Chickenpox in Pregnancy

RCOG Chickenpox in Pregnancy (Green-top Guideline No.13). Last reviewed 2024.

NICE CKS Chickenpox – Scenario: Pregnant woman. Last revised: Nov 2023.

Article Last Updated:02/04/2026

Background Information

Chickenpox and Shingles

Both chickenpox and shingles are caused by varicella-zoster virus (VZV) (human herpesvirus 3):

Chickenpox = primary VZV infection
Shingles (herpes zoster) = reactivation of VZV from sensory nerve root ganglia, following primary infection

Clinical Features

Chickenpox

Systemic symptoms (fever and malaise)

Presence of a widespread pruritic vesicular rash:

Small erythematous macules (on the scalp, face, trunk, proximal limbs)
→ Intensely itchy vesicles
→ Crusting (~5 days)

Classic exam phrase: lesions at different stages of healing simultaneously

Shingles

Prodromal phase of 2-3 days

Pain in the affected dermatome
Abnormal skin sensations (e.g. pruritus, paraesthesia, dysesthesia, numbness)

Unilateral painful rash in a dermatomal distribution (does not cross midline)

Erythematous maculopapular rash for 1-2 days
→ Vesicles for 3-4 days
→ Pustules within 1 week
→ Ulceration and crusting after 3-5 days
→ Healing over 2-4 weeks, often with scarring and permanent pigmentation

Complications

While chickenpox is often mild in children, it is more severe and serious in adults and pregnant women, with increased morbidity.

Maternal consequences

Pneumonia – major and significant contributor to maternal morbidity and mortality
Hepatitis
Encephalitis
Haemorrhagic rash

Fetal baby consequences

Spontaneous miscarriage (only in the 2nd and 3rd trimester)

Fetal varicella syndrome

Risk is highest following maternal infection during the first 20 weeks (low risk >20 weeks)
Characterised by several congenital anomalies

Neonatal varicella

May occur if maternal infection occurs in the month before delivery
Maternal infection from 5 days before to 2 days after delivery has the highest risk of severe, disseminated infection

Shingles in infancy

Due to reactivation of latent VZV acquired either in utero (asymptomatic or minimally symptomatic infection) or postnatally
It presents as a dermatomal vesicular eruption, usually within the first year of life

Management

Post-Chickenpox / Shingles Exposure in Pregnancy

The overall management pathway for post-exposure assessment and treatment is the same for both chickenpox and shingles exposure.

Steps	Description	Subsequent action
1 – Check if exposure is significant or not	Significant exposure definition for chickenpox: Contact occurred during the infectious period, and Significant contact (any of the following) Being in the same room for ≥15 min Continuous exposure (e.g. living in the same household, being in a nursery setting) Face-to-face contact Contact within a large open ward Significant exposure definition for shingles (any of the following): Disseminated shingles Shingles in an exposed area that cannot be covered (e.g. shingles on the face, ophthalmic shingles) Localised shingles in an immunocompromised individual (due to greater viral shedding)	If there is NO significant exposure → no further action is necessary If there IS significant exposure → proceed to step 2 (determine immunity)
2 – Determine immunity	A woman is considered immune to VZV if ANY of the following is present: Definite past history of chickenpox or shingles, or Received 2 doses of varicella vaccine If the above does not apply (i.e. no history of chickenpox or shingles, no history of vaccine, patient is uncertain) → perform blood test for VZV IgG antibodies +ve IgG antibodies → immune -ve IgG antibodies = non-immune	Only proceed to step 3 (post-exposure prophylaxis) if the patient is non-immune If the patient is immune → no further action is necessary
3 – Post-exposure prophylaxis	1st line: oral antivirals (aciclovir or valaciclovir) Antivirals should be given 7-14 days post-exposure (as immediate administration has been shown to be less effective) 2nd line: IM VZIG To be given ASAP, latest within 10 days of exposure

Steps

Description

Subsequent action

1 – Check if exposure is significant or not

Significant exposure definition for chickenpox:

Contact occurred during the infectious period, and
Significant contact (any of the following)
- Being in the same room for ≥15 min
- Continuous exposure (e.g. living in the same household, being in a nursery setting)
- Face-to-face contact
- Contact within a large open ward

Significant exposure definition for shingles (any of the following):

