Skip to main content
UploadLanguage (EN)Support
BusinessMobileSocial MediaMarketingTechnologyArt & PhotosCareerDesignEducationPresentations & Public SpeakingGovernment & NonprofitHealthcareInternetLawLeadership & ManagementAutomotiveEngineeringSoftwareRecruiting & HRRetailSalesServicesScienceSmall Business & EntrepreneurshipFoodEnvironmentEconomy & FinanceData & AnalyticsInvestor RelationsSportsSpiritualNews & PoliticsTravelSelf ImprovementReal EstateEntertainment & HumorHealth & MedicineDevices & HardwareLifestyle
Fahmida Swati, profile picture
Uploaded byFahmida Swati
PPTX, PDF22 views

Chikungunya in Pregnancy. for BD Physician .pptx

High risk Pregnancy

Health & Medicine◦
Download to read offline
Pregnancy with Chikungunya & Zika Virus Infections Fahmida Rashid Swati FCPS, MS, MSc(UK), FRM(Infertility & ART) Assistant Professor, Obs & Gynae, CMC Infertility Specialist, CHEVRON Fertility Centre Country Representative-ASPIRE Member-REI subcommittee –SAFOG
Introduction World Population Lives in endemic regions 17% of all infectious diseases Globally: Vector-borne diseases > 1 million deaths/Year Major global health concerns Arboviral Disease: • Chikungunya • Dengue • Zika Pan American Health Organization. Chikungunya: Communicable Diseases and Health Analysis World Health Organization. 2020.
Global Cases of Arboviral Diseases in 2024 620000 24000 Zika Chikungunya https://www.who.int/initiatives/global-arbovirus-initiative DOI: 10.1038/s41467-025-62640-x 7.6 million dengue
Mosquito vectors : Ae. aegypti & Ae. albopictus Chikungunya virus [alphavirus] Zika virus [flavivirus] Dengue virus [flavivirus] Can cocirculate & Coinfect in a geographic region Mode of Transmission of Chikungunya__Zika_Dengue Virus Infection:
A mosquito bites a person with Chikungunya/Zika Mosquitoes become infective after virus multiplying 10 days within mosquito Infective mosquito bites a Healthy person Incubation period: Chikungunya:3-7days Zika: 3-14 days Fever persists for 3-10 days Chikungunya: High Grade Zika: Low Grade Mode of Primary Transmission of Chikungunya__Zika Virus Infection: • Daytime biters, • Peak in early morning & late afternoon https://www.cdc.gov/chikungunya/php/transmission/index.html
Chikungunya Fever: Other route of Transmission Maternal-fetal Transmission: 3rd Trimester Mainly Blood products (rare) Panning M et al, 2008
Mosquito Bite: Infected Aedes aegypti, A. albopictus Blood Products Organ and Tissue Transplant (rare) Maternal-fetal Transmission Sexual Transmission (male or female partners) Laboratory Exposure Fertility Treatmen t Breastfeedin g Rare Zika : Other Modes of Transmission Intrauterin e Perinatal https://www.cdc.gov/zika/php/transmission/index.html
Zika Virus & Sexual Transmission Modes of Sexual Transmission Spread through vaginal, anal, oral sex, via sharing sex toys Virus persists longer in semen than in vaginal fluids, urine, or blood Can occur before symptoms, during illness, after recovery — even if no symptoms develop https://www.cdc.gov/zika/php/transmission/index.html
• ֎Female traveler: • Use barrier method or abstain for at least 8 weeks after return, symptom onset, or diagnosis • ֎Male traveler: • Use barrier method or abstain for at least 6 months after return, symptom onset, or diagnosis After Travel to Zika-Risk Areas/After being Infected Prevention of Sexual Transmission of ZIKA
Chikungunya Fever in Pregnancy
Chikungunya fever : Rapid geographic spread & Large outbreaks – 2013–2017 Africa, Asia, Indian Ocean islands, Europe, Americas > two million suspected cases in recent decades • CHIK Virus : A Single-stranded RNA virus Pan American Health Organization. Chikungunya: Communicable Diseases and Health Analysis World Health Organization. 2020.
