Journal of Midwifery & Women’s Health www.jmwh.

org
Clinical Rounds

Herpes Zoster in Pregnancy

Robyn Schafer1 , CNM, MSN , Melissa Davis2 , CNM, DNP, FNP-BC , Julia C. Phillippi2 , CNM, PhD

Herpes zoster (shingles) is the reactivation of dormant varicella zoster virus in individuals who previously experienced varicella infection or
vaccination. Herpes zoster can occur in pregnancy, although it is rare. This case report describes the clinical presentation and diagnosis of herpes
zoster and reviews current recommendations for treatment. Preventative measures and the role of immunization are discussed in addition to
clinical implications for intrapartum, postpartum, and newborn care to guide practitioners in caring for women experiencing or exposed to
herpes zoster in pregnancy.
J Midwifery Womens Health 2019;00:1–6  c 2019 by the American College of Nurse-Midwives.

Keywords: herpes zoster, shingles, varicella zoster virus, pregnancy complications, infectious, midwifery

CASE STUDY
L.K., a 32-year-old gravida 6, para 4014 with no signif-
icant health history, presented for her 35-week antepar-
tum visit concerned about a “bumpy rash”, which she
described as painful and itchy, on her right breast and
back. She explained that she first noticed the lesions about
2 days ago and thought they were spider bites. She did not
have any generalized symptoms such as headache, fever, or
malaise. She reported no recent outdoor activities, travel,
family illnesses, or exposure to anyone with rashes or
viruses.
On examination, the midwife observed a 3-cm erythe-
matous area with grouped vesicular lesions on the right
upper back and a similar 4-cm area on the upper outer
quadrant of the right breast, along the bra line. Both clus-
ters of lesions were located within the T4 dermatome. Af-
ter reviewing the health history, the midwife noted that
L.K. had documented immunity to varicella zoster (chick-
enpox). Based on this clinical presentation, the midwife
suspected that L.K. was experiencing acute herpes zoster,
commonly known as shingles.
The midwife explained the condition to L.K. and dis-
cussed options for treatment, including antiviral medica-
tions or expectant management with comfort measures. Af-
ter a review of the risks and benefits, L.K. elected to start
antiviral therapy, stating that she hoped to hasten the heal-
ing process and decrease the likelihood of being contagious
postpartum and possibly infecting her newborn. The mid-
wife prescribed acyclovir (Zovirax) 800 mg 5 times daily
for 7 days. She also discussed comfort measures and edu-
cated L.K. about contact precautions to prevent spread of
the infection to individuals who were not immune to vari-
cella. At her next visit, 10 days after presenting with the
1 in those aged more than 50 years.1,2 The CDC estimates
Division of Advanced Nursing Practice Rutgers School of
Nursing, Newark, New Jersey
2
Vanderbilt University School of Nursing, Nashville,
Tennessee
Correspondence
Robyn Schafer
Email: Robyn.Schafer@vanderbilt.edu
lesions, L.K. explained that she had stopped taking the pre-
scribed medication after 3 days. She stated that the lesions
were much less painful and itchy and that she had no new
symptoms. Examination revealed that the erythema had di-
minished significantly and that the lesions had become dry
and crusted over.
After consulting with the rest of the care team and Cen-
ters for Disease Control and Prevention (CDC) guidelines,
the midwife advised L.K. that it was not necessary to restart
antiviral therapy and that she could receive standard care
for the remainder of her pregnancy, without any indication
for increased antepartum fetal surveillance, induction of
labor, or breastfeeding restrictions.
One week later, L.K. went into spontaneous labor. On
admission, the lesions were noted to be dry and reduced
in size, without any evidence of a secondary infection. L.K.
had a normal, vaginal birth and breastfed successfully. The
pediatric care team was notified of the previous herpes
zoster outbreak, and after an unremarkable assessment,
L.K.’s newborn received standard neonatal care and timely
discharge. Contact was established with the outpatient pe-
diatric provider to ensure continuity of care. At her post-
partum visit, L.K. reported that her lesions had resolved
spontaneously without sequelae and that her newborn was
healthy and nursing well.
INTRODUCTION
Varicella zoster virus is a human alpha herpesvirus that causes
both varicella (chickenpox) and herpes zoster (shingles). Her-
pes zoster is not a reportable infection, so its exact preva-
lence is unknown. Approximately 1 out of every 3 people in
the United States are projected to experience herpes zoster
over the course of their lifetime, with the majority (68%)
of cases occurring in immunocompromised individuals or
1,000,000 cases of herpes zoster annually in the United States.2
In women of reproductive age, the overall incidence is 2
cases per 1000 (age adjusted for the 2000 US population),3
affecting an estimated 1 in every 20,000 pregnancies.4
However, rates of herpes zoster among adults are steadily
rising,5 and the CDC states that the reason for this long-term

