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CLINICAL GUIDELINE

Herpes Simplex in Pregnancy

Compiled by Suzanne Garland

Herpes Simplex in Pregnancy

Management of pregnant women with rst episode genital herpes


Obtain HSV serology (type specic), HSV genital culture and ideally test the serum in parallel with rst antenatally collected sample to dene the episode as primary (no previous HSV infection) or rst episode.

First and second trimester acquisition


Management of the woman should be in line with the clinical HSV presentation and may involve the use of either oral or intravenous (IV) aciclovir in standard doses. Providing that delivery does not ensue, and no lesions are evident at delivery the pregnancy should be managed expectantly with vaginal delivery anticipated. Continuous suppressive aciclovir in the last four weeks of pregnancy may be indicated for the patient with multiple clinical recurrences to prevent recurrences at delivery and hence the need for Caesarean section. That is, primary HSV at less than 34 weeks with no lesions at the time of labour should be managed by vaginal delivery. Primary HSV less than 34 weeks and with lesions in labour and ruptured membranes for less than 6 hours should be managed with Caesarean section.

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Third trimester acquisition


Apart from aciclovir treatment, Caesarean section should be considered for all women, particularly those developing symptoms within 6 weeks of delivery as their infants are at greatest risk of viral transmission due to the lack of time for development of maternal neutralizing antibodies and their lack of transplacental passage. For diagnosis late in pregnancy where there is a high risk of neonatal HSV, one should consider maternal suppressive oral aciclovir . Where infants are born via vaginal delivery with active disease and no maternal treatment, the infant should be treated with IV aciclovir. The neonatal attack rate for those exposed before development of maternal seroconversion is in the order of 30 to 50%.

Management of the neonate


Babies born to mothers with rst episode genital herpes at the onset of labour To allow early identication of infected babies, surface swabs should be taken from the oropharynx, eyes, urine as well as collecting CSF for identication of HS V (by PCR, culture or antigen detection). In addition EDTA blood for HSV PCR should be taken. Intravenous aciclovir 20mg/kg/tds should be commenced and continued dependent upon cultures/pcr (14 days treatment or 21 days if the CSF is found to be abnormal. If aciclovir is not started immediately the neonate should be closely monitored for signs of lethargy, fever, poor feeding, or lesions consistent with neonatal HSV infection. Aciclovir should be commenced immediately should any cultures become positive. Neonatal Herpes - Neonatal herpes is a very rare, but serious infection with high morbidity and mortality. The incidence in Australia is 3.9/ 100,000 live births.

Herpes Simplex in Pregnancy

Risk of neonatal HSV and delivery mode:


Primary Initial episode with seroconversion prior to delivery (prior to 30-34 weeks) 3%. the shedding risk is 7% and neonatal HSV risk is < With a primary/initial episode less than 6 weeks before delivery the risk of neonatal HSV is 30-50%. Recurrent HSV No lesions and vaginal delivery. Risk of asymptomatic HSV shedding is in the order of 1.4% and the risk of neonatal HSV is 0.02 to 3% (non-shedding vs HSV shedding respectively). For those with recurrent lesions and vaginal delivery (shedding risk by culture is 20%) and the risk of neonatal HSV is < 1%.

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Management of pregnant women with recurrent genital herpes Sequential third trimester cultures to predict viral shedding at term are NOT indicated. Caesarean section to prevent neonatal herpes is only indicated for women who have genital lesions evident at delivery. Symptomatic recurrences of genital herpes during the third trimester will be brief and vaginal delivery is appropriate if no lesions are present at delivery. For those with multiple recurrences in pregnancy and in order to avoid a Caesarean section, consider suppressive aciclovir treatment at 400mg tds. Maternal specimens for HSV culture (sweep genital swab) are advised at delivery if the baby is delivered vaginally, in order to identify the babies exposed to women asymptomatically shedding HSV. Management of women with genital lesions at onset of labour Current practice is for delivery by Caesarean section, particularly if the membranes have been ruptured for less than six hours. There is evidence that the risks of viral transmission to the neonate following vaginal delivery are small and must be weighed against risks of Caesarean section to the mother. Use of invasive monitoring (foetal scalp electrode, forceps and vacuum delivery) are advised against, and should be used only for de ned obstetric indications.

Herpes Simplex in Pregnancy

Management of the neonate


Babies born to mothers with recurrent genital herpes at the onset of labour One set of specimens for viral culture should be collected after delivery for early identication of infection. If cultures are positive, aciclovir treatment of the infant is advised. Parents should be advised to report early signs of infection (lethargy, fever, poor feeding or lesions). Babies born to asymptomatic mothers with a history of genital herpes Routine viral culture is not recommended. Parents should be advised to report early signs of infection (lethargy, fever, poor feeding or lesions).

Post-natal care of mother and child

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Breastfeeding is recommended unless the mother has lesions around the nipples. Aciclovir is excreted in breast milk but its use is not contra-indicated as it does not cause harm to the infant.

Prevention of acquisition of infection


There is a dearth of evidence on which to formulate guidelines for prevention. Any strategy for prevention of neonatal herpes needs to involve both parents. All women should be asked at their rst antenatal visit if they or their partner have ever had genital herpes. Women without a history of genital herpes, whose partners have genital herpes should be strongly advised not to have sex when genital lesions are present (i.e. recurrence of genital herpes). Type specic serology may help conrm risk of primary infection and identify potential risk of asymptomatic shedding in those women already infected but undiagnosed. Conscientious use of condoms throughout pregnancy may diminish the risk of acquisition.