Viremia develops within days of infection Viral invasion & replication in joints(Fibroblast), synovium, tenosynovium, & skeletal muscle satellite cells, myotendinous insertions Inflammatory response: proinflammatory cytokines, chemokines → leukocyte recruitment Clearance: virus cleared from blood in days; joints in 1–2 weeks Viral RNA persistence: may remain in tissues for weeks–months (variable findings) Chronic arthritis persists (~70% at 3 months) Pathogenesis: Chikungunya fever: Epidemiology, clinical manifestations, and diagnosis. In UpToDate. Retrieved October 3, 2025
Skin Epithelial Attack The virus affects skin epidermis, leading to rash and discomfort.
Pregnancy Susceptibility and Risk Factors of Chikungunya Infection Susceptibility ↑ risk due to immune changes Endemic or epidemic Regions 90% pregnancies in risky areas Higher risk of adverse pregnancy outcomes In last trimester
Maternal Outcome during Pregnancy Symptoms Mimic Pregnancy-Related Discomforts Generally, no significant harm to mother or fetus Some link to- Pre-eclampsia Sepsis Hemorrhage
Maternal and Fetal Complications:Vertical transmission 2–48% 3rd trimester Risk of transmission highest in during intrapartum period (2 days before delivery -2 days after delivery)
Maternal Monitoring • Viremic mothers near delivery require close monitoring due to ~50% vertical transmission risk Chikungunya fever: Epidemiology, clinical manifestations, and diagnosis. In UpToDate. Retrieved October 3, 2025
No evidence of ↑↑ miscarriage or malformations Maternal-fetal transmission in Symptomatic women : 1st Trimester Chikungunya fever: Epidemiology, clinical manifestations, and diagnosis. In UpToDate. Retrieved October 3, 2025
Chikungunya transmission during pregnancy Transmission prevention C-section or postponing delivery does not prevent transmission. Pregnancy risks Unlike dengue, there is no risk of ↑ abruption, hemorrhage, preterm birth, or LBW.
Clinical Presentation Exposure to Virus Symptoms Appear 3-7 days later Viremia Stage First 5-7 days Convalescent Stage: Next 10 days Chronic Phase Persistent symptoms > months - yr Acute phase illness Virus cannot be detected in the blood Joint pain & fatigue
CLINICAL MANIFESTATIONS: a s, Acute Chikungunya Infection Incubation: 3–7 days (range 1–14) Duration of acute illness : 7–10 days Onset: Abrupt – fever, malaise; joint pain may precede fever Fever: High grade (>39°C), lasts 3–5 days Musculoskeletal: Arthralgia (70%), rapid polyarthritis, bilateral & symmetric, distal joints, synovitis, tenosynovitis, ↓ grip strength Dermatologic: Rash (40–75%), pruritic; atypical – bullous lesions (children), hyperpigmentation, ear chondritis Other: Headache, myalgia, conjunctivitis, lymphadenopathy, GI upset, oral ulcers Chikungunya fever: Epidemiology, clinical manifestations, and diagnosis. In UpToDate. Retrieved October 3, 2025
Severe Complications : In mainly in elderly, children, comorbidities Systemic: Respiratory failure, myocarditis, CV decompensation, hepatitis, renal failure, hemorrhage Neurologic: Meningoencephalitis Guillain-Barré syndrome, myelitis, seizures (children), cranial palsies Ocular: Uveitis, retinitis, episcleritis, hearing loss Rare: Skin necrosis Mortality: Reported in major outbreaks Chikungunya fever: Epidemiology, clinical manifestations, and diagnosis. In UpToDate. Retrieved October 3, 2025
Chronic Arthritis & Arthralgia Prevalence: 25–75% develop chronic musculoskeletal disease Persistence: Months–years; median resolution ~6 months Risk factors: Age ≥45, severe acute arthritis, pre-existing OA, >4 days acute symptoms Imaging/biopsy: Inflammatory arthritis changes Chikungunya fever: Epidemiology, clinical manifestations, and diagnosis. In UpToDate. Retrieved October 3, 2025
Infection at paediatric ages, neonates and small infants <6 months : highest risk for case fatality & lifelong disabilities
Fetal Complications of Chikungunya Fetal Complications Antepartum Fetal Deaths In 2nd & 3rd trimesters(rare) Labor Issues common- FHR decelerations & meconium-stained liquor Chikungunya fever: Epidemiology, clinical manifestations, and diagnosis. In UpToDate. Retrieved October 3, 2025 Preterm Labour Fetal loss