1526-9523/09/$36.00 doi:10.1111/jmwh.12953 
c 2019 by the American College of Nurse-Midwives 1
 Figure 1. Herpes Zoster Outbreak
Reprinted with permission from Diepgen and Yihune.6

upward trend has not yet been identified.2 This article re-
views the pathophysiology and clinical presentation of her-
pes zoster; describes approaches to its diagnosis, treatment,
and prevention; presents up-to-date information about im-
munization; and discusses clinical implications to guide prac-
titioners in caring for women experiencing or exposed to
herpes zoster in pregnancy.

PATHOPHYSIOLOGY
The first time that varicella zoster virus infects a host, it causes
varicella (chickenpox). After this initial infection resolves, the
virus lies dormant in the dorsal root ganglia, most often in
the spinal nerves. A similar process happens after vaccination.
The varicella zoster virus can become reactivated as immu-
nity naturally wanes over time or in cases of immunosuppres-
sion. When this happens, the virus manifests as herpes zoster
(shingles).
CLINICAL PRESENTATION
In both pregnant and nonpregnant adults, the most common
symptom of herpes zoster is an erythematous papulovesicu-
lar cutaneous eruption, most commonly on the torso or back
(see Figure 1). Zoster lesions are unilateral, not crossing the
midline of the body. Usually only one dermatome is affected,
but in more severe cases, multiple adjacent dermatomes can
be involved (see Figure 2). The most commonly affected der-
matomes innervate the thorax, head, or neck. In pregnant
women, outbreaks are most common in the scapular and in-
tercostal area, right along the bra line.8 In rare and serious
cases, cranial or central nerves can be affected, potentially
leading to ocular or neurologic complications.
Typical progression of herpes zoster involves a prodromal
period, followed by active lesions, then a gradual resolution,
Figure 2. Dermatome Map
Reprinted with permission from Modric.7
with pain being the last symptom to resolve. During the pro-
dromal stage, approximately 80% of individuals experience
preherpetic neuralgia, often described as itching, tingling, or
burning in the affected area within 5 days prior to eruption
of lesions.8 Other prodromal symptoms, such as a headache,
fatigue, malaise, or low-grade fever, occur in less than 20% of
individuals.9 Lymph nodes that drain the affected area may
also become enlarged and tender.10
After prodromal symptoms, an erythematous macular
rash develops. These flat, reddened areas are often subtle and
might otherwise go unnoticed if not for feelings of itching
and irritation. After this initial rash, erythematous papules de-
velop within the reddened areas and transition into grouped
vesicles or bullae (blisters). These fluid-filled lesions are con-
tagious, excreting live varicella zoster virus that, if directly
contacted by a non-varicella-immune individual, could lead
to a primary varicella infection.
Over a period of 7 to 12 days, these vesicles evolve into
pustular lesions, then proceed to ulceration and crusting.8

