hypoplasia,ocular and neurological manifestations what is the risk? 10%?? .Prenatal diagnostic options are available.This would include a detailed ultrasound scan in fetal medicine unit for evidence oflimb and cerebral anomalies when should she be referred for the scan? . Amniocentesis is another option but detection of VZ DNA does not imply FVS so why do it? Why are you telling the GP? . Negative USS and negative Amniocentesis almost rules out FVS.Positive amniocentesis and positive USS findings increase the risk of FVS hence termination of pregnancy can be offerd.Positive amniocentesis with negative USS requires a follow up USS after 3-4 weeks and if still normal the risf of FVS is low why are you telling the GP? .
Posted by Reiaz M.
Sun Jan 13, 2008 08:56 pm
Chicken pox in pregnancy is associated with adverse fetal and maternal effects. In this patient who has been in contact with an affected child it is important to determine the degree of exposure that occured.
It is important to determine if the patient has had chicken pox in the past. The extent of exposure is also important and so the GP should ascertain the duration and proximity of the contact.
The disease is contagious for two days before the rash appears until the lesions crust over. It should be dtermined whether contact occured during this period.
It should also be determined whether or not the patient was previously vaccinated against chicken pox.

b)
The management of thius patient will depend on whether the patient is susceptible to infection or not.

If she has a history of chicken pox in the past she can be reassured that there is no risk of developing chicken pox in pregnancy. Although can develop shingles this poses no fetal risk.

If she is unsure as to whether she has had chicken pox in the past, antibody testing for chicken pox should be done. This can be done on previously stored maternal serum. Results may take between 3-5 days and no intervention is necessary during this time. If the results show that the patient is not immune then she should be counseled on administration of Varicella Zoster Immuno Globulin (VZIG). If she consents this should be administered.

Patients who have been exposed to chicken pox should be advised to avoid contact with other pregnant patients and immunocompromised individuals.


c) Chicken pox in pregnancy is associated with both maternal and fetal effects. However the majority of pregnancies affected by chicken pox will have no detrimental effects.

Contact with other pregnant patients and immunocompromised individuals should be avoided. This can be facilitated by home antenatal visits.

If the rash has developed within 24 hours aciclovir can be prescribed. The patient should be counseled on the possible benefits and the possible side effects of aciclvir in the 1st half of pregnancy. If she consents to its use aciclovir can be prescribed.

Patients should be advised on the use of emollients to aid with the pruritus. Calamine lotion can be applied. Oral antihistamines can be safely used to alleviate pruritus. Oral antibiotics may become necessary to avoid secondary bacterial infections of chicken pox lesions. Oral paracetamoil can be prescribed for associated fever if required.

The patient can be reassured that chicken pox is not associated with an increased risk of miscarriage. There is a risk of fetal varicella syndrome. This may result in limb hypoplasia, eye defects such as cataracts, neurological abnormalites and skin scarring in a dermatomal distribution. After the infective period is over this patient can be referred to a tertiary centre for further care. A detailed ultrasound scan should be done at 20 weeks to rule out any congenital abnormalities. Serial growth scans should be performed every 4 weeks to assess fetal growth parameters. Amniocentesis can be performed to assess the likelihood of inutero infection.

Maternal complications can icnclude hepatitis, encephalitis and pneumonia. Immunocompromised patients are at increased risk of these complications. Patients should have a baseline full blood count, renal function tests and liver function tests done. Patients who smoke are at increased risk of pneumonia and should be advised to stop smoking. Referral to hospital should be done if any signs or symptoms of complications develop. Patients referred to hospital should be kept quarantined from other patients. Intavenous aciclovir may be needed in management of these complications. Early referral to an anesthesist is necessary in cases of pneumonia as assisted ventilation may become necessary.