Neonatal Infection – due to Vertical Transmission Onset: 3–7 days after delivery & Low or undetectable viral load at birth Clinical features: Most of the infected neonates were born healthy, But later develop CHIKV sepsis clinical syndrome within the first week of life- Fever, poor feeding, petechiae, skin rash, intertriginous aphthous-like ulcer, peripheral edema Neurodevelopmental outcomes: Delayed coordination, language, movement/posture, sociability Confirm: Detection of chikungunya viral RNA via RT-PCR or IgM- & IgG-specific serology Lab abnormalities: ↑ Liver enzymes ↓ Lymphocytes Thrombocytopenia, ↑ Prothrombin time Chikungunya fever: Epidemiology, clinical manifestations, and diagnosis. In UpToDate. Retrieved October 3, 2025
Life- Threatening Complications occurs in ½ of the neonates Lethargy CHIKV-associated CNS Disease Multiple Organ Dysfunction Syndrome Hemorrhages disseminated intravascular Coagulation) Life-Threatening Complications in Neonates Encephalopathy or encephalitis Cerebral edema Intracranial hemorrhage Circulatory Collapse Myocardial involvement
Diagnosis
Diagnosis Challenging →Due to overlapping features with dengue and other arboviruses. Detect Viral RNA Detection of viral RNA through molecular tests Identify Antibodies Detection of virus- specific antibodies in blood Blood test
Clinical suspicion: Acute onset of fever + polyarthralgia Epidemiologic exposure (travel/residence in endemic area) Day 1–7(Acute Phase) : RT-PCR (RNA virus in Blood) Positive confirms CHIKV infection Detects viral RNA with Sensitivity 100%, Specificity 98% Day ≥8(Subacute/Chronic) or (-)ive RT-PCR: Serology (ELISA) +ive IgM or IgG confirms infection IgM: Detectable ~Day 5, persists for weeks–3M IgG: Appears ~2 weeks, persists for years → indicates past infection Positive IgG indicates prior infection, not necessarily current arthritic symptoms Chikungunya fever: Epidemiology, clinical manifestations, and diagnosis. In UpToDate. Retrieved October 3, 2025
Test for dengue and Zika viruses, as symptoms overlap A single PCR test for CHIKV, dengue, and Zika is available In pregnancy Rule out other causes of fever/arthralgia (e.g., parvovirus, rubella) to guide management Chikungunya fever: Epidemiology, clinical manifestations, and diagnosis. In UpToDate. Retrieved October 3, 2025
Management of Pregnant Patient
Treatment of Chikungunya Infection in Pregnancy: : General Principles Rx depends on disease phase & symptom severity No specific antiviral therapy; Mx: supportive & symptomatic Pregnancy requires cautious medication use to minimize fetal risks, especially during viremia (first ~9 days) Chikungunya fever: Treatment and prevention. In UpToDate. Retrieved October 3, 2025,
Acute Phase (First 7–10 Days, Up to 1 Month): Supportive Care: Rest, hydration Acetaminophen (Paracetamol): First-line for fever/pain (500–1000 mg, 3x daily). NSAIDs (e.g., Naproxen, Ibuprofen): If acetaminophen inadequate& dengue excluded Opioids (e.g., Tramadol, Oxycodone): For severe pain – lowest dose, shortest duration. Topical Treatments: Calamine lotion, antihistamines for rash/itching Systemic glucocorticoids: Avoid during the acute phase [exacerbate viremia] Lowest dose & shortest duration: Naproxen 375–500 mg twice daily, Ibuprofen 400–800 mg three times daily Contraindication: 3rd trimester (fetal ductus arteriosus closure risk). Chikungunya fever: Treatment and prevention. In UpToDate. Retrieved October 3, 2025,
Post-Acute Phase (1–3 Months): Symptoms: Persistent joint pain, tendinitis, or bursitis. Continue acetaminophen/NSAIDs at minimal doses; attempt to taper/discontinue. Glucocorticoids: Use glucocorticoids cautiously during pregnancy & Monitor fetal safety. Indication: For severe synovitis with elevated inflammatory markers Dose: prednisone 10–20 mg daily for 5 days, tapered over 10 days. Chikungunya fever: Treatment and prevention. In UpToDate. Retrieved October 3, 2025,
