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Rare and serious complications

01 January 2010

Mrs W, a 28-year-old woman, was 34 weeks’ pregnant with her first child. Her pregnancy had been uneventful up to this point, although she had received input from the local smoking cessation service, having had difficulty giving up during the second trimester.

She attended her GP with a widespread rash. Her GP, Dr G, documented an erythematous vesicular rash, with multiple lesions over Mrs W’s face and trunk. He made the clinical diagnosis of chickenpox. She was noted to be systemically well. Dr G gave advice regarding symptomatic treatment of the condition.

Three days later, Mrs W developed a cough overnight and requested a GP visit the following morning. Dr G attended and recorded the visit in the medical notes. He stated that Mrs W was unwell, and had a persistent cough. Dr G noted basal crackles on auscultating the lungs, and documented that this was a severe case of chickenpox. He did not prescribe any treatment and did not arrange to see Mrs W again.

Mrs W was reassured that “chickenpox is not dangerous to the baby at this stage of pregnancy”. Admission to hospital was not discussed.

A further three days later, Mrs W rang the surgery again and reported feeling unwell. Her cough had continued and was preventing sleep. A visit was advised, but before this could take place Mrs W experienced symptoms suggestive of premature labour, and made her own way to hospital.

Mrs W delivered a baby boy soon after admission to labour ward. The baby unfortunately died within hours of birth, due to neonatal chickenpox infection. Mrs W was diagnosed with pneumonia and required intensive care and ventilation. She later made a good recovery.

Mr and Mrs W made a claim against Dr G. The case was settled for a moderate sum.

Learning points

Although the incidence of chickenpox is much lower in adults, the disease can lead to significant morbidity and mortality in the adult population. Those that are immunologically compromised are particularly at risk.

Remember that pregnancy is a state of immunocompromise, when many conditions may manifest as more severe or be associated with complications.

Remember the complications of varicella. It can lead to pneumonia and encephalitis in pregnant and non-pregnant patients. The mortality of varicella pneumonia in pregnant women is much higher than in non-pregnant adults. Chest symptoms in a pregnant woman with chickenpox should be an indication for close monitoring or admission.

Although many pregnant women with chickenpox do not require admission, it is good practice to review such patients closely on a regular basis.

From a risk management perspective, as well as for good patient care, it is important to have safety-netting procedures in place – for example, to advise patients of particular symptoms that they should alert their doctor to if these should develop, and if their condition worsens.