Varicella Zoster in First Trimester of Pregnancy

Varicella Zoster in First Trimester of Pregnancy Is the risk of vertical transmission in a pregnant woman with a reactivation outbreak of varicella zoster (shingles) in her first trimester similar to that of a primary outbreak of chickenpox? profAskTheExpert state, pregnancy,varicela,pregnanacy,zoaster,h,shingle,varcella,varacella,chickenpox,chicken pox, herpes zoster,varecella,veracella,varicella,zooster,varicilla,vericella,pregancy,virus,varicella zoster,shingles,viral,pregnant Désirée Lie, MD, MSEd, Associate Clinical Professor of Family Medicine and Director, Division of International Faculty Development, Irvine Medical Center, University of California, Irvine Medscape Medscape Primary Care 03/21/2003 5 1 <h3>Question</h3> Is the risk of vertical transmission in a pregnant woman with a reactivation outbreak of varicella zoster (shingles) in her first trimester similar to that of a primary outbreak of chickenpox in the first trimester? <H3>Response</H3> from , 03/21/2003 Ninety percent of varicella cases occur in children, with only 2% occurring in adults older than 20 years of age. Infection with the virus generally confers lifelong immunity. However, viral reactivation in the dorsal root ganglia can occur later, for example, with immunosuppression, resulting in herpes zoster or shingles. The incidence of primary varicella or chickenpox in pregnancy has been estimated to be 1 to 5 cases per 10,000 pregnancies.[1] Susceptibility to varicella in pregnancy (as measured by antibody levels) in women with no history of chickenpox ranges from 5% to a high of 16% in women from tropical and subtropical regions.[2] First-trimester maternal varicella infection may lead to: <ol> <li>Fetal infection with congenital varicella syndrome (embryopathy), and</li> <li>Maternal complications including serious pneumonia, associated with a 40% mortality</li> </ol> Vertical transmission is believed to occur through maternal viremia and placental infection, resulting in fetal chickenpox followed by encephalitis and dorsal root ganglia infection. Cell destruction of nerve tissues may then account for limb denervation and other changes subsequently seen in congenital varicella syndrome. Studies between 1960 and 1986 provided estimates of vertical transmission risk between 0% and 9%.[3,4] More recent studies with prospective, longitudinal follow-up of infants born to mothers with clinical primary varicella disease during pregnancy put the estimate lower, at 0.4% to 2%,[5,6] with risk being higher when maternal infection occurred in the second and third trimesters. The risk of congenital varicella syndrome ranged from 0% to 0.4% when maternal rash occurred before 13 weeks gestation.[5,6] In a recent study,[7] which enrolled 362 pregnant women with clinical chickenpox or herpes zoster from 10 perinatal centers, only 1 infant was born with congenital varicella syndrome. This infant's mother had rash onset at 24 weeks gestation. Two fetal losses occurred, but there was no evidence of varicella at perinatal autopsy. In these 2 cases, maternal rash occurred at 5 and 11 weeks gestation. If these 2 cases were included, the risk of fetal transmission is still low at 1.3%. Follow-up of all infants included audiologic and ophthalmologic evaluations, continuing until 30 months after delivery. In this cohort, 15 of the recruited women had herpes zoster, but they were excluded from the results analysis. Only 1 study[6] has included women with herpes zoster in the analysis. In this prospective study of 1739 cases of varicella disease in pregnancy, none of the offspring of 366 women with herpes zoster developed congenital varicella syndrome. One recent retrospective study of neonates with neurologic problems[8] raised the possibility of vertical transmission in the absence of clinical varicella infection in the mother. Of 201 neonates screened for congenital viral infections, 4 were identified with cerebrospinal fluid varicella antibodies, and their mothers were documented as having had significant rises in serum titers of antibody to varicella antigen during pregnancy. The authors concluded that