Chronic Phase (>3 Months): Symptoms: Chronic arthritis , resembling rheumatoid arthritis or spondyloarthritis Confirm CHIKV with IgG serology; Rule out other arthritis DMARDs: Sulfasalazine (SSZ) Glucocorticoids: Low-dose prednisone (5–7.5 mg daily) or SSZ if needed, with obstetric consultation. Chronic Arthritis Impact: May affect maternal mobility and caregiving; Mx: supportive care & physical therapy. Chikungunya fever: Treatment and prevention. In UpToDate. Retrieved October 3, 2025,
Chikungunya Vaccine Development : Current Status Pregnancy data are limited, & Most public-health organisations recommend deferring routine chikungunya vaccination until after delivery Authorized : one live-attenuated vaccine (IXCHIQ/VLA1553) and one non-replicating/virus-like-particle vaccine
in Pregnancy
Why is it called Zika Virus(ZIKV)??? Zika Virus Named after Zika Forest Uganda 1947 Major outbreaks: • French Polynesia (2013–14) • Brazil (2015–16) | DOI:10.1038/s41598-017-00253-1
Why important now? Petersen E et.al. 2016 at http://wwwnc.cdc.gov/eid Zika Virus Spreads Rapidly Microcephaly Rise Global Emergency Linked to congenital anomalies & impaired neurodevelopment Declared by the WHO- 2016 Zika Virus Rapid spread in Americas Petersen E et al. 2016 at http://www.cdc.gov/eid
Zika in Pregnancy Pros Cons No increased susceptibilit y Limited information Infection can occur in any trimester No evidence of severe disease in pregnancy No breastfeeding spread Unknown incidence
Incubation Period Viremia Duration Infected Pregnant Women Semen Persistence In some, Zika virus persists in blood longer than expected 3–14 days. Few days to 1 week. The virus remains in semen longer than in blood. Incubation and viremia
Fever (Low Grade: 37.8°C and 38.5°C) Maculopapular rash (often pruritic) Myalgia/ Arthralgia (small Joint of hand & Feet),swollen Conjunctivitis Symptoms appear 3–14 days post- exposure Maternal Clinical Features: range from mild to severe Symptoms: • Often mild • ~20% symptomatic [1 in 4 ]
Post-infection asthenia Prolonged weakness after infection Neurological complications Retro-ocular Headache Zika symptoms range from mild to severe complications. Guillain–Barré syndrome reported
Clinical features Feature Chikungunya Zika Dengue Fever +++[High] ++[Low] +++ Rash ++ +++ + Conjunctivitis - ++ - Arthralgia +++ ++ + Myalgia + + ++ Headache ++ + ++ Hemorrhage - - ++ Shock - - -
DIAGNOSES & TESTING FOR ZIKA NO test if NO travel history to risk area Test if ≥2 symptoms during or within 2 weeks of travel
Ask about travel/residence or unprotected sexual contact with persons from endemic areas Symptomatic pregnant patients Test ASAP Serum & urine for ZIKV rRT-PCR [NAAT] + IgM; Test for dengue concurrently Asymptomatic with ongoing exposure rRT-PCR [NAAT] up to 3 times during pregnancy Asymptomatic with limited exposure Individualized testing Diagnosis of ZIKA in Pregnancy NAAT: nucleic acid amplification test Zika virus infection: Evaluation and management of pregnant patients. In UpToDate. Retrieved October 3, 2025
Zika Virus Diagnostic Timeline in Pregnancy Paired Serum Samples First 2 Weeks Up to 12 Weeks Any Time Acute Infection Diagnosis rRT-PCR detects viral RNA in maternal serum, urine, or amniotic fluid Serological Testing Plaque reduction neutralization test(PRNT) identifies virus- specific neutralizing antibodies Tissue Analysis IgM & neutralizing antibodies tested in serum, may cross- react with other flaviviruses Immunohistochemical (IHC) staining or RT-PCR on fixed tissues detects viral antigens
How can Zika affect pregnancies? Pass from a pregnant woman to fetus during pregnancy Or around time of birth
Risk throughout pregnancy • Reported vertical transmission rates: 26–65% Transmission occurs in symptomatic & asymptomatic mothers Vertical Transmission Zika virus infection: Evaluation and management of pregnant patients. In UpToDate. Retrieved October 3, 2025