2 Volume 00, No. 0, xxxx 2019

Once lesions are crusted and dry, they are no longer con-
tagious. Crusted lesions may remain for several weeks. The
majority of lesions heal well without any intervention or
permanent skin changes, although scarring or alterations in
pigmentation can occasionally persist long term. Women’s
genetic makeup and predisposition to scarring appear to have
more influence on persistent skin changes than the use of any
specific treatment modalities.
Rarely, serious complications with herpes zoster can
occur. In about 10% of individuals, persistent pain known
as postherpetic neuralgia can develop in the affected
dermatome.9 Postherpetic neuralgia is diagnosed when pain
persists for a considerable time (longer than 30 to 90 days)
after resolution of the lesions; this nerve pain can last for
months or even years after the acute zoster outbreak.11 Other
less likely complications include superimposed bacterial
infections, cutaneous dissemination, ocular complications
(herpes zoster ophthalmicus), meningitis, pneumonitis, hep-
atitis, cranial or peripheral nerve palsies, and Ramsay Hunt
syndrome (herpes zoster oticus).2,12,13 Such complications
and adverse sequelae from herpes zoster are more common
in people who are older or immunocompromised. Although
pregnancy may be considered a state of immunosuppression,
there is no evidence that pregnancy is a risk factor for severe
sequelae to herpes zoster.
DIAGNOSTIC APPROACHES
Diagnosis of herpes zoster is typically based on clinical pre-
sentation with a reported history of varicella infection or vac-
cination. Symptomatology is usually sufficient for diagnosis,
because common differentials such as impetigo, contact der-
matitis, folliculitis, scabies, insect bites, papular urticaria, can-
dida, dermatitis herpetiformis, and drug eruptions do not
have the unique characteristics of a herpes zoster outbreak as
outlined above.10 However, herpes simplex virus (HSV) in-
fection may occur in a dermatomal distribution and be mis-
taken for herpes zoster; therefore, HSV screening may be war-
ranted in cases of recurrent lesions. In instances in which pain
is severe along the thoracic dermatomes and lesions have not
yet erupted, prodromal symptoms may seem suspicious for
gallbladder disease, appendicitis, or myocardial infarction.8
When lesions present in an atypical pattern and additional
diagnostic approaches are warranted, polymerase chain reac-
tion (PCR) testing of lesions or other bodily fluids is preferred
over other methods, such as direct immunofluorescence assay
or viral cultures, because of its high sensitivity and specificity
and quickly available results.2,12,14
In standard prenatal care, routine serologic testing for
varicella immunity is not required. However, all pregnant
women should be assessed for immunity through a de-
tailed health history regarding prior varicella infection or
vaccination.14 If a pregnant woman has no history of either,
documentation of immunity can be accomplished with the use
of varicella IgG serology. Serologic testing can also be used to
differentiate a primary varicella infection from a herpes zoster
outbreak and guide postpartum vaccination in non-varicella-
immune women.2,15 However, it is important to note that IgG
and IgM results can be difficult to interpret and have limited
usefulness in confirming herpes zoster. Serologic testing is
Journal of Midwifery & Women’s Health r www.jmwh.org
Table 1. Antiviral Treatment Options for Herpes Zoster During
Pregnancy
Dosing, Frequency, Duration,
Medication mg Route per d d
Acyclovir 800 Oral 5 7-10
(Zovirax)
Valacyclovir 1000 Oral 3 7
(Valtrex)
Note: Although famciclovir (Famvir) and brivudin (Zostex) may be used in
nonpregnant individuals, they are not recommended in pregnancy or lactation.12,17
only recommended when clinical presentation is unclear and
adequate samples of vesicular or crusted lesions are unavail-
able for PCR testing.2
TREATMENT
In treating herpes zoster, the goals are to decrease dura-
tion and severity of the lesions, relieve painful or pru-
ritic symptoms, and prevent complications and transmis-
sion. As in all health care, treatment should be customized
to meet the woman’s preferences and individual needs. In
pregnant women, pharmacologic treatment is often appro-
priate, but not essential, to shorten the duration and sever-
ity of the outbreak, minimize pain from neuritis, decrease
viral shedding, and reduce the likelihood of postherpetic
neuralgia.8,9 Although antiviral medications have not been
studied prospectively in pregnant women, retrospective stud-
ies do not demonstrate any increased risk in this population,
and these medications are generally considered safe for use in
pregnancy.16
Antiviral medications are most helpful when initiated
within 72 hours of onset of dermatological symptoms.11
Common medications used for antiviral therapy along with
