Obstetric infectious disease emergencies

No. 274-Management of Varicella Infection (Chickenpox) in Pregnancy

OBJECTIVE

To review the existing data regarding varicella zoster virus infection (chickenpox) in pregnancy, interventions to reduce maternal complications and fetal infection, and antepartum and peripartum management .

METHODS

The maternal and fetal outcomes in varicella zoster infection were reviewed, as well as the benefit of the different treatment modalities in altering maternal and fetal sequelae.

EVIDENCE

Medline was searched for articles and clinical guidelines published in English between January 1970 and November 2010.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table).

RECOMMENDATIONS

Sepsis during pregnancy or the postpartum period

Sepsis is an important cause of maternal morbidity and mortality worldwide. Early recognition and timely treatment are the key to ensuring a favourable outcome. This article reviews recent literature about definitions, pathophysiology, incidence, diagnosis, management, treatment, prevention and outcome of sepsis during pregnancy and the postpartum period.

Sepsis and pregnancy: do we know how to treat this situation?

Sepsis is defined as an acute inflammatory response syndrome secondary to an infectious focus. It has a high incidence, morbidity and mortality, causing substantial financial costs, especially due to complications such as septic shock and multiple organ dysfunction. The pathogen toxins associated with individual susceptibility culminate with cytokine release, which promotes a systemic inflammatory response that can progress to multiple organ dysfunction and eventual patient death.

Specifically, sepsis incidence, morbidity and mortality are lower in pregnant women, as this group is typically younger with fewer comorbidities having a polymicrobial etiology resulting in sepsis.

Pregnant women exhibit physiological characteristics that may confer specific clinical presentation and laboratory patterns during the sepsis course. Thus, a better understanding of these changes is critical for better identification and management of these patients. The presence of a fetus also requires unique approaches in a pregnant woman with sepsis.

Sepsis treatment is based on certain guidelines that were established after major clinical trials, which, unfortunately, all classified pregnancy as a exclusion criteria.

Thus, the treatment of sepsis in the general population has been extrapolated to the pregnant population, with the following main goals: maintenance of tissue perfusion with fluid replacement and vasoactive drugs (initial resuscitation), adequate oxygenation, control of the infection source and an early start of antibiotic therapy, corticosteroid infusion and blood transfusion when properly indicated, prophylaxis, and specifically monitoring and maintenance of fetal heath.

Maternal sepsis

Maternal sepsis is relatively common. Most of these infections are the result of tissue damage during labor and delivery and physiologic changes normally occurring during pregnancy. These infections, whether directly pregnancy-related or simply aggravated by normal pregnancy physiology, ultimately have the potential to progress to severe sepsis and septic shock. This article discusses commonly encountered entities and septic shock. The expeditious recognition of common maternal sepsis and meticulous attention to appropriate management to prevent the progression to severe sepsis and septic shock are emphasized. Also discussed are principles and new approaches for the management of septic shock.

Management of varicella infection (chickenpox) in pregnancy

OBJECTIVE

To review the existing data regarding varicella zoster virus infection (chickenpox) in pregnancy, interventions to reduce maternal complications and fetal infection, and antepartum and peripartum management.

METHODS

The maternal and fetal outcomes in varicella zoster infection were reviewed, as well as the benefit of the different treatment modalities in altering maternal and fetal sequelae.

EVIDENCE

Medline was searched for articles and clinical guidelines published in English between January 1970 and November 2010.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table).

RECOMMENDATIONS

1. Varicella immunization is recommended for all non-immune women as part of pre-pregnancy and postpartum care. (II-3B) 2. Varicella vaccination should not be administered in pregnancy. However, termination of pregnancy should not be advised because of inadvertent vaccination during pregnancy. (II-3D) 3. The antenatal varicella immunity status of all pregnant women should be documented by history of previous infection, varicella vaccination, or varicella zoster immunoglobulin G serology. (III-C) 4. All non-immune pregnant women should be informed of the risk of varicella infection to themselves and their fetuses. They should be instructed to seek medical help following any contact with a person who may have been contagious. (II-3B) 5. In the case of a possible exposure to varicella in a pregnant woman with unknown immune status, serum testing should be performed. If the serum results are negative or unavailable within 96 hours from exposure, varicella zoster immunoglobulin should be administered. (III-C) 6. Women who develop varicella infection in pregnancy need to be made aware of the potential adverse maternal and fetal sequelae, the risk of transmission to the fetus, and the options available for prenatal diagnosis. (II-3C) 7. Detailed ultrasound and appropriate follow-up is recommended for all women who develop varicella in pregnancy to screen for fetal consequences of infection. (III-B) 8. Women with significant (e.g., pneumonitis) varicella infection in pregnancy should be treated with oral antiviral agents (e.g., acyclovir 800 mg 5 times daily). In cases of progression to varicella pneumonitis, maternal admission to hospital should be seriously considered. Intravenous acyclovir can be considered for severe complications in pregnancy (oral forms have poor bioavailability). The dose is usually 10 to 15 mg/kg of BW or 500 mg/m² IV every 8 h for 5 to 10 days for varicella pneumonitis, and it should be started within 24 to 72 h of the onset of rash. (III-C) 9. Neonatal health care providers should be informed of peripartum varicella exposure in order to optimize early neonatal care with varicella zoster immunoglobulin and immunization. (III-C) Varicella zoster immunoglobulin should be administered to neonates whenever the onset of maternal disease is between 5 days before and 2 days after delivery. (III-C).

