Journal of the Accident and Medical Practitioners Association (JAMPA) 2004; Vol. 1 (No. 1)
 Accident and Medical Practitioners Association, New Zealand
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Practice Tips, No. 1
Helen Overton, MB, ChB, Dip. Obstets, FAMPA
Mt Eden, Auckland
About the author
Dr Helen Overton, MB, ChB, Dip. Obstets, FAMPA qualified in 1979 and works in both
general practice and accident clinics. Her principal clinical interests include wound
management and geriatrics. She is also interested in collating and distributing management
and safety tips related to community accident work, and would welcome feedback or other
topics for this column.
Address for correspondence: Dr Helen Overton, P.O. Box 67014, Mt Eden, Auckland
E-mail: nhbarlev@hotmail.com
Practice tips in this issue

Chicken pox contact during pregnancy

Treatment of uncomplicated urinary tract infections in the A&M setting

Morphine use in the A&M setting

Treatment of acute tonsillitis in the A&M setting
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Chicken Pox Contact During Pregnancy
Important points to consider:

Whether the contact was significant, e.g. in the same room for one hour, living with the
contact?
Management tips:

In a person with chicken pox, the most infectious time is in the 2 days prior to and 2 days
after appearance of the rash.

Decide if the woman is immune. If she can remember having chicken pox, she is more
than 95% likely to be immune. However, 22% of 14- to 19-year-olds, 14% of 20- to 24year-olds, and 5% of 25- to 29-year-olds will not be immune.

If uncertain, varicella-zoster immune globulin (VZIG) can be administered but this must
be done within about 72 to 96 hours of the contact. This will obviously require clinical
judgement. In rural areas, discuss with an expert.

Where the contact has been significant and no immunity is considered likely, VZIG must
be given within 72 to 96 hours.
Risks to the mother:

As there is a higher chance of severe chicken pox occurring in pregnancy, it is advisable
to give IgG (if possible).
Risks to the fetus:

With exposure prior to 20 weeks’ gestation, there is about 0.4% to 2% chance of fetal
abnormalities. With exposure prior to 12 weeks, the risk is only about 0.4%, but the risk
increases with exposure after 12 weeks.

Congenital chicken pox poses the greatest risk to the fetus, so any pregnant woman who
has been exposed to chicken pox, particularly in the last 2 to 3 weeks of pregnancy, must
have her immune status established and IgG given if she is non-immune. Very severe
chicken pox can develop in babies born shortly after maternal infection, with up to 30%
mortality.
References
3
1.
Taylor S (Microbiologist at Diagnostic Medlab). Lecture on chicken pox, 2003.
2.
NZ Immunisation Handbook.
3.
Pediatric Oncall. Varicella infection in pregnancy – consequences for foetus and neonate.
Available from:
www.pediatriconcall.com/fordoctor/DiseasesandCondition/varicellainfectinpreg.asp
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Treatment of Uncomplicated Urinary Tract Infections (UTIs) in the
A&M Setting
Management tips:

Diagnose and treat for UTI if patient has dysuria, frequency and no vaginal discharge
(probability of UTI approximately 96%).[1]

If vaginal discharge is present, consider genital tract infection.

Although sensitivity tests show that only about 70% of common pathogens are
susceptible, most uncomplicated UTIs in young females are able to be treated with:
- trimethoprim 300 mg once daily for 3 to 4 days (Note: contraindicated in pregnancy)
- nitrofurantoin 50 mg qid for those who experience adverse reactions with trimethoprim.

Keep a supply of trimethoprim in the clinic and give to the patient in a labelled envelope
(to be used as directed).

Also provide the patient with a prescription for norfloxacin or amoxycillin/clavulanic acid
which they can fill if trimethoprim doesn’t eradicate the infection.
This approach is generally associated with few adverse effects in women, is cost-saving (both
for the patient and the healthcare system), and reduces the likelihood of more resistant
organisms developing.
References
1.
Bent S, Nallamothu BK, Simel DL, Fihn SD, Saint S. Does this woman have an acute
uncomplicated urinary tract infection? JAMA 2002;287(20):2701-10.
2.
Infection POEMS Best Practice Advocacy Centre, May 2003, 14-16.
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Morphine Use in the A&M Setting
Administration tip:

For intravenous morphine delivery in acute settings, dilute 1.0 mL of morphine 10
mg/mL injection solution by adding it to 9.0 mL normal saline.

This provides a 1 mg/mL morphine solution which makes dose titration very easy for any
age group (e.g. as 1-2 mL aliquots)

Note: always tape the vial to the syringe.
■
Treatment of Acute Tonsillitis in the A&M Setting
Important points to consider:

Common causes of acute tonsillitis are viruses and beta-haemolytic streptococci.

Glandular fever is often present in young adults.
Management tips:

The best antibiotic is still penicillin-V (phenoxymethylpenicillin) which will eradicate
beta-haemolytic streptococci and, unlike amoxycillin, does not cause a rash in those have
glandular fever. Penicillin V is preferable to amoxycillin in all age groups over 5 years.

Note: amoxycillin/clavulanic acid + metronidazole may be preferable in chronic pustular
tonsillitis (quinsy) where the causative organisms can include Haemophilus sp.,
staphylococci, and anaerobic bacteria.

In deciding whether to treat the patient with antibiotics, a validated scheme[1] for scoring
acute sore throats (1 point each) is to assess the following characteristics:
- history of fever or measured temperature higher than 38 degrees C
- absence of cough
- tender anterior cervical lymphadenopathy
- tonsillar swelling or exudates
- age younger than 15 years.

Suggested management (for scores out of 5):
- 4-5: administer antibiotics
5
- 2-3: throat swab for culture; base decision about antibiotics on the culture results
- 0-1 withhold treatment.
Reference
1.
McIsaac WJ, Goel V, To T, Low DE. The validity of a sore throat score in family
practice. CMAJ 2000;163(7):811-5. Available from:
http://www.cmaj.ca/cgi/content/full/163/7/811
Dr Overton would welcome feedback or other topics for this column
E-mail address: nhbarlev@hotmail.com