Posted by Reena M.
Sun Jan 13, 2008 10:13 pm
[a] I would like to get additional information regarding whether teacher had chicken pox or herpes zoster .in the past . I would like yo know her gestational age , whether she smokes. I would like to know if she is immnunocompromised or she on steroids for any reason .. Duration of contact is also important .
[b]Her immune status should be investigated Around 90 % of people are immune to chicken pox. IgG status should be done . IF she is IgG positive , she is immnue to chicken pox and she is reassured. If her IgG status is negative , she is susceptible to chicken pox infection and she should be offered VZIG within 96hrs of significant contact.It will protect aganist chicken pox , & decreases the severity .
[c]She is not to be followed in ANC clinic as she is infectious during vesicular stage , and should be seen in infectious disease clinic . inorder to minimse the transmission to other pregnant woman . Sympatamatic traetment incluiding antihistamines , antipyrectics , soothening agents like calamine lotion should be given . Acyclovir 500mg 4thrly x5days is given .Acyclovir decreaseas the severity of eruption and complication . If secondary infection of vesicle is seen antibiotics are to be given. .She should be advised to report for admission if there is hemorhagic rash, any neurologic symptoms , dysponea or cough or sever mucosl involvment
There is 10 % varicella pneumnia in pregnancy with 10 % moratlity , which needs in patient traetment with parentral acyclovir , respiartory support . Varicella pneumonia is more often seen in patient who smoke and are immnunocompromised.
Varicella affection in early pregnancy have fetal affection seen in 2% Hence she should be given appointment for detailed anomaly scan after 6 wks . Dermatologic scarring , limb affection , opthalmic involvement are seen .
Labor and delivery are expected to be normal as in unaffected pregnant ladies
After delivery , baby should be examined by pediatricain to rule out any congenital affection . She should be told . varicella infection produce life long immnunity
Posted by PAUL A.
Mon Jan 14, 2008 02:37 am
Chicken pox in pregnancy is associated with adverse fetal and maternal effects. In this patient who has been in contact with an affected child it is important to determine the degree of exposure that occured.
It is important to determine if the patient has had chicken pox in the past (1) . The extent of exposure is also important and so the GP should ascertain the duration and proximity of the contact (1) .
The disease is contagious for two days before the rash appears until the lesions crust over. It should be dtermined whether contact occured during this period (1) .
It should also be determined whether or not the patient was previously vaccinated against chicken pox.

b)
The management of thius patient will depend on whether the patient is susceptible to infection or not.

If she has a history of chicken pox in the past she can be reassured that there is no risk of developing chicken pox in pregnancy confirm by testing for IgG . Although can develop shingles this poses no fetal risk.

If she is unsure as to whether she has had chicken pox in the past, antibody testing for chicken pox should be done. This can be done on previously stored maternal serum. Results may take between 3-5 days and no intervention is necessary during this time. If the results show that the patient is not immune then she should be counseled on administration of Varicella Zoster Immuno Globulin (VZIG) (1) what if she is immune?. If she consents this should be administered.

Patients who have been exposed to chicken pox should be advised to avoid contact with other pregnant patients and immunocompromised individuals.


c) Chicken pox in pregnancy is associated with both maternal and fetal effects. However the majority of pregnancies affected by chicken pox will have no detrimental effects.

Contact with other pregnant patients and immunocompromised individuals should be avoided (1) . This can be facilitated by home antenatal visits.

If the rash has developed within 24 hours aciclovir can be prescribed. The patient should be counseled on the possible benefits and the possible side effects of aciclvir in the 1st half of pregnancy you are advising the GP ? what should he tell her bout benefits / risks? . If she consents to its use aciclovir can be prescribed.

Patients should be advised on the use of emollients to aid with the pruritus. Calamine lotion can be applied. Oral antihistamines can be safely used to alleviate pruritus. Oral antibiotics may become necessary to avoid secondary bacterial infections no indication for prophylactic antibiotics of chicken pox lesions. Oral paracetamoil can be prescribed for associated fever if required.

The patient can be reassured that chicken pox is not associated with an increased risk of miscarriage. There is a risk of fetal varicella syndrome what is the risk? . This may result in limb hypoplasia, eye defects such as cataracts, neurological abnormalites and skin scarring in a dermatomal distribution. After the infective period is over this patient can be referred to a tertiary centre for further care when??? . A detailed ultrasound scan should be done at 20 weeks no, 5 weeks after infection to rule out any congenital abnormalities. Serial growth scans should be performed every 4 weeks to assess fetal growth parameters why? . Amniocentesis can be performed to assess the likelihood of inutero infection how does this help and why are you telling the GP? .

Maternal complications can icnclude hepatitis, encephalitis and pneumonia. Immunocompromised she is healthy patients are at increased risk of these complications. Patients should have a baseline full blood count, renal function tests and liver function tests done why? . Patients who smoke are at increased risk of pneumonia and should be advised to stop smoking what is the evidence that stopping smoking will make any difference . Referral to hospital should be done if any signs or symptoms of complications develop what should the GP look out for? . Patients referred to hospital should be kept quarantined from other patients. Intavenous aciclovir may be needed in management of these complications. Early referral to an anesthesist is necessary in cases of pneumonia as assisted ventilation may become necessary why are you telling the GP?

