CHICKENPOX EXPOSURE IN PREGNANCY

Angela Storms

32 years, Female

Role-play cases simulate real clinical practice to guide how candidates respond to clinical scenarios and real life practice.

Name: Angela Storms
Age: 32 years
Gender: Female

Opening Scenario:
You are 20 weeks pregnant and recently attended a birthday party where you may have been exposed to chickenpox. You're feeling anxious about the potential risks to your baby, especially considering your fertility journey.

Your opening line: "I'm really worried because I was exposed to chickenpox last weekend, and I'm concerned about how this might affect my baby."
Additional Information (Provide only if asked relevant questions):

Symptoms / Problem:

At a birthday party last weekend, you were around a child who was later confirmed to have chickenpox.
Afterward, you spoke to your mother, who suggested you contact your GP. She recalls that you may have had chickenpox as a child and confirms that you were vaccinated.
Since the party, you’ve had several sleepless nights, worrying about the possible implications for your pregnancy.
You’re hoping the doctor can either reassure you that everything is okay or offer a test to check if the baby has been affected.

Medical History:

You underwent IVF treatment to achieve this pregnancy, making it even more precious to you.
You have no other significant medical issues.

Social History:

You work as a library assistant and are very happy with your job. You find your workplace supportive.
You are married, and your husband is very excited about the pregnancy. He’s aware of your concerns about the chickenpox exposure and agrees that it’s important to have it checked out.

Behaviour:
You are visibly anxious due to your history with IVF and the fear of any risk to your pregnancy.
Despite your worries, you remain hopeful and excited about the pregnancy.

Ideas,: You’re particularly anxious about how chickenpox might affect your baby, given the challenges you faced to conceive.
Concerns: You hope the doctor can reassure you or offer a test to confirm the baby’s health.
Expectations: You’re registered with a private antenatal clinic and are keen on ensuring that every aspect of your pregnancy is closely monitored.
Your husband’s support and excitement about the pregnancy add to your hope, but you still need professional reassurance to feel at ease.

You are a doctor in your routine clinic, ready to begin your day of consultations. A patient has been booked to see you,

Name: Angela Storms

Age: 32 years

Gender: Female

Past medical history: Nil

Medication: Folic acid

Last consultation, 3 months ago.

Patient currently pregnant, happy with news. Advised pregnancy vitamins. BP121/73. G1PO. Advise book with ANC, agreed to make appointment.

Positive and Negative Descriptors for Doctor's Performance

Global Task

Positive Descriptors:

Demonstrates a comprehensive understanding of the patient’s concerns and addresses them thoroughly.
Provides clear and accurate information about the risks of chickenpox during pregnancy.
Ensures the patient leaves the consultation feeling reassured and well-informed.
Demonstrates good judgment in deciding whether further investigations or tests are necessary.
Handles the case with empathy and professionalism, acknowledging the patient’s anxiety related to her IVF history.

Negative Descriptors:

Fails to address the patient’s specific concerns about chickenpox exposure during pregnancy.
Provides vague or incorrect information, leading to increased patient anxiety.
Misses the opportunity to reassure the patient or to offer appropriate follow-up.
Displays poor clinical judgment by not considering relevant tests or consultations.
Dismisses the patient’s concerns, leading to dissatisfaction or distrust.

Data Gathering

Positive Descriptors:

Asks open-ended and specific questions to gather detailed information about the exposure to chickenpox, medical history, and vaccination status.
Elicits the patient's concerns, including her anxiety due to IVF and the importance of this pregnancy.
Gathers relevant information about the patient's social and family support system.
Clarifies the timeline of events related to the exposure and any symptoms experienced by the patient.
Ensures a thorough review of the patient's antenatal care and any previous pregnancy-related tests.

Negative Descriptors:

Fails to ask key questions about the chickenpox exposure, such as duration and proximity to the infected child.
Overlooks important aspects of the patient's medical history, such as the IVF treatment.
Does not inquire about the patient's vaccination history or past exposure to chickenpox.
Misses the opportunity to understand the patient's support system and how it might affect her anxiety.
Neglects to review the patient’s antenatal care history or relevant previous test results.

Interpersonal Skills

Positive Descriptors:

Listens actively and empathetically to the patient’s concerns, allowing her to express her anxiety fully.
Communicates in a clear, reassuring manner, using language that is easily understood.
Demonstrates empathy by acknowledging the patient’s anxiety, especially in relation to her fertility journey.
Establishes a supportive and trusting relationship with the patient, encouraging open dialogue.
Responds to the patient’s emotional cues, providing comfort and reassurance as needed.

Negative Descriptors:

Interrupts the patient or fails to listen actively, leading to a lack of understanding of her concerns.
Uses medical jargon or unclear language, causing confusion or increasing the patient's anxiety.
Lacks empathy or dismisses the patient’s emotional concerns, particularly regarding her IVF experience.
Fails to build rapport, making the patient feel unsupported or misunderstood.
Ignores the patient’s emotional cues or appears indifferent to her anxiety.

Clinical Management

Positive Descriptors:

Provides a clear plan of action, including any necessary tests or follow-up appointments.
Discusses the potential risks of chickenpox exposure in pregnancy and how they can be managed.
Offers appropriate reassurance, explaining the implications of past vaccination and potential immunity.
Suggests suitable referrals or consultations if further expertise is needed.
Involves the patient in decision-making, respecting her wishes and concerns.