their appropriate dosage and duration are presented in
Table 1. Typical recommended oral dosages are acyclovir
(Zovirax) 800 mg 5 times a day for 7 to 10 days or valacy-
clovir (Valtrex) 1000 mg 3 times a day for 7 days.17 In the
nonpregnant population, valacyclovir is often preferable
because of ease of dosing and higher levels of antiviral drug
activity.12 However, acyclovir has the greatest evidence of
safety in pregnancy for the fetus and proven efficacy in
shortening the duration of herpes zoster symptoms and viral
shedding.14,18 Valacyclovir can be substituted if the required
5 times daily dosing of acyclovir presents problems in treat-
ment adherence, as the drugs have similar safety profiles.18
Intravenous administration may be considered for severe or
complicated cases or for immunocompromised individuals.8
Neither corticosteroids nor topical antiviral treatments are
recommended for treatment of herpes zoster or its associated
symptoms in pregnant women.11
Herpes zoster is not highly contagious; however, it does
have the potential to cause varicella in nonimmune individ-
uals. Contact precautions should be taken to limit spread of
the virus. Although rare instances of airborne transmission
have been reported, preventing direct contact with lesions in
the acute phase is all that is recommended.19 Until lesions
are crusted over, it is best to keep the affected area clean and
3
covered with a nonocclusive, nonstick sterile bandage such as
gauze. Steps should be taken to avoid any direct contact be-
tween non-varicella-immune individuals and contagious le-
sions or any items that may have contacted them, such as used
bandages or bath towels.13
For women experiencing pain or pruritis, recommended
comfort measures include the use of cool, wet compresses
soaked in tap water or Burrow’s solution or immersion in
a bath with colloidal oatmeal.17,20 Application of topical lo-
tions or creams containing calamine, pramoxine, or menthol
may be soothing and can be especially comforting when kept
cool in a refrigerator.10 Alternatively, oral or topical diphen-
hydramine (Benadryl) may be used. Small amounts of topical
lidocaine may be beneficial for relief of superficial pain, with
acetaminophen (Tylenol) reserved for reduction of deep pain
or neuralgia unresponsive to topical treatments.21 Short-term
opioid analgesics may be considered and used with caution for
treatment of rare, severe, acute pain for select women.9 Unless
signs of a bacterial superinfection are present, topical antibi-
otics should be avoided.11
Uncomplicated herpes zoster may be managed by the ma-
ternity or primary care provider. However, for individuals ex-
periencing prolonged or severe symptoms or for those with
complicated presentations, referral to a specialist is advised.
Women experiencing changes to their vision should be re-
ferred for prompt evaluation by an ophthalmologist, as this
can indicate ocular involvement with potential for severe oph-
thalmic complications.12 Similarly, if a woman experiences
any neurological changes, facial paralysis, or ear pain, she
should be evaluated for potential complications and referred
appropriately.
IMPLICATIONS OF HERPES ZOSTER FOR
INTRAPARTUM, POSTPARTUM, AND NEWBORN
CARE
Although primary varicella zoster infection can have signif-
icant consequences for the fetus, including the possibility of
congenital varicella syndrome, reactivation of the virus as her-
pes zoster is generally not associated with any fetal compli-
cations. There is one reported case (unconfirmed by sero-
logic testing) in which a maternal herpes zoster was associated
with congenital varicella; however, no evidence of varicella
syndrome or fetal infection following maternal herpes zoster
has been clearly identified.22–24 It is thought that the low rate
of in utero transmission with maternal herpes zoster is due
to preexisting maternal antibodies and low levels of viremia
compared with primary maternal varicella zoster infection.13
For otherwise healthy women, uncomplicated herpes zoster
does not change the standard of care provided in pregnancy
and postpartum, beyond those steps necessary to avoid trans-
mission to the newborn. Women with preexisting immuno-
compromised conditions such as HIV infection and women
who develop secondary complications such as pneumonia will
need additional surveillance and management depending on
their presentation.
Women with herpes zoster should be encouraged to
breastfeed as long as precautions are taken to avoid direct con-
tact between the infant and any contagious (not crusted) le-
sions. If the herpes zoster eruption involves the breast, the
4 Volume 00, No. 0, xxxx 2019
woman may breastfeed using the unaffected side and pump
or manually express milk from the affected breast. Any con-
tagious lesions should be covered, and anyone who contacts
the lesions or dressings should use thorough handwashing