maternal subclinical varicella infection can cause congenital varicella infection with neurologic outcomes. The impact of all the research highlights the need for adequate screening and immunization of women of childbearing age who are susceptible to varicella infection during pregnancy. In conclusion, both chickenpox and herpes zoster infection are rare during pregnancy. The data currently confirm that vertical transmission risk in the first trimester is extremely low (0% to 0.4%), and may be lower for herpes zoster than for chickenpox. The reason for the lower risk in women with zoster may simply be that viremia is uncommon in the immunocompetent individual with zoster compared with chickenpox, thus reducing the risk of placental viral transmission. <ol> <li>Stagno S, Whitley RJ. Herpesvirus infections of pregnancy. Part II. Herpes simplex virus and varicella-zoster virus infections. N Engl J Med. 1985;313:1327-1330.</li> <li>Gershon AA, Raker R, Steinberg S, et al. Antibody to varicella-zoster virus in parturient women and their offspring during the first year of life. Pediatrics. 1976;58:692-696. <a href="http://intapp.medscape.com/px/medlineapp/getdoc?pmi=185578&data=6B0fZkDd8uNM.8rGXu28DM6SZ8m0hw389JXR884GHv68.nGpZ8sUhQT8ChFQY82WxtA8DOaOO8lQHPg8xb5u7826xsM8sGpwr8xh6pSdJ5CWRdB6&grp=MEDSCAPE&z&cid=med">Abstract</a></li> <li>Manson MM, Logan WPD, Loy RM. Rubella and other virus infections in pregnancy. In: Reports on public health and medical subjects (No. 101). Ministry of Health, Her Majesty's Stationary Office, London, England; 1960.</li> <li>Paryani SG, Arvin AM. Intrauterine infection with varicella-zoster virus after maternal varicella. N Engl J Med. 1986;314:1542-1546. <a href="http://intapp.medscape.com/px/medlineapp/getdoc?pmi=3012334&data=6B0fZkDd8uNM.8rGXu28DM6SZ8m0hw389JXR884GHv68.nGpZ8sUhQT8ChFQY82WxtA8DOaOO8lQHPg8xb5u7826xsM8sGpwr8xh6pSdJ5CWRdB6&grp=MEDSCAPE&z&cid=med">Abstract</a></li> <li>Pastuszak AL, Levy M, Schick B, et al. Outcome after maternal varicella infection in the first 20 weeks of pregnancy. N Engl J Med. 1994;330:901-905. <a href="http://intapp.medscape.com/px/medlineapp/getdoc?pmi=8114861&data=6B0fZkDd8uNM.8rGXu28DM6SZ8m0hw389JXR884GHv68.nGpZ8sUhQT8ChFQY82WxtA8DOaOO8lQHPg8xb5u7826xsM8sGpwr8xh6pSdJ5CWRdB6&grp=MEDSCAPE&z&cid=med">Abstract</a></li> <li>Enders G, Miller E, Cradock-Watson J, Bolley I, Ridehalgh M. Consequences of varicella and herpes zoster in pregnancy: prospective study of 1739 cases. Lancet. 1994;343:1548-1551. <a href="http://intapp.medscape.com/px/medlineapp/getdoc?pmi=7802767&data=6B0fZkDd8uNM.8rGXu28DM6SZ8m0hw389JXR884GHv68.nGpZ8sUhQT8ChFQY82WxtA8DOaOO8lQHPg8xb5u7826xsM8sGpwr8xh6pSdJ5CWRdB6&grp=MEDSCAPE&z&cid=med">Abstract</a></li> <li>Harger JH, Ernest JME, Thurnau GR, et al. Frequency of congenital varicella syndrome in a prospective cohort of 347 pregnant women. Obstet Gynecol. 2002;100:260-265. <a href="http://intapp.medscape.com/px/medlineapp/getdoc?pmi=12151147&data=6B0fZkDd8uNM.8rGXu28DM6SZ8m0hw389JXR884GHv68.nGpZ8sUhQT8ChFQY82WxtA8DOaOO8lQHPg8xb5u7826xsM8sGpwr8xh6pSdJ5CWRdB6&grp=MEDSCAPE&z&cid=med">Abstract</a></li> <li>Mustonen K, Mustakangas P, Valanne L, Professor MH, Koskiniemi M. Congenital varicella-zoster virus infection after maternal subclinical infection: clinical and neuropathological findings. J Perinatol. 2001;21:141-146. <a href="http://intapp.medscape.com/px/medlineapp/getdoc?pmi=11324362&data=6B0fZkDd8uNM.8rGXu28DM6SZ8m0hw389JXR884GHv68.nGpZ8sUhQT8ChFQY82WxtA8DOaOO8lQHPg8xb5u7826xsM8sGpwr8xh6pSdJ5CWRdB6&grp=MEDSCAPE&z&cid=med">Abstract</a></li> </ol> Albrecht A. Treatment and prevention of herpes zoster. UpToDate review. Last updated August 2002. Available at <a href="http://www.utdol.com" target="_blank">www.utdol.com</a> (by subscription only). Barss V. Immunization of pregnant women. UpToDate review. Last updated December 2001. Available at <a href="http://www.utdol.com" target="_blank">www.utdol.com</a> (by subscription only). Riley L. Varicella-zoster virus infection in pregnancy. UpToDate review. Last updated August 2002. Available at <a href="http://www.utdol.com" target="_blank">www.utdol.com</a> (by subscription only).