Fetal outcome and amniocentesis results in pregnancies complicated by varicella infection

OBJECTIVE

To evaluate the outcome of infants born to mothers with varicella zoster virus (VZV) infection in pregnancy who had second trimester amniocentesis for detection of placental transfer.

METHODS

We interviewed women who had had VZV infection in pregnancy and who underwent diagnostic amniocentesis to detect transplacental infection using both polymerase chain reaction (PCR) and cell culture methods to characterize their children's clinical and psychomotor development.

RESULTS

Twenty women who had a diagnosis of primary VZV during pregnancy were available for interview. The mean gestational age at which primary VZV was acquired was 11±3.5 weeks. One infant had hypospadias and developmental delay. He was born to an epileptic mother who had been treated during pregnancy with sodium valproate and clonazepam. Another infant had abnormal brainstem auditory-evoked potentials. All other infants were reported to have normal clinical and psychomotor development.

CONCLUSION

In cases of varicella infection during pregnancy, negative studies of amniotic fluid using PCR may contribute to decision making.

Imitators of severe pre-eclampsia

There are many obstetric, medial, and surgical disorders that share many of the clinical and laboratory findings of patients with severe pre-eclampsia-eclampsia. Imitators of severe pre-eclampsia-eclampsia are life-threatening emergencies that can develop during pregnancy or in the postpartum period. These conditions are associated with high maternal and perinatal mortalities and morbidities, and survivors may face long-term sequelae. The pathophysiologic abnormalities in many of these disorders include vasospasm, platelet activation or destruction, microvascular thrombosis, endothelial cell dysfunction, and reduced tissue perfusion. Some of these disorders include acute fatty liver of pregnancy, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, acute exacerbation of systemic lupus erythematosus, and disseminated herpes simplex and sepsis syndromes. Differential diagnosis may be difficult due to the overlap of several clinical and laboratory findings of these syndrome. It is important that the clinician make the accurate diagnosis when possible because the management and complications from these syndromes may be different. Because of the rarity of these conditions during pregnancy and postpartum, the available literature includes only case reports and case series describing these syndromes. This review focuses on diagnosis, management, and counseling of women who develop these syndromes based on results of recent studies and my own clinical experience.

Sepsis and acute renal failure in pregnancy

The unique physiology of pregnancy poses several problems for clinicians charged with caring for critically ill pregnant patients. This focused review summarizes two problems encountered in critically ill pregnant patients: pregnancy-related sepsis and acute renal failure. Common causes, and the effects of pregnancy on diagnosis and treatment are discussed.

Two Cases of Chickenpox Complicating Pregnancy and an Update on Management

Susceptible pregnant women with chickenpox exposure are uncommon but are medical emergency conditions. Chickenpox infection in the first trimester is associated with the congenital varicella syndrome and in the third trimester is associated with fatal complications and the neonatal varicella syndrome. In this article, two cases and the management of chickenpox during pregnancy are discussed.

Early goal directed therapy for sepsis during pregnancy

Sepsis is a leading cause of death in pregnancy and results in significant perinatal mortality. These deaths occur despite the younger age of pregnant patients, the low rate of comorbid conditions and the potential for effective interventions that should result in rapid resolution of illness. To date, no "evidence-based" recommendations are specific to the pregnant patient who is critically ill or septic. Optimal care for the septic patient requires a multidisciplinary team with expertise in obstetrics, maternal-fetal medicine, critical care, infectious disease, anesthesia, and pharmacy. Coordination of care and good communication amongst team members is essential. Incorporation of early goal directed therapy for suspected sepsis into obstetric practice is needed to optimize maternal and neonatal outcomes.

Sepsis during pregnancy

OBJECTIVES

To provide a current review of the literature regarding the assessment and management of sepsis during pregnancy.

DESIGN

A comprehensive review of current English-language literature search was performed with Ovid MEDLINE using the Medical Subject Headings pregnancy and sepsis, with Medical Subject Headings or keywords seeking randomized controlled trials and clinical reports, and by reviewing the bibliographies of clinical practice guidelines.

RESULTS

Sepsis-related maternal morbidity and mortality is a significant and persistent problem in the modern critical care obstetric unit. The management of sepsis during pregnancy is challenging. The obstetric intensivist must simultaneously discern the effect of maternal physiologic changes on fetal vulnerability and the effect of the fetus on maternal status throughout the various phases of pregnancy. Little direct evidence exists to validate the extrapolation of some sepsis treatment modalities from other nonpregnant patient populations. Nevertheless, early detection, accurate diagnosis, and aggressive appropriate treatment strategies may significantly improve outcome. Approaches like the Surviving Sepsis Campaign guidelines are unproven but seem reasonable and practical.

CONCLUSIONS

Sepsis during pregnancy is uncommon yet potentially fatal. Diagnostic and therapeutic guidelines should predominantly pattern those currently utilized for nonpregnant patients.

Anaesthetic considerations in a parturient with varicella presenting for Caesarean section

A parturient with varicella (chickenpox) presented for an elective Caesarean section and spinal anaesthesia was employed for surgery. A review of the literature is presented and the anaesthetic issues are discussed.