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Commonly known as chickenpox, varicella-zoster virus (VZV) infection has a fairly benign course when incurred during childhood but may result in serious illness in adults, particularly during pregnancy. Infection results in lifelong immunity. Approximately 95% of women born in the United States have VZV antibodies by the time they reach reproductive age. The incidence of VZV infection during pregnancy has been reported as up to 7:10,000. The vaccine is contraindicated in pregnancy because the effects of the vaccine on the fetus are unknown. Nonpregnant women who are vaccinated should avoid pregnancy for 1 month after injection. Inadvertent vaccination in early pregnancy or within a month of pregnancy is not an indication for termination, although women should be counseled about theoretical risks.

CLINICAL FINDINGS

A. Symptoms and Signs

The incubation period for this infection is 10–20 days. A primary infection follows and is characterized by a flu-like syndrome with malaise, fever, and development of a pruritic maculopapular rash on the trunk, which becomes vesicular and then crusts. Pregnant women are prone to the development of VZV pneumonia, often a fulminant infection sometimes requiring respiratory support. After primary infection, the virus becomes latent, ascending to dorsal root ganglia. Subsequent reactivation can occur as zoster, often under circumstances of immunocompromise, although this is rare during pregnancy.

Two types of fetal infection have been documented. The first is congenital VZV syndrome, which typically occurs in 0.4–2% of fetuses exposed to primary VZV infection during the first trimester. Anomalies include limb and digit abnormalities, microphthalmos, and microcephaly.

Infection during the second and third trimesters is less threatening. Maternal IgG crosses the placenta, protecting the fetus. The only infants at risk for severe infection are those born after maternal viremia but before development of maternal protective antibody. Maternal infection manifesting 5 days before or up to 2 days after delivery is the time period believed to be most hazardous for transmission to the fetus.

B. Laboratory Findings

Diagnosis is commonly made on clinical grounds. Laboratory verification is made by enzyme-linked immunosorbent assay (ELISA), fluorescent antibody, and hemagglutination inhibition antibody techniques. Vesicular fluid can be sent for qualitative varicella polymerase chain reaction assay.

TREATMENT

Varicella-zoster immune globulin (VZIG) has been shown to prevent or modify the symptoms of infection in exposed persons. Treatment success depends on identification of susceptible women at or just following exposure. Exposed women with a questionable or negative history of chickenpox should be checked for antibody, since the overwhelming majority will have been previously exposed. If the antibody is negative, VZIG (625 units intramuscularly) should ideally be given within 96 hours of exposure for greatest efficacy, but the CDC reports it can be given for up to 10 days. There are no known adverse effects of VZIG administration during pregnancy, although the incubation period for disease can be lengthened. ...

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