You were not asked about the management of chickenpox in pregnancy. You were asked to advise a GP who has a patient with chickenpox
.
Posted by PAUL A.
Mon Jan 14, 2008 02:48 am
[a] I would like to get additional information regarding whether teacher had chicken pox or herpes zoster .in the past (1) . I would like yo know her gestational age (1) , whether she smokes. I would like to know if she is immnunocompromised or she on steroids for any reason read the question - healthy .. Duration of contact is also important meaning?? .
[b]Her immune status should be investigated Around 90 % of people are immune to chicken pox. IgG status should be done . IF she is IgG positive , she is immnue to chicken pox and she is reassured (1) . If her IgG status is negative , she is susceptible to chicken pox infection and she should be counselled offered VZIG within 96hrs of significant contact.It will protect aganist chicken pox , & decreases the severity .
[c]She is not to be followed in ANC clinic as she is infectious during vesicular stage , and should be seen in infectious disease clinic clinic visit not necessary . inorder to minimse the transmission to other pregnant woman . Sympatamatic traetment incluiding antihistamines , antipyrectics , soothening agents like calamine lotion should be given (1) . Acyclovir 500mg 4thrly x5days is given need discussion with consultant .Acyclovir decreaseas the severity of eruption and complication . If secondary infection of vesicle is seen antibiotics are to be given. .She should be advised to report for admission if there is hemorhagic rash, any neurologic symptoms , dysponea or cough or sever mucosl involvement (1)
There is 10 % varicella pneumnia in pregnancy with 10 % moratlity , which needs in patient traetment with parentral acyclovir , respiartory support . Varicella pneumonia is more often seen in patient who smoke and are immnunocompromised read the question ? healthy woman .
Varicella affection in early pregnancy have fetal affection seen in 2% Hence she should be given appointment for detailed anomaly scan after 6 wks (1) . Dermatologic scarring , limb affection , opthalmic involvement are seen .
Labor and delivery are expected to be normal as in unaffected pregnant ladies
After delivery , baby should be examined by pediatricain to rule out any congenital affection . She should be told . varicella infection produce life long immnunity

you need a more detailed answer - see NOTES > INFECTIONS IN PREGNANCY > VARICELLA
Posted by Mahmud  K.
Mon Jan 14, 2008 07:17 pm
Information about closeness and duration of contact should be requested. Face to face contact for 5minutes or indoor contact more than 15 min is significant.The timing of the exposure should be asked. Close contact during the period of infectiousness is significant. .Vericella Immune status of the woman should be assessed by obtaining information of definite history of chickenpox /shingles and presence of vericella antibodies VZV IgG in serum.
She can be reassured that 90% of the antenatal population in the UK are seropositive for VZV immunoglobulin IgG antibody. So primary infection is uncommon. After assess infectiousness and degree of exposure, serum should be checked in cases of uncertainty for VZV IgG .If the women is not immune to VZV, she should be given Varicella zoster immunoglobulin up to maximum of ten days after significant contact.. Woman should be asked to notify her doctor or midwife early if a rash develops .If VZIG is given ,the pregnant women should be managed as potentially infectious from 8-28 days after VZIG.

The infected woman should be advised to avoid susceptible individuals until the lesions have crusted over This is usually about 5 days after the appear of rash. She develops chickenpox in the first 20 weeks of pregnancy, there is a 1-2%risk of fetal varicella syndrome(FVS) .A detailed ultrasound examination approximately 5-6 weeks after the infection should be performed.Ultrasound performed before 5 weeks after the primary infection has failed to detect the deformities like shortened limbs, skin scarring,growth restriction. Amniocentesis is not routinely advised .If ultrasound scan showed deformity appropriate treatment should be decided in consultation with multidisciplinary team: fetal medicine specialist, virologists , obstreticians. Symtomatic treatment and hygiene is advised to prevent secondary bacterial infections.VZIG has no therapeutic benefit once chickenpox develop. Aciclovir should not be used before 20 weeks of gestation.
She should be reffered to hospital if chest symptoms,neurological symptoms, hemorrhagic rash or bleeding develop.
Posted by PAUL A.
Tue Jan 15, 2008 03:06 am
Information about closeness and duration of contact should be requested. Face to face contact for 5minutes or indoor contact more than 15 min is significant (1) .The timing of the exposure should be asked. Close contact how different is this from face to face contact mentioned earlier? during the period of infectiousness is significant when is the period of infectiousness? . .Vericella Immune status of the woman should be assessed by obtaining information of definite history of chickenpox /shingles (1) and presence of vericella antibodies VZV IgG in serum.
Presume this is part (b) She can be reassured that 90% of the antenatal population in the UK are seropositive for VZV immunoglobulin IgG antibody. So primary infection is uncommon. After assess infectiousness and degree of exposure, serum should be checked in cases of uncertainty for VZV IgG .If the women is not immune to VZV, she should be counselled given Varicella zoster immunoglobulin up to maximum of ten days after significant contact.. Woman should be asked to notify her doctor or midwife early if a rash develops .If VZIG is given ,the pregnant women should be managed as potentially infectious what does this mean? What should be done? from 8-28 days after VZIG.

