Genital Herpes in Pregnancy
Summary of the RCOG guideline.
( The recommendation in the guideline are based on differing levels of evidence. For the sake of conciseness, the levels of evidence have not been mentioned)
Herpes Simplex infection in the neonate may be – Localized or Disseminated.
Localized Infection may be a. Skin/Eyes/Mouth or
b. CNS infection
Incidence of neonatal herpes- 1.65/100 000 live births between 1986 to 1991—the incidence appears to be increasing, likely in tandem with increasing incidence of sexually transmitted infections.
Neonatal herpes may be caused by HSV-1 HSV-2.
Approximately 50% of neonatal herpes is due to HSV-1 and 50% due to HSV-2.
Most cases – due to direct contact with infected maternal secretions.
In 25 % – possible postnatal exposure( to mother or close relative, maybe due to orolabial herpes).
Congenital herpes – may occur as a result of transplacental intrauterine infection. Case reports
suggest that the skin, eyes and CNS may be affected and there may be fetal growth restriction or
fetal death.
Transmission depends on
1. – Type of maternal infection (primary or recurrent),
2. – Presence of transplacental maternal neutralising antibodies, the duration of rupture of membranes before delivery.
3. – Use of fetal scalp electrodes, and
4. – Mode of delivery
PRIMARY GENITAL HERPES IN THE THIRD TRIMESTER( particularly within 6 weeks of delivery) carries the highest risk to the baby. Particularly increased risk if new infection within 6 weeks of delivery( as viral shedding may persist and the baby is likely to be born before the
development of protective maternal antibodies).
Recurrent Genital Herpes– Often asymptomatic or unrecognized. Very low risk of neonatal herpes. But may cause Local Herpes in the neonate( Both CNS or skin/eye/mouth) .
Transplacentally acquired HSV antibodies do not prevent herpes virus spreading to the brain of the neonate.
Disseminated Herpes Infection in Mother – rare in adults- though more common in pregnant especially immunocompromised.
Primary HSV Infection before 27 weeks 6 days gestation-
No evidence of an increased risk of spontaneous miscarriage or of congenital malformation.
If suspected genital herpes – refer to a genitourinary medicine physician.
Treatment to be initiated as soon as possible– Acyclovir- Oral 400 mg TID usually for 5days.( i.v in disseminated infection) .
Symptomatic treatment– Paracetamol and topical lidocaine 2%.
Acyclovir treatment is associated with a reduction in the duration and severity of symptoms and a decrease in the duration of viral shedding.
Aciclovir is not licensed for use in pregnancy but is considered safe and has not been associated with an increased incidence of birth defects. Also, it is well tolerated in pregnancy.
Aciclovir, famciclovir or valaciclovir ( valine ester of acyclovir) – if used in the first trimester, there is no evidence of an increased risk of birth defects with acyclovir. But famciclovir and valaciclovir are not recommended as first-line because of lack of data.
Start acyclovir again from 36 weeks- 400 mg TID till delivery- reduces HSV lesions at term
( hence reduces the need for caesarean delivery) and also reduces asymptomatic viral shedding.
Manage the pregnancy expectantly and vaginal delivery can be allowed. ( except when the delivery occurs within 6 weeks of the primary infection)
HSV in the Third trimester (from 28 weeks of gestation)
There is insufficient evidence to suggest an association between HSV and stillbirth.
Treatment- commence ASAP- Acyclovir oral 400 mg TID. Continue till delivery.
Women developing first- episode genital herpes in the third trimester, ( particularly those developing symptoms within 6 weeks of expected delivery)- risk of neonatal transmission of HSV is
very high ( 41%.) – DELIVERY SHOULD BE BY CAESAREAN SECTION.
First episode of clinical HSV in third trimester- about 15% will actually be recurrent infection.
Management- Take viral PCR swab. Check for HSV 1 and 2 antibody ( IgG and IgM).
( characterizing the infection as primary or recurrent will influence the advice given regarding mode of delivery and risk of neonatal herpes infection- -e.g presence of the antibody to the same HSV type found in the swab would mean it’s a Secondary infection) .
Recurrent infection does not need caesarean delivery to prevent neonatal infection.
(The test results may take 2-3 weeks to be released- meanwhile it is prudent to make a plan for delivery- ASSUMING THAT ALL FIRST EPISODE LESIONS ARE PRIMARY GENITAL HERPES. This plan can then be modified if HSV antibody test results subsequently confirm a recurrent infection) .