techniques before touching the infant. Because of the risk for
neonatal varicella infection, pediatric care providers should
be notified of the maternal herpes zoster outbreak and may
advise administration of varicella zoster immune globulin
(VariZIG or VZIG) to newborns as prophylaxis. Consultation
with current CDC guidelines and referral to a pediatric care
provider is appropriate for these infants.25
IMMUNIZATION
Comprehensive preconception care should include screen-
ing for varicella immunity based on previous vaccination or
infection.14 For women who do not have a history of ei-
ther, serological testing may be performed to assess immunity.
Nonimmune women should be offered varicella zoster vacci-
nation prior to conception.
Because the varicella zoster vaccine contains live, atten-
uated virus, it has the potential to cause varicella infection
and is contraindicated in pregnancy.14 Pregnant women who
are not immune to varicella should be informed of the risks
associated with infection and offered vaccination postpar-
tum, with one dose after birth and the second dose at the 6-
week postpartum visit.26 Additionally, nonimmune pregnant
women should avoid contact with individuals experiencing
varicella infection and any direct contact with herpes zoster
lesions. If a nonimmune pregnant woman was exposed to
someone with active varicella or herpes zoster, she should be
offered postexposure prophylaxis such as VZIG to avoid the
possibility of a primary varicella infection.25 However, preg-
nant women who are immune to varicella zoster virus by ei-
ther previous varicella infection or vaccination are not at risk
of contracting the virus from contact with herpes zoster le-
sions, so postexposure prophylaxis is not necessary for this
population. Pediatric care providers may consider adminis-
tering VZIG to infants exposed to maternal herpes zoster and
should be consulted.
Although a vaccine for herpes zoster exists, its safety and
efficacy has only been demonstrated in individuals aged 50
years and older.27,28 Immunization decreases the frequency
and severity of outbreaks, as well as the likelihood of pos-
therpetic neuralgia, and is routinely recommended for non-
immunocompromised individuals after the age of 50, regard-
less of history of herpes zoster.29 The vaccine requires 2 doses,
2 to 6 months apart. It should not be administered during a
herpes zoster outbreak but instead deferred until after symp-
toms resolve.30 Although current recommendations support
use of the recombinant (rather than live virus) version of the
vaccine, this vaccine has not been evaluated or approved for
use in pregnant or breastfeeding women.30
CONCLUSION
Although it is not common in women of reproductive age,
herpes zoster can affect pregnant women, as it did in L.K.’s
case. These outbreaks occur when a dormant varicella zoster
virus is reactivated. Herpes zoster commonly presents as
unilateral erythematous papulovesicular cutaneous eruption
within a single dermatome. It progresses through a series
of predictable stages from prodromal symptoms to pustular
lesions that ulcerate and crust over. In typical presentations in
individuals with a history of varicella infection or vaccination,
diagnosis is made on the basis of clinical presentation alone.
In this case, the midwife correctly diagnosed L.K.’s condition
and provided her with current clinical recommendations
regarding use of oral antiviral therapy with acyclovir (or,
alternatively, valacyclovir) to decrease duration and severity
of the lesions, relieve painful and pruritic symptoms, prevent
adverse sequalae, and reduce risk of transmission to non-
varicella-immune individuals, including the newborn. Even
though she stopped the medication prior to completion of
the recommended dose, L.K. received adequate counseling
regarding relevant preventative and comfort measures. The
midwife took steps to inform other care providers, ensuring
that L.K. was not treated as high risk and that her neonate
received appropriate follow-up. At the postpartum visit, the
midwife assessed L.K. for any complications, such as neuro-
logical or ophthalmological changes or lingering pain suspi-
cious for postherpetic neuralgia that would have warranted
referral. Despite the existence of a recombinant version of the
herpes zoster vaccine, postpartum immunization was not rec-
ommended for L.K. because of her age. In this way, the mid-
wife provided evidence-based care that was individualized to
meet L.K.’s unique circumstances, needs, and preferences.
ACKNOWLEDGMENTS
During manuscript production, Dr. Julia C. Phillippi was sup-
ported by grant number K08HS024733 from the Agency for
Healthcare Research and Quality. The content is solely the re-
sponsibility of the authors and does not necessarily represent
the official views of the Agency for Healthcare Research and
Quality.
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