The infected woman should be advised to avoid susceptible individuals until the lesions have crusted over how will she know who is susceptible? This is usually about 5 days after the appear of rash. She develops chickenpox in the first 20 weeks of pregnancy, there is a 1-2%risk of fetal varicella syndrome(FVS) (1) .A detailed ultrasound examination approximately 5-6 weeks after the infection should be performed (1) .Ultrasound performed before 5 weeks after the primary infection has failed to detect the deformities like shortened limbs, skin scarring,growth restriction. Amniocentesis is not routinely advised .If ultrasound scan showed deformity appropriate treatment should be decided in consultation with multidisciplinary team: fetal medicine specialist, virologists , obstreticians. Symtomatic treatment and hygiene is advised to prevent secondary bacterial infections (1) .VZIG has no therapeutic benefit once chickenpox develop. Aciclovir should not be used before 20 weeks of gestation why not? .
She should be reffered to hospital if chest symptoms,neurological symptoms, hemorrhagic rash or bleeding develop (1) .
Posted by PAUL A.
Tue Jan 15, 2008 03:08 am
A good candidate should

(a) Know the importance of (4 marks)

? Gestation age
? Date and nature of contact
? Nature of the lesions in the child
? Whether the woman has a previous history of chickenpox


(b) With respect to management options

? If the woman has a history of chickenpox, check for varicella zoster IgG and IgM. Reassure if IgG positive (1)

? If there is no history of chickenpox, take blood for varicella zoster IgG and IgM. 85% of women will be IgG positive and can be reassured (1)

? If the woman is varicella zoster IgG negative, explain the risks associated chickenpox in pregnancy including increased maternal morbidity and mortality (1) .

? If < 28 weeks gestation, explain risk of congenital varicella. Counsel and offer varicella zoster immune globulin (1) .

? Advise to avoid contact with other pregnant women. Check for sero-conversion 3 weeks after exposure (1) .

(c ) With respect to the development of chickenpox at 18 weeks gestation

? Explain the need to avoid contact with other pregnant women and neonates until lesions crust over (1)

? Explain that chickenpox in pregnancy associated with higher risk of mortality and morbidity including pneumonia, hepatitis and encephalitis (2) .

? Symptomatic treatment and hygiene to prevent secondary bacterial infection of lesions (1)

? Acyclovir should be used with following discussion with consultant obstetrician and consultant in infectious diseases and if the woman presents within 24h of development of rash ? reduces duration of symptoms (2)

? If the woman is a smoker, recommend hospital assessment (1)

? Advise referral to hospital if she develops chest, neurological symptoms or a dense / haemorrhagic rash (1)

? Explain the risk of congenital varicella syndrome (1)

? Explain need for referral to a tertiary centre for detailed scan 5 weeks after infection (1)
Posted by Toyin A.
Tue Jan 15, 2008 08:20 pm
a) I would want to know her gestation and her parity.I would also ask the GP if the patient has a past history of chicken pox or shingles because about 90% of the antenatal population will and therefore she will be immune to further infection.I would ask the GP for the significance of the contact and duration of exposure,for example was it face to face or in the same room for 15 minutes or more?If so,the contact is significant. I would also ask the GP the timing of the exposure,i.e was the pupil still infectious at the time,was a rash still present or not,had the lesions crusted over?

b) Management options will depend on her immunity to varicella.
If there is uncertainty about her immunity to chickenpox or there is no previous history of it,she will need blood taking for serum varicella zoster IgG(or saved serum from booking bloods can be used).If the result is negative,she is not immune and should be advised to have varicella zoster immune globulin as soon as possible or within ten days of the exposure to minimise her risks of developing chickenpox.She will need to be treated as infectios for 8 to 28 days post immune globulin and advised to report any rash developing to the GP9or midwife).
If she has a past history of chickenpox or shingles,one can assume she is immune to varicella therefore she does not need serum IgG or zoster immune globulin but she must also be counselled to report any rash developing to GP or midwife.