Disseminated shingles
Shingles in an exposed area that cannot be covered (e.g. shingles on the face, ophthalmic shingles)
Localised shingles in an immunocompromised individual (due to greater viral shedding)

If there is NO significant exposure → no further action is necessary

If there IS significant exposure → proceed to step 2 (determine immunity)

2 – Determine immunity

A woman is considered immune to VZV if ANY of the following is present:

Definite past history of chickenpox or shingles, or
Received 2 doses of varicella vaccine

If the above does not apply (i.e. no history of chickenpox or shingles, no history of vaccine, patient is uncertain) → perform blood test for VZV IgG antibodies

+ve IgG antibodies → immune
-ve IgG antibodies = non-immune

Only proceed to step 3 (post-exposure prophylaxis) if the patient is non-immune

If the patient is immune → no further action is necessary

3 – Post-exposure prophylaxis

1st line: oral antivirals (aciclovir or valaciclovir)

Antivirals should be given 7-14 days post-exposure (as immediate administration has been shown to be less effective)

2nd line: IM VZIG

To be given ASAP, latest within 10 days of exposure

In summary, post-exposure prophylaxis is only indicated if BOTH of the following conditions are met:

Exposure is significant (see table above)
Patient is NON-immune to VZV
- No or uncertain past history of chickenpox or shingles, or
- No or uncertain vaccination history, or
- -ve VZV IgG antibodies

Pregnant Women Who Develop Chickenpox

Management should be guided by a specialist.

Aspect	Management
Advice on the infectious period	The person is infectious from 24 hours before the rash appears until all lesions have crusted over During the infectious period, the person should avoid contact with: Immunocompromised people Other pregnant women Infants <4 w/o
Symptomatic management	Conservative: Encourage adequate fluid intake to avoid dehydration Dress appropriately to avoid overheating or shivering Wear smooth, cotton fabrics Keep nails short to minimise damage from scratching Pharmacological: Consider paracetamol for instant pain or fever Topical calamine lotion for itching The following drugs should be avoided: NSAIDs – associated with increased risk of severe skin and soft tissue infections (esp. necrotising fasciitis) Chlorphenamine (antihistamine)
Antiviral	Oral antiviral (aciclovir) is indicated if the woman presented <24 hours after onset of the rash RCOG states offer if >20 weeks gestation, and consider if <20 weeks gestation IV aciclovir is indicated for severe chickenpox – ANY of the following: Respiratory symptoms (e.g. pneumonia, dyspnoea) Neurological symptoms (e.g. photophobia, seizures, drowsiness) Haemorrhagic rash or any unexplained bleeding Dense rash +/- mucosal lesions

Aspect

Management

Advice on the infectious period

The person is infectious from 24 hours before the rash appears until all lesions have crusted over

During the infectious period, the person should avoid contact with:

Immunocompromised people
Other pregnant women
Infants <4 w/o

Symptomatic management

Conservative:

Encourage adequate fluid intake to avoid dehydration
Dress appropriately to avoid overheating or shivering
Wear smooth, cotton fabrics
Keep nails short to minimise damage from scratching

Pharmacological:

Consider paracetamol for instant pain or fever
Topical calamine lotion for itching

The following drugs should be avoided:

NSAIDs – associated with increased risk of severe skin and soft tissue infections (esp. necrotising fasciitis)
Chlorphenamine (antihistamine)

Antiviral

Oral antiviral (aciclovir) is indicated if the woman presented <24 hours after onset of the rash

RCOG states offer if >20 weeks gestation, and consider if <20 weeks gestation

IV aciclovir is indicated for severe chickenpox – ANY of the following:

Respiratory symptoms (e.g. pneumonia, dyspnoea)
Neurological symptoms (e.g. photophobia, seizures, drowsiness)
Haemorrhagic rash or any unexplained bleeding
Dense rash +/- mucosal lesions

VZIG has no therapeutic benefit once chickenpox has developed; therefore, it should not be used in pregnant women who DEVELOP chickenpox.

VZIG is only used in the context of chickenpox/shingles post-EXPOSURE prophylaxis – covered in the section above.

References

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Chickenpox in Pregnancy

Background Information

Chickenpox and Shingles

Clinical Features

Chickenpox

Shingles

Complications

Management

Post-Chickenpox / Shingles Exposure in Pregnancy

Pregnant Women Who Develop Chickenpox

References

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