Herpes simplex virus (HSV) infections
during pregnancy Informations Point
1:. Twenty five to 65 per cent of pregnant women in the U.S. have
genital infection with herpes simplex virus type I or 2 (HSV-1 or HSV-2). HSV:-Information Point 2 to remember :Mode
of transmission:-Vertical transmission to the newborn is accompanied by
devastating consequences (30-60% mortality rate, 20-90% neurologic damage in
survivors). HSV:-Information
Point 3 to remember : There are 3 forms of HSV-associated neonatal
disease: disseminated (25%), central nervous system (30%), and cutaneous (45%),
in decreasing order of adverse neonatal outcomes. HSV:-Information Point 4 to remember The
frequency of neonatal HSV infection varies between 8 to 60 cases per 100,000
live births by population studied, and is the result of exposure to HSV in the
genital tract during delivery. HSV:-Information Point 5 to remember . The neonatal risk is
greatest in women who acquire HSV for the first time during the pregnancy, as
compared to women with longstanding HSV whose infection is reactivated during
the pregnancy (risk 25-50% vs. ulcer>crusted lesion), and by viral inoculum
(80% positive for primary lesions, 40% positive for recurrent lesions). . HSV:-Information Point 6 to remember
Polymerase chain reaction techniques (PCR) have superior sensitivity compared
to culture, but unfortunately are not yet currently standardized or FDA
approved. They are most likely to become the standard of care soon, and should
be sufficiently sensitive to detect asymptomatic viral shedding. HSV:-Information Point 7 to remember.
Second generation type-specific glycoprotein-G HSV serologic assays are
available and have sensitivities and specificities of 80-98%, but
first-generation tests still abound, and percentage of false negatives and
positives is much higher. . HSV:-Information
Point 8 to remember There is no current evidence that screening
asymptomatic patients is cost-effective, and such a strategy is not recommended
by American College of Obstetricians and Gynecologist, (ACOG), the Center for
Disease Control and Prevention (CDC), or the US Preventative Services Task
Force (USPSTF). HSV:-Information
Point 10 to remember . IgM testing for HSV is likewise neither sensitive
nor specific, and is not clinically useful. HSV:-Information Point 11 to remember.
Differentiation of primary HSV
infection from a Repeat episode during pregnancy (secondary or recurrent infection)
can only be made by positive viral detection and a negative second generation
serologic test result. Treatment of primary HSV infection:
All primary HSV
outbreaks during pregnancy should be treated at presentation to reduce the
severity of the symptoms, shorten the duration of the outbreak, and reduce the
duration of viral shedding. .
The following regimens
are recommended: A) . Acyclovir
400 mg po 3x daily x 7-10 days –or
B) . Valacyclovir 1000
mg po 2x daily x 7-10 days C) . Topical therapy with acyclovir cream
is ineffectual, but many women may have severe symptoms with fever and
urinary retention and require local symptomatic treatment, D) oral analgesics,
and/or urinary drainage until the lesions crust over and the pain is relieved.4)
. Very severe cases :-Women with complications that require hospitalization
should receive Intravenous antiviral agents:-- Acyclovir 5-10 mg/kg IV q8h x
2-7 days, followed by 10 days of oral therapy
5. Recurrent HSV infections: A. Episodic
treatment of recurrences: The following treatment regimens are recommended: a.
Acyclovir 400 mg po 3x daily x 5 days -ORb. Valacyclovir 1000 mg po 2x daily x
5 day B. Suppressive therapy for recurrent HSV: Women who have active genital
recurrences will benefit from suppressive treatment at 36 weeks as it can
reduce the frequency of recurrences by 75%, reduce the incidence of cesarean
delivery by 40%, and reduce the rate of shedding (as determined by PCR) by 90%.
Nevertheless, none of the current evidence is able to demonstrate that
suppressive treatment near term is able to decrease the incidence of neonatal
infection. If the patient has a recurrence during the index pregnancy, or
within 12 months of her EDD, then the suggested regimen is: a. Acyclovir 400 mg
po 3x daily from 36 weeks gestation b. Valacyclovir 500 mg po 2x daily from 36
weeks gestation c. While treatment of discordant heterosexual couples decreases
transmission to the uninfected partner,
When wife is affected with HSV then Treatment of partner is debatable and no unanimous
opinion is there !!! Members view please. Ans: There
is no current evidence that treating the partners of women with known HSV
infection is effective in the prevention of neonatal HSV infection. Consistent
condom use and abstinence during acute episodes should be encouraged, but
likewise has not been demonstrated to prevent neonatal infection. Acyclovir has not been demonstrated to be teratogenic,
and is considered safe in all trimesters. The drug only becomes active in viral
infected cells. It has been associated with transient neonatal leukopenia in up
to 20% of the infants of mothers taking the drug, but no long term adverse
effects have been observed.
Valacyclovir is
costlier, but have better bioavailability compared to acyclovir, and are
metabolized to acyclovir in vivo.. Please note that women at risk are begun on
suppressive therapy at 36 weeks gestation, not earlier in the pregnancy.
Mode
of delivery: ?? Intrapartum Care :-. Cesarean delivery is
indicated for women with active genital HSV lesions or significant prodromal
symptoms (vulvodynia) at the time of active labor. Nevertheless, neonatal
infection may occur in 1.2% of women delivered abdominally and cesarean is not
able to prevent all vertical transmission. There is no evidence that there is a
duration of ruptured membranes beyond which cesarean delivery is not beneficial
or not recommended in women with active HSV infection. Women with preterm premature rupture of
membranes prior to 34 weeks who have active disease do not present a
contraindication to antenatal corticosteroid therapy for fetal lung maturation.
Treatment with an antiviral agent may also be considered. d. Invasive fetal
monitoring (scalp electrodes) is associated with a 6-fold increase in the
vertical transmission of HSV, and should be avoided in at risk women. e. Women
with recurrent HSV nongenital lesions (e.g., on the face, buttocks or thigh) do
not require cesarean delivery, but the lesions should be isolated with an
occlusive dressing. What about Br
feeding?? . Breastfeeding is not contraindicated in women with active genital
lesions, but good hand washing is counseled before handling the infant
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