c)I would advise the GP to counsel the patient to avoid contact with susceptible people such as other pregnant women and new born babies until her lesions have crusted over(which is usually about 5 days after the rash started)because she is infectious until then.
I would advise the GP to encourage her to keep good personal hygiene of her rash to reduce the chance of secondary bacterial infections developing.
I would advise the GP to counsel her about a 7 day course of aciclovir to start within 24 hours of her rash appearing,to reduce her symptoms.I would tell GP to counsel her that aciclovir does not increase the risk of fetal malformation but if used below 20 weeks gestation,it should be used with caution because of a theoretical risk of teratogenesis.i would advise the GP that using zoster immune globulin will be ineffective now she has developed chickenpox.
I would advise the GP to counsel the patient about the potential risks to her with chickenpox of developing pneumonia(which is about 10%),encephalitis,hepatitis and very rarely,death.
I would advise the GP that she should report any chest or neurological symptoms to the GP so she can be referred for hospital review by a multidisciplinary team as soon as possible.
I would advise GP that if the patient is a smoker,a hospital review is warranted even if she is asymptomatic as she is more at risk of pneumonia.
I would advise the GP to counsel the woman about risks to her baby,namely developing fetal varicella syndrome.i would tell the GP to counsel her that this risk at 18 weeks is very small,less than 1%.I would advise the GP to refer the patient for review and a detailed ultrasound scan with a fetal medicine specialist 5 weeks after she developed chickenpox.
Posted by Toyin A.
Thu Jan 17, 2008 09:27 pm
Sorry Paul,have just seen ur msg to post replies b4 answer structure comes at end of the week,any chance my answer could still be marked?thanx!
Posted by PAUL A.
Thu Jan 24, 2008 03:51 am
a) I would want to know her gestation age. Gestation = pregnancy and her parity ? relevance of parity?? .I would also ask the GP if the patient has a past history of chicken pox or shingles (1) because about 90% of the antenatal population will and therefore she will be immune to further infection.I would ask the GP for the significance of the contact and duration of exposure,for example was it face to face or in the same room for 15 minutes or more (1) ?If so,the contact is significant. I would also ask the GP the timing of the exposure,i.e was the pupil still infectious at the time,was a rash still present or not,had the lesions crusted over (1) ?

b) Management options will depend on her immunity to varicella.
If there is uncertainty about her immunity to chickenpox or there is no previous history of it,she will need blood taking for serum varicella zoster IgG(or saved serum from booking bloods can be used) (1) .If the result is negative,she is not immune and should be advised to have varicella zoster immune globulin as soon as possible or within ten days of the exposure to minimise her risks of developing chickenpox (1) counsel and offer .She will need to be treated as infectios for 8 to 28 days post immune globulin and advised to report any rash developing to the GP9or midwife). ? explain risk of congenital varicella if <28 weeks ? this is the main reason for offering VZIG
If she has a past history of chickenpox or shingles,one can assume she is immune to varicella therefore she does not need serum guidelines say it is good practice to confirm immunity IgG or zoster immune globulin but she must also be counselled to report any rash developing to GP or midwife.

c)I would advise the GP to counsel the patient to avoid contact with susceptible people such as other pregnant women and new born babies until her lesions have crusted over (1) (which is usually about 5 days after the rash started)because she is infectious until then.
I would advise the GP to encourage her to keep good personal hygiene of her rash to reduce the chance of secondary bacterial infections developing (1) .
I would advise the GP to counsel her about a 7 day course of aciclovir to start within 24 hours of her rash appearing,to reduce her symptoms.I would tell GP to counsel her that aciclovir does not increase the risk of fetal malformation but if used below 20 weeks gestation,it should be used with caution because of a theoretical risk of teratogenesis (1) what does use with caution mean in practical terms? Will you expect terratogenesis at 18 weeks? .i would advise the GP that using zoster immune globulin will be ineffective now she has developed chickenpox.
I would advise the GP to counsel the patient about the potential risks to her with chickenpox of developing pneumonia(which is about 10%),encephalitis,hepatitis (1) and very rarely,death.
I would advise the GP that she should report any chest or neurological symptoms to the GP so she can be referred for hospital review by a multidisciplinary team as soon as possible (1) .
I would advise GP that if the patient is a smoker,a hospital review is warranted (1) even if she is asymptomatic as she is more at risk of pneumonia.
I would advise the GP to counsel the woman about risks to her baby,namely developing fetal varicella syndrome.i would tell the GP to counsel her that this risk at 18 weeks is very small,less than 1% (1) .I would advise the GP to refer the patient for review and a detailed ultrasound scan with a fetal medicine specialist 5 weeks after she developed chickenpox (1)

good answer
.
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Mon May 7, 2012 01:36 am

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