FIRST TRIMESTER Disrupting neurogenesis Leads to severe congenital neurological abnormalities: Absent or poorly developed brain structures Including microcephaly DURING PREGNANCY Congenital Zika syndrome Linked to – miscarriage, stillbirth, Birth defects: Eye, ear(hearing),Impaired growth Transmission in FIRST TRIMESTER Zika virus infection: Evaluation and management of pregnant patients. In UpToDate. Retrieved October 3, 2025
Maternal infection Placental infection Fetal brain ZIKV targets neuronal progenitor cells Disrupts growth, proliferation, migration, differentiation Impaired neurodevelopment Greatest vulnerability in first half of pregnancy Congenital Infection – Pathogenesis Zika virus infection: Evaluation and management of pregnant patients. In UpToDate. Retrieved October 3, 2025
Congenital Zika Syndrome and Birth Defects Severe Microcephaly(Primary/Secondary) → partially collapsed skull ↓Brain Tissue with brain damage Ventriculomegaly, cortical malformations Defects Limited Joint Motion---Club foot Arthrogryposis[multiple congenital joint contractures] ↑Muscle Tone→ restricting body movement soon after birth Distinct pattern of birth defects in fetuses & infants Ocular abnormalities: maculopathy, optic nerve changes Damage to back of eye with a specific pattern of scarring & ↑ pigment Intracranial calcifications Growth restriction, fetal loss Zika virus infection: Evaluation and management of pregnant patients. In UpToDate. Retrieved October 3,
Head circumference >2 SD below mean or <3rd percentile Previous infection will not affect future pregnancies Can be proportionate or disproportionate May develop postnatally (secondary microcephaly) More frequent with first-trimester infection Microcephaly Zika virus infection: Evaluation and management of pregnant patients. In UpToDate. Retrieved October 3, 2025
• For all lab- confirmed ZIKV Prenatal ultrasound every 3–4 weeks • Earliest abnormalities detected USG at ~18–20 weeks • Every 4 weeks (at least one between 28– 33 weeks) Serial scans • For clarification of abnormal USG MRI Antenatal Monitoring: Fetal Imaging • Recommend: Referral to a maternal- fetal medicine specialist If Positive or inconclusive Zika virus testing results in serum or amniotic fluid Zika virus infection: Evaluation and management of pregnant patients. In UpToDate. Retrieved October 3, 2025
Zika Infection Monitoring and Detection During Pregnancy Detect Microcephaly Detect Brain Abnormalities Grade Severity Based on HC From 2nd trimester onward.
Range of Microcephaly Severity Severe microcephaly – limited life expectancy & poor brain function: Neurological impairment, epilepsy, cerebral palsy, intellectual disability, feeding difficulties, vision/hearing impairment. HC > –3 SD below the mean. HC –2 to –3 SD below the mean symptomatic or have milder developmental delay
What to test in Pregnancy to confirm Vertical Transmission? Antepartum Consider amniocentesis if abnormal ultrasound and/or positive maternal test: RT-PCR Zika virus infection: Evaluation and management of pregnant patients. In UpToDate. Retrieved October 3, 2025
Amniocentesis Timeline Consider if: – Abnormal fetal USG – Positive or inconclusive maternal ZIKV test – Results affect pregnancy Mx Best timing: ≥21 weeks gestation & at least 6–8 weeks after maternal infection (allows virus to reach amniotic fluid) Positive rRT-PCR in amniotic fluid = Indicate fetal exposure (but not predictive of severity) Negative rRT-PCR does not exclude fetal infection Zika virus infection: Evaluation and management of pregnant patients. In UpToDate. Retrieved October 3, 2025
Postnatal/ Placental Testing Timeline At delivery (if maternal ZIKV infection suspected): Test placenta & cord by rRT-PCR & IHC Evaluate newborn for congenital ZIKV syndrome Serology of cord blood[IgM and neutralizing antibodies] For fetal loss/stillbirth: ZIKV rRT-PCR & histopathology on fetal tissues, placenta, cord Zika virus infection: Evaluation and management of pregnant patients. In UpToDate. Retrieved October 3, 2025
Neonatal screening • Measure after 24 hours of birth Head circumference • with standard nomogram Compare • USG/CT/MRI of brain If microcephaly Zika virus infection: Evaluation and management of pregnant patients. In UpToDate. Retrieved October 3, 2025