Interpretation of serology can be complicated- Discuss the result with a virologist or genitourinary medicine physician.
Recurrent genital herpes in pregnancy-
The risk of neonatal herpes is low, even if lesions are present at the time of delivery
(0–3% for vaginal delivery).
No increased risk of preterm labour/ preterm prelabour rupture of Membrane/ fetal growth restriction/ congenital abnormalities.
Majority of recurrent episodes of genital herpes resolve within 7–10 days.
Treatment- supportive( saline bath+ paracetamol) .
– Consider acyclovir 400 mg TID from 36 weeks.
– Vaginal delivery can be allowed.
If there are Genital lesions at the onset of labour –
– as there is no time for lab tests, management is based on clinical assessment.
– History to ascertain whether it is primary or recurrent infection
– Take a viral swab ( may influence treatment of the neonate) .
– Inform neonatologist.
If primary HSV infection within 6 weeks of delivery, or primary lesions at time of delivery– Caesarean delivery, preferably within 4 hours of membrane rupture( if 4 hours have elapsed after membrane rupture, still do Caesarean section, although the benefit for the neonate will be reduced) .
If mother opts for Vaginal delivery– give i.v acyclovir to her ( 5 mg/kg every 8 hours)-although there is insufficient evidence whether it reduces the risk of neonatal HSV infection.
Acyclovir to the neonate after delivery( 20 mg/kg every 8 hours). Also , avoid artificial rupture of membranes , application of fetal scalp electrodes, fetal blood sampling,
artificial rupture of membranes and/or instrumental deliveries.
Recurrent genital herpes lesions at time of delivery-
Advise her that the risk to the baby of neonatal herpes is low (0–3% for vaginal delivery. )
Vaginal delivery should be offered to women with recurrent genital herpes lesions at the onset of labour. The final choice of vaginal delivery versus caesarean section should be made by the mother (Her decision should be based on the very low risk of transmission VS other obstetric risk factors and the risks associated with caesarean section) .
Fetal blood sampling, application of fetal scalp electrodes, artificial rupture of membranes and/or instrumental deliveries can be done if needed.
If spontaneous membrane rupture at term- expedite delivery. ( No recommendation- but good practice) .
Genital Herpes in Preterm Prelabor Rupture of Membranes( PPROM) –
Primary Genital Herpes in PPROM- There is limited evidence.
Management decision should be by Multidisciplinary Team ( Involving obstetricians, neonatologists
and genitourinary medicine physicians). Decision will also depend on gestational age at which PPROM occurs. If there is decision for immediate delivery- Emergency caesarean section should be done.
If delivery is indicated within 6 weeks of primary infection- Caesarean Delivery may still offer some benefit.
If there is initial conservative management – I.V Acyclovir 5 mg /kg every 8 hours should be recommended to the mother. Consider corticosteroids for fetal lung maturity.
Recurrent genital herpes in PPROM –
the risk of neonatal transmission is very small.
If PPROM before 34 weeks- Expectant management is appropriate. Oral acyclovir 400 mg TID to the mother.
If PPROM after 34 weeks- manage like any other PPROM( according to the RCOG/ NICE guideline on PPROM) .The management is NOT influenced by the presence of Genital Herpes.
HIV-positive women with HSV infection –
There is some evidence that HIV antibody positive women with genital HSV ulceration in pregnancy are more likely to transmit HIV infection independent of other factors. However, this is not a consistent finding across all studies.
Another factor to keep in mind will be the increased incidence of preterm labor in HIV positive women
(That will warrant earlier initiation of suppressive acyclovir) .
Primary HSV infection with HIV- managed according to the recommendations for all women with primary genital HSV infection.
Recurrent HSV infection with HIV-
1. If vaginal delivery is planned- start suppressive acyclovir ( 400 mg , oral three times a day) from 32 weeks.
2. Mode of delivery- should be according to the HIV in pregnancy guideline.
3. If HSV 1 or 2 positive, with HIV , BUT no history of genital herpes- No need for daily suppressive treatment.
The care of the neonate will not be discussed in this summary.
However, the important points for the OBGYN are-
Inform the neonatologist.
Breastfeeding is recommended unless the mother has herpetic lesions around the nipples.
Parents should be warned to report any early signs of infection such
as poor feeding, lethargy, fever or any suspicious lesions.
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