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Practice bulletins > #220 Management of Genital Herpes in Pregnancy > Flashcards

#220 Management of Genital Herpes in Pregnancy Flashcards

1
Q

What is the prevalence of HSV-2 infection in 14- to 49-year-old females?

A

15.9%

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2
Q

What type of virus is HSV?

A

Double-stranded DNA virus

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3
Q

What differentiates HSV 1 and 2?

A

Glycoproteins in the lipid bilayer envelope. Glycoprotein G1 (HSV1) and G2 (HSV2)

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4
Q

What is HSV 1 the primary etiologic agent of?

A

Herpes labialis, gingivostomatitis, and keratoconjunctivitis. Increasingly common cause of oral and genital infections

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5
Q

What does HSV2 cause?

A

genital herpes

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6
Q

How is HSV transmitted?

A

Person to person through direct contact

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7
Q

What is the incubation period after acquisition of HSV1 or HSV2?

A

2 days to 12 days

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8
Q

Where does HSV remain latent?

A

In sensory nerves

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9
Q

When do type-specific antibodies to HSV viral proteins develop after infection?

A

2-3 weeks after infection

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10
Q

How do you determine a primary HSV outbreak?

A

HSV1 or HSV2 is detected from a lesion in an individual with no evidence of antibodies to either viral type in the serum

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11
Q

How do you determine a nonprimary first-episode infection of HSV?

A

When one viral type is detected in lesions from individual with evidence of antibodies to the other viral type in serum

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12
Q

How do you determine a recurrent HSV infection?

A

When HSV is detected in lesions from individuals with evidence of antibodies to the same viral type in the serum

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13
Q

Approximately what % of patients with infections report recognition of their infections?

A

5-15%

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14
Q

Approximately what % of US women have serologic evidence of HSV2?

A

~21%

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15
Q

Among women susceptible to HSV infection, what is the incidence of new HSV infection during pregnancy?

A

Approximately 2%

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16
Q

When is a woman during pregnancy more likely to be infected with HSV?

A

Timing of infection is relatively evenly distributed

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17
Q

Among women with recurrent genital HSV, approximately what % will have at least one recurrence during pregnancy?

A

Approximately 75%

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18
Q

Among women with recurrent genital HSV, approximately what % will have prodromal symptoms or clinical recurrence at delivery?

A

Approximately 14%

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19
Q

When is neonatal herpes usually acquired?

A

During intrapartum period through exposure to the virus in the maternal genital tract

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20
Q

Approximately how many cases of neonatal herpes occur annually in the US?

A

1,200-1,500

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21
Q

What fraction of neonatal herpes cases are caused by HSV-1?

A

1/3 to 1/2

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22
Q

What types of neonatal HSV infection are there?

A

Disseminated disease (25%), CNS disease (30%), and disease limited to the skin, eyes or mouth (45%)

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23
Q

What is the risk of mortality for disseminated neonatal HSV?

A

30%

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24
Q

What is the mortality risk for CNS neonatal HSV?

A

4%

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25
Q

What % of survivors of neonatal herpes have long-term neurologic sequelae?

A

~20%

26
Q

What is the preferred method of testing for patients who present with genital vesicles, ulcers, or other mucocutaneous lesions?

A

Virologic tests - include viral culture and HSV antigen detection by PCR

27
Q

How should you collect a genital specimen for HSV culture?

A

Unroof the vesicle, if present, and vesicular fluid should be collected

28
Q

How is the sensitivity of viral culture for HSV?

A

Low. 80% for primary lesions, 40% for recurrent lesions

29
Q

How does the sensitivity of an HSV PCR compare to culture?

A

PCR is 3-5x more likely to be positive

30
Q

Up to what % of first-episode infections during pregnancy are recurrent HSV infections?

A

15%

31
Q

What is a primary outbreak of HSV in the first trimester of pregnancy associated with?

A

Neonatal chorioretinitis, microcephaly, and skin lesions

32
Q

Is routine HSV screening recommended in pregnant women?

A

No

33
Q

What are the three common oral antiviral agents used to treat HSV infections?

A

Acyclovir, valacyclovir, and famciclovir

34
Q

True or false, acyclovir is considered safe in the first trimester?

A

True

35
Q

How does acyclovir work?