Negative Descriptors:

Fails to create a clear management plan, leaving the patient uncertain about the next steps.
Does not address the risks of chickenpox exposure adequately, potentially missing important clinical considerations.
Provides insufficient reassurance or fails to explain the significance of the patient’s vaccination history.
Does not consider or suggest further tests, referrals, or consultations when appropriate.
Excludes the patient from the decision-making process, leading to dissatisfaction or confusion.

These are the key issues in this clinical scenario.

Key Issues/Pointers:
Able to explain in clear concise manner about management of chickenpox rash or exposure in pregnancy.
Offer explanation based on patient’s immunization history
Avoid use of medical jargon – immunoglobulin, varicella, fetal varicella syndrome (etc)
Robust focused data gathering on clinical case/concerns and pregnancy, support and career.
Poor Performances
Failing to ask about pregnancy history or reassuring the pregnant woman who may be anxious and worried about baby.
Did not demonstrate holistic management of chickenpox exposure including evidence-based practice
Not offering explanation relevant to patient’s concerns, history
Poor explanations, use of medical jargons
Poor use of PSO and support systems for the pregnant woman
Did not provide thorough information and advice tailored to the patient's needs.
Missed health promotion opportunities

Here are the key management and referral guidelines:
Explain to pregnant mother
Using her immunization history (previous exposure/disease and vaccination = likely immunized) – this is reassuring to an anxious mum.
NICE/CKS: If the woman has a definite history of chickenpox or shingles or two doses of a varicella containing vaccine, and is not immunocompromised, reassure her that she is not at risk of chickenpox because immunity can be assumed.
If not immune, explain (without alarming patient) that they are at risk and may develop chickenpox.
Chickenpox in pregnant women can cause serious illness for mother (pneumonia, hepatitis, encephalitis) and the baby (fetal varicella syndrome = skin scarring, eye, brain, limbs) and important for check to make sure it doesn’t happen (please read in details of complications)
Offer blood tests asap
Testing for Varicella Zoster IgG antibodies, results available in 24-48 hours (local policies may differ).- Book next day follow-up to discuss results.
Advise that if IgG antibodies positive  evidence of immunity from past infection or immunization), the woman can be reassured that she is immune.
If Ig antibodies negative  urgently discuss with a specialist the need for prophylaxis (antiviral treatment or human varicella-zoster immunoglobulin [VZIG])..
If IgG antibodies negative, seen urgent A&G and/or refer to the obstetricians. Explain
Varicella Zoster Immunoglobulin (VZIG) is prophylaxis to prevent full disease, given as IV drugs.
Discuss follow-up after hospital visit. Explain if any new rash, fever, feeling unwell – contact asap (Safety netting advice).
NICE/CKS: Advise all women to promptly seek advice if they develop a rash and/or symptoms and have had contact with chickenpox (regardless of whether they have received anti-virals, VZIG or have a history of chickenpox, shingles, or varicella vaccine).
Direct patients to reliable sources for further information and exercise guidance
The NHS website.
Bumps
Offer written patient information, such as that from the Royal College of Obstetricians and Gynaecologists on Chickenpox and pregnancy.
Consider informing her midwife for follow-up.

Approach: Women’s Health.

Follow the consultation steps.
Ask about the pregnancy; number, order, previous pregnancy, LMP, was it difficult getting pregnant?
Ask about planned, accepted – do not be too quick to give congratulation without checking if appropriate. How does she feel about being pregnant?
Red flags; PV bleeding and discharge, Abd pain, fetalmovement if preg > 20 weeks + appropriate clinical red flag for case.
Past Medical History: Think DM, Epilepsy – folic acid requirement, complications in pregnancy.
Contraception and cervical smear
Partner – Where? Supportive? How do they feel about the pregnancy?
Finances and career (Impact, PSO)
ANC – Healthy Start Questions

Clinical Management
• Agenda setting in your clinical management – gives you structure.
• Laws regarding paternity testing: private, only licensed gov labs, will need to partner involvement (DNA testing consent: it is illegal to do any DNA test without consent) - https://www.gov.uk/paternity-pay-leave
• State you will talk about managing clinical and then other pregnancy aspects.
• If noted parts of healthy start not done, need to address.
• if unplanned pregnancy requesting TOP, will need contraception afterwards
• If pregnant asking about Down’s syndrome, need f/up to offer more support after screening.
• Keep medical options short and feasible. Address any emergency.
• Negotiate; show understanding of the unique situation pregnancy has on parenting, career, etc.

Healthy Start Scheme

Registered for ANC? – got their pregnancy pack? What has been done/shared? (open question)
Dating Scan – depending on age of pregnancy (some patient may have early private scans).
Vitamins – folic 400mcg (5mg in risk of neural defects, DM, epilepsy) + 10mg Vit D (10mcg daily)
Food to avoid: Vit A, liver, blue-cheese (Listeria), fish high in methylmercury or partially cook meats/fish/egg.
Fish to eat: healthy meals + peanuts (if not allergic), limit caffeine to 200mg (one mug daily, caffeine also present in coffee, tea, chocolate, and colas.
Annual flu vaccine
Lifestyle: Exercise, Smoking, Alcohol, Stress
Avoid OTC meds not prescribed – can speak to pharma
MATB1 certificate, Paternity Leave, NHS Prescription Exemption.