Assessment: neurologic abnormalities, dysmorphic features, enlarged liver or spleen, and rash/other skin lesions Specialist Consultation for any abnormal findings Ophthalmologic Evaluation before hospital discharge or within 1 month after birth Hearing Evaluation by evoked otoacoustic emissions testing or auditory brainstem response testing before hospital discharge or within 1 month after birth Evaluation for all infants with positive or inconclusive Zika virus test results Zika virus infection: Evaluation and management of pregnant patients. In UpToDate. Retrieved October 3, 2025
Long-term follow-up of infants with positive or inconclusive Zika virus test results Hearing screen at 6 months & audiology follow-up of abnormal newborn hearing screening Continued evaluation of developmental characteristics- milestones & HC, through 1st year of life Consultation with appropriate medical specialists (e.g., pediatric neurology, developmental and behavioral pediatrics, physical and speech therapy) if any abnormalities are noted and as concerns arise
Zika and Guillain-Barre Syndrome Case Rate 2.3 Guillain-Barré cases per 1,000 Zika patients. 1 Zika and Guillain- Barre Association 2 WHO Discussion
Management of Pregnant Patient
No specific antiviral treatment Symptomatic management: rest, fluids, acetaminophen Avoid NSAIDs until dengue ruled out & after 32 weeks gestation Psychosocial support for affected families Management of Pregnant Patient No vaccine or medications or anti-viral Rx are available to prevent or treat Zika infections. Avoid Mosquito Bites in 1st week pf Infection . It Prevents further transmission Zika virus infection: Evaluation and management of pregnant patients. In UpToDate. Retrieved October 3, 2025
Labor & Delivery Routine obstetric policies for timing and mode of Delivery Spinal/Epidural anaesthesia safe if no Guillain-Barré syndrome Evaluate placenta/cord post-delivery if maternal infection suspected Zika virus infection: Evaluation and management of pregnant patients. In UpToDate. Retrieved October 3, 2025
• It is Not a medical treatment for Zika • But an option in context of poor fetal prognosis suspected. • Role determined by local laws, maternal choice, and ethical frameworks Role of Termination of pregnancy in cases of Zika-related Severe microcephal y Aiken A, Aiken CE, Trussell J. In the midst of Zika pregnancy advisories, termination of pregnancy is the elephant in the room. BJOG. 2017;124(4):546-548. doi:10.1111/1471-0528.14296
Prevention No vaccine available yet Avoid travel to ZIKV areas if pregnant Strict mosquito protection Sexual transmission prevention Follow blood donation & standard precautions Zika virus infection: Evaluation and management of pregnant patients. In UpToDate. Retrieved October 3, 2025
Take-Home Message – Chikungunya in Pregnancy Pregnancy does not markedly worsen maternal illness, but vertical transmission can occur, particularly if the mother is viremic at delivery. Most pregnancies have a favourable outcome; Neonates infected intrapartum may develop sepsis-like illness, encephalitis or long-term neurodevelopmental problems. No vaccine or specific antiviral treatment exists in Pregnancy; Care : supportive Prevention is critical
Take-Home Message – Zika Virus in Pregnancy Infection can occur in any trimester - often mild, Congenital Zika syndrome - result from first-trimester exposure Congenital Zika syndrome: severe microcephaly, cortical malformations, eye lesions, clubfoot, hypertonia and long- term neurodevelopmental impairment. No vaccine or specific antiviral therapy; Mx is supportive Prevention remains the mainstay All pregnant women with possible exposure should be counselled & tested appropriately Serial fetal ultrasound every 3– 4 weeks is recommended if infection is suspected or confirmed. Infants of exposed mothers require cranial imaging, ophthalmic and auditory evaluation, and long-term developmental follow-up.
Thank You