A

It is a nucleoside analogue that enters virally infected cells and acts specifically to inhibit the viral thymidine kinase and, thus, DNA replication

36
Q

How is valacyclovir related to acyclovir?

A

Prodrug of acyclovir, rapidly converted in the liver.

37
Q

What is the rate of acyclovir resistance in HSV in immunocompetent and immunocompromised patient?

A

0.3-0.6% in immunocompetent. 6-7% in immunocompromised.

38
Q

When should you offer suppressive therapy for HSV in pregnant women?

A

At 36wks, if has had outbreak in pregnancy or clinical hx of genital herpes

39
Q

What is the dosing of acyclovir for primary or first-episode HSV infection?

A

Acyclovir 400mg orally, three times daily, for 7-10days. (may extend if healing incomplete after 10d of therapy)

40
Q

What is the dosing of valacyclovir for primary or first-episode HSV infection?

A

1g orally, twice daily, for 7-10d (can extend if healing incomplete)

41
Q

What is the dosing of acyclovir for symptomatic recurrent episode of HSV?

A

400mg orally, three times daily, for 5 days or 800mg orally, twice daily for 5 days

42
Q

What is the dosing of valacyclovir for symptomatic recurrent episode of HSV?

A

500mg orally, twice daily, for 3 days or 1g orally, daily, for 5 days

43
Q

What is the acyclovir dosing for daily HSV suppression?

A

400mg orally three times daily, from 36wks until delivery

44
Q

What is the valacyclovir daily suppression dosing for HSV?

A

500mg orally, twice daily, from 36wk until delivery.

45
Q

What is the acyclovir dosing for severe or disseminated HSV disease?

A

5-10mg/kg IV every 8 hours for 2-7d, then oral therapy for primary infection to complete 10d

46
Q

What is the risk of vertical HSV transmission when primary outbreak occurs at the time of delivery?

A

Approx 40-80%

47
Q

Why do neonates have higher risk of vertical transmission of HSV infection if delivery is at time of primary outbreak?

A
  1. Reduced protective HSV-2 specific antibodies that cross the placenta
  2. Increased virus exposure in genital tract
48
Q

What is the mean viral shedding length in untreated women with primary herpes infection?

A

15 days

49
Q

What % of women with primary herpes infection have cervical shedding?

A

90%

50
Q

True or false, dosing for suppressive HSV therapy is the same in pregnant and nonpregnant individuals?

A

False. Higher renal clearance means higher doses for pregnant women

51
Q

True or false, cesarean delivery is indicated in women with prodromal HSV symptoms?

A

True, may indicated viral shedding

52
Q

What is the risk of neonatal herpes in women with HSV isolated from genital secretions at time of delivery for vaginal vs CS delivery?

A

Vaginal - 1.2%

CS - 7.7%

53
Q

True or false, CS performed before ROM prevents HSV transmission to neonate?

A

False. Can still have transmission, although decreased risk.

54
Q

Does a primary HSV outbreak during 3rd trimester of pregnancy affect delivery method recommendation?

A

Can consider CS due to possibility of prolonged viral shedding

55
Q

Is CS recommended for women with recurrent HSV lesions on back, thigh, or buttock?

A

No. These lesions may be covered with an occlusive dressing and patient may give birth vaginally

56
Q

In a patient with active HSV lesions and ROM at term, should CS be performed?

A

Yes.

57
Q

In a patient with active HSV lesions and PPROM, should CS be performed?

A

Risks of prematurity should be weighed against risk of neonatal HSV in considering expectant management.

58
Q

True or false, transabdominal invasive procedures (CVS, amnio, PUBS) should be deferred during active HSV infection?

A

False. May be performed when genital lesions are present.

59
Q

True or false, transcervical invasive procedures should be deferred during active HSV infection?

A

True. Seems reasonable to delay procedures until lesions appear to have resolved.

60
Q

Is breastfeeding contraindicated with HSV?

A

Only if HSV lesions on breast. Should advise women to take special considerations with handwashing

61
Q

True or false, postnatally acquired HSV is less lethal than HSV acquired during delivery?

A

False. Can be just as lethal.

62
Q

True or false, valacyclovir is safe for breastfeeding women?

A

True

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