Prevention of acquisition of infection (continued)


Pregnant women should be advised of the risk of acquiring genital HSV-1 as a result of oro-genital contact. Identifying susceptible women by means of type-speci c antibody testing has been evaluated in Australia with a seroprevalence of HSV 2 of 12.5% and HSV 1 of 80% reported. Whilst 3% acquired HSV 2 during pregnancy, none seroconverted to HSV 1 and no cases of neonatal HSV were seen. Therefore it was concluded in low prevalence communities, it is not cost e ective to o er type speci c serology to pregnant women and their partners. All women, not just those with a history of genital herpes, should undergo careful genital inspection at the onset of labour to look for clinical signs of herpes infection. Fetal scalp electrode, forceps and vacuum delivery should be avoided. Mothers, sta and other relatives/friends with active oral lesions should be advised about the risk of post-natal transmission.

Herpes Simplex in Pregnancy

Bibliography
Arvin A, Hensleigh PA, Prober CC, et al. Failure of antepartum maternal cultures to predict the infants risk of exposure to herpes simplex virus at delivery. New England Journal of Medicine 1986;315:796-800. Brown lA, Vontver LA, Benedetti J, et al. Eects on infants of a rst episode of genital herpes during pregnancy. New England Journal of Medicine 1987;317:1246-1251. Brown ZA, Benedetti J, Ashley RL, et al. Neonatal herpes simplex virus infection in relation to asymptomatic maternal infection at the time of labor. New England Journal of Medicine 1991;324:1247-1252. Brown ZA, Selke S, Zeh J, et al. The acquisition of herpes simplex virus during pregnancy. New England Journal of Medicine 1997;337:509. Brown ZA, Wald A, Ashley R, et al. Eect of serologic status and caesarean delivery on transmission rates of herpes simplex virus from mother to infant. Journal of the American Medical Association 2003;289(2);203-209. Chuang T. Neonatal herpes: incidence, prevention and consequences. American Journal of Preventive Medicine, 1988;4:47-53. Corey L, Whitley RJ, Stone EF, Mohan K. Di erence between herpes simplex virus type 1 and type 2 neonatal herpes encephalitis in neurological outcome. Lancet 1988;8575-6:1-4. Forsgren M. Genital herpes simplex virus infection and incide nce of neonatal disease in Sweden. Scandinavian Journal of Infections 1994;69:37-41. Haddad J, Langer B, Astruc D, Messer J, Lokiec F. Oral acyclovir and recurrent genital herpes during late pregnancy. Obstetrics and Gynecology 1993;82:102-104. Jones CA, Isaacs D, McIntyre P, Cunningham A, Garland S. Neonatal herpes simplex virus infection. Tenth Annual Report of the Australian Paediatric Surveillance Unit, 2002. Lissauer T J, Shaw PJ, Underhill G. Neonatal herpes simplex pneumonia. Arch Dis Child 1984;59(7):668-670. Mindel A, Taylor J, Tideman RL, et al. Neonatal herpes prevention: a minor public health problem in some communities. Sexually Transmitted Infections 2000;76(4):287-91. Nahmias AJ, Josey WE, Nail ZN, et al. Perinatal risk associated with maternal genital herpes simplex infection. American Journal of Obstetrics and Gynecology 1971;110:825-834. Palasanthiran, P., Starr M, Jones C. (Editors) Management of Perinatal Infections. Australasian Society for Infectious Disease. 2002. http://www.racp.edu.au/asid/resources_perinatal.htm. Prober CG, Corey L, Brown lA, et al. The management of pregnancies complicated by genital infections with herpes simplex virus. Clinical Infectious Diseases 1992;15:1031-1038. Prober CG, Sullender WM, Yasukawa LL, et al. Low risk of herpes simplex virus infections in neonates exposed to the virus at the time of vaginal delivery to mothers with recurrent genital herpes. New England Journal of Medicine 1987;316:240-244. Randolph AR, Washington E, Prober CG. Caesarean deliver y for woman presenting with genital herpes lesions: efcacy, risks and costs. Journal of the American Medical Association 1993;270:77-82. Scott LL, Sanchez PJ, Jackson GL, et al. Acyclovir suppression to prevent Caesarean deliver y after rst-episode genital herpes. Obstetrics and Gynecology 1996;87:69-73. Spangler JG, Kirk JK, Knudson MP. Uses and safety of acyclovir in pregnancy. Journal of Family Practice 1994;38:186-191. Stone KM, Brooks CA, Guinan ME, Alexander ER. National Surveillance for neonatal herpes simplex virus infection. Sexually Transmitted Diseases 1989;16:152-156. Stray-Pederson B. Acyclovir in late pregnancy to prevent neonatal herpes simplex (letter). Lancet 1990;336:756. Tookey PA, Peckham CS. Neonatal herpes simplex virus infection in the British Isles. Pediatric and Perinatal Epidemiology 1996;10:432-442.
1998 First Printed 2002 Re-Printed 2004 Revised and Re-Printed 2006 Revised and Re-Printed 2009 Revised e-publication 2011 Re-edited e-publication
Disclaimer The AHMF have made considerable e orts to ensure the information upon which this guideline is based reproduces the evidence as accurately as possible. Users of this guideline are strongly recommended to con rm that the information contained within it, especially drug indications, is correct by way of independent sources, as this guideline does not indicate an exclusive course of action or serve as a standard of medical care. The AHMF accepts no responsibility for any inaccuracies, information perceived as misleading, or success of any treatment regime detailed in this guideline.

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Australian Herpes Management Forum (AHMF) C/- STIRC, Marian Villa, Westmead Hospital, Westmead NSW 2145 Australia Telephone +61 2 8230 3843 Facsimile +61 2 9845 6287 www.ahmf.com.au