North Thames (
East ) Regional Health Authority
Management of Genital Herpes in
Pregnancy
Website address: http://www.nthivgumaudit.demon.co.uk/int/hsvpre.htm
*Management of Genital Herpes in pregnancy has not been
clearly established or evaluated.
The main issues of
concern:
1) Risk of vertical transmission of HSV
to the foetus
2) Strategies to reduce risk, including
the use of Acyclovir.
3) The role of the GU physician involves
informing women of the risks relevant todecision making
about their care.
4) Women should be strongly encouraged to
inform their primary obstetric carer of any history of
genital herpes in themselves or their sexual
partner.
The following points should be
considered in discussion with the
patient:
1. Vertical Transmission / Neonatal
Herpes
a) The risk of transmission is
significantly higher in women presenting with primary HSV
infection than during a recurrent episode.
b) Primary HSV infection may also be
associated with an increased risk of spontaneous abortion,
but there is little published data to support this.
c) Recurrent episodes of HSV during
pregnancy are not thought to be harmful to the
foetus
d) Although neonatal herpes infection is
associated with a higher fatality and morbidity rate,
incidence in the UK is extremely low (71cases have been
reported to the British Paediatric Surveillance Unit between
July 1986 and August 1991, of whom only 19 were associated
with known maternal HSV infection ).
e) Most cases of neonatal herpes are
associated with asymptomatic viral shedding and absence of a
history of genital herpes (c. 70 % ).
f) However, repeated virological
screening for asymptomatic shedding may not identify those
at risk.
g) In women found to have active lesions
at the time of delivery, Caesarean section might be
considered an option. However, this has not been shown to
reduce the incidence of neonatal herpes and may pose a risk
to the mother.In women without active lesions, normal
vaginal delivery is recommended.
1. Use of Acyclovir in
Pregnancy
a) Acyclovir is currently not licensed in
pregnancy and therefore should not be used during pregnancy
unless the potential benefit justifies the potential risk to
the foetus.
b) Indication for systemic Acyclovir in
pregnancy may possibly include:
i ) Life threatening maternal HSV
infection e.g. disseminated
ii ) Clinical primary HSV
infection
c) From the CDC registry, there appears
to be no increase in the incidence of birth defects in
infants born to mothers exposed to Acyclovir during
pregnancy. However, insufficient evidence cannot exclude a
relative increase in risk below 2 fold.
If Acyclovir is offered, each of the
following points should be discussed and recorded in the
notes:
1. Possible foetal and maternal
complications of HSV at that stage of pregnancy
2. General risks of foetal abnormality in
normal pregnancy
3. Potential benefits of taking
Acyclovir
4. That Acyclovir is not licensed for use
in pregnancy
5. Worldwide experience to date with use
of Acyclovir in pregnancy.
6. NB It is advisable that written
consent is obtained if Acyclovir is to be used in
pregnancy
Working Party: Dr I Williams, Dr
Mac Donald Burns, Dr Coelho, Dr Davidson Parker North Thames
Region - clinical audit GUM / HIV.
References:
- Pregnancy Outcomes following systemic
prenatal Acyclovir exposure June 1, 1984 - June 30, 1993.
MMWR 42. 41: 806 - 809.
- The management of pregnancy
complicated by genital infection with Herpes simplex
Virus. Prober, C. G., Corey, L., Brown, Z. A. et al.
Clinical Infectious Disease 1992, 15 103 &endash;
8
- CDC Sexually Transmited Diseases
Treatment guidelines ISSTDR, 1993
- Intra-Uterine and Neonatal HSV
Infection. Jeffries, D. J. Scand. J. Infect - Dis Suppl.
1991 80:20-6
- Recurrent Genital Herpes: a
Management focus Kinghorn, G. R. 1991
- HSV Infections in the Immunocompetent
Mindel, A. 1992
- Genital Herpes During Pregnancy. Risk
Factors Associated with Recurrences and Asymptomatic
shedding Brown, Z.A., et al 1985
*******
IHMF
Recommendations.
Taken from their website - http://www.pps.co.uk/ihmf/ihmf0023.htm
Management of Recurrent Genital
Herpes in the Pregnant Woman
"Women with a history of recurrent
genital herpes should be examined at the onset of labour to
identify herpetic lesions. Women who have been educated
about genital herpes may be able to identify lesions more
accurately than their physician and point to anatomical
sites which the physician can examine carefully with a
magnifying glass under bright light. The woman should also
be asked about prodromal symptoms and women with prodromal
symptoms treated as if they had lesions.
Suppressive acyclovir therapy in late
pregnancy (2-4 weeks pre-term) is being studied in women
with a history of genital herpes with the aim of reducing
the numbers of Caesarean sections and decreasing the
incidence of neonatal herpes. Although the preliminary data
look promising in reducing the numbers of Caesarean
sections, more data are required before this therapy can be
recommended."
History of recurrent genital
herpes without lesions at delivery
"In the woman without lesions or symptoms
at the onset of labour and a history of genital herpes,
vaginal delivery is recommended. The patient should be
reassured about the low risk of neonatal herpes. Studies
have shown that taking specimens for culture from all HSV-2
seropositive pregnant women at delivery is not
cost-effective; however, other physicians believe taking
cultures may be useful in identifying the child exposed to
HSV.
The woman's HSV status should be
indicated on both her chart and her infant's to increase the
likelihood of
diagnosis if the child subsequently
develops neonatal herpes. In women who are HSV-2
seropositive or with a
history of genital herpes, routine
instrumented deliveries (e.g. use of fetal scalp electrodes)
should be avoided if possible to reduce the risk of
transmission of the virus to the child."
Symptoms of recurrent genital
herpes at labour
"The risks of transmission of the virus
to the neonate during vaginal delivery need to be weighed
against the risks of Caesarean section to the mother. The
woman should be informed about the risks and allowed to make
an informed choice early in pregnancy. In symptomatic
recurrent genital herpes at labour, vaginal delivery may be
indicated because there is only a very small risk (less than
3%) of transmission of HSV to the child. Culture of
specimens from the cervix and lesions within 24 hours of
delivery should be performed. Use of suppressive acyclovir
to reduce viral load is under investigation. Routine use of
instrumented delivery or artificial rupture of the membranes
should be avoided unless the obstetrical benefit outweighs
the risks."
Maternal recurrent genital
herpes without lesions at delivery
"The baby born to the woman without
lesions at delivery is at low risk of developing neonatal
herpes. The child's chart should be marked to indicate that
the mother has a history of HSV infection to include
neonatal herpes as a potential diagnosis if the child
becomes ill. The parents should also be educated about the
signs and symptoms of neonatal herpes and how to report it.
The baby's progress should be monitored for the first 4
weeks of life.
If the child develops suspected neonatal
herpes, specimens should be taken for viral culture and
empirical therapy with intravenous acyclovir
started."
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