Genital Herpes in Pregnancy, Management Flashcards
- Women with suspected genital herpes in pregnancy?
- refer to GUM physician to confirm or refute diagnosis by viral PCR, advise on management of genital herpes
- arrange a screen for other STIs.
MX of pregnant genital herpes first acquisition first or second trimester (until 27+6 weeks of gestation)
What are general measures?
Safety data for aciclovir may be extrapolated to valaciclovir (val-ə-ˈsī-klō-ˌvir) in late pregnancy, as it is the valine ester, but as there is less experience with use of valaciclovir or famciclovir, they are not recommended as a firstline
treatment.
● The obstetrician should be informed
● Paracetamol and topical lidocaine 2% gel can be offered as symptomatic relief. (There is no evidence that either is harmful in pregnancy in standard doses.)
● Women with suspected genital herpes who are having midwifery-led care should be referred for review by an obstetrician, ideally after review by GUM physician.
MX of pregnant genital herpes first acquisition first or second trimester (until 27+6 weeks of gestation)
How to reduces HSV lesions at term & asymptomatic viral shedding.
●Following first or second trimester acquisition, daily suppressive aciclovir 400 mg three times daily from 36 weeks of gestation reduces HSV lesions at term and hence the need for delivery by caesarean section.
It has also been shown to reduce asymptomatic viral shedding (similar results have been seen with valaciclovir (val-ə-ˈsī-klō-ˌvir), although valaciclovir is not recommended for use in pregnancy in view of lack of experience with its use).
Third trimester acquisition (from 28 weeks of gestation)
● Treatment should not be delayed.
- MX should be in line with her clinical condition and will usually involve use of oral (or IV for disseminated HSV) aciclovir in standard doses (400 mg three times daily, usually for 5 days).
- In the third trimester, treatment will usually continue with daily suppressive aciclovir 400 mg three times daily
until delivery.
Third trimester acquisition (from 28 weeks of gestation)
Mode of deivery and rationale
●CS should be recommended mode of delivery for all women developing first episode genital herpes in third trimester, particularly those developing symptoms within 6 weeks of expected delivery, as risk of neonatal transmission of HSV is very high at 41%.
Third trimester acquisition (from 28 weeks of gestation)
recurrence rather than a primary infection
●It can be difficult to distinguish clinically between primary and recurrent genital HSV infections, as in up to 15% of cases where a woman presents with a first episode of clinical HSV infection, it will actually be a recurrent infection.
- For women presenting with first episode genital herpes in third trimester, particularly within 6 weeks of expected delivery, type specific HSV antibody testing (IgG to
HSV-1 and HSV-2) is advisable. - For these women, characterising infection will influence advice given regarding mode of delivery and
risk of neonatal herpes infection. - The presence of antibodies of same type as HSV isolated from genital swabs would confirm this episode
to be a recurrence rather than a primary infection and elective caesarean section would not be indicated to prevent neonatal transmission. - However, it should be noted that it may take 2–3 weeks for the results of this test to become available. It is therefore recommended that an initial plan of delivery should be based on the assumption that all first episode
lesions are primary genital herpes. - This plan can then be modified if HSV antibody test results subsequently confirm a recurrent, rather than primary, infection.
- As interpretation of serology can be complicated, results should be discussed with virologist or GUM physician
MX of pregnant with recurrent genital herpes
Risk of transmission
● should be informed that risk of neonatal herpes is low, even if lesions are present at the time of delivery
(0–3% for vaginal delivery).
MX of pregnant with recurrent genital herpes
● treatment for woman
● Although there is no evidence that aciclovir is unsafe in early pregnancy, majority of recurrent episodes of genital herpes are short-lasting and resolve within 7–10 days without antiviral treatment.
- Supportive treatment measures using saline bathing and analgesia with standard doses of paracetamol alone will usually suffice.
MX of pregnant with recurrent genital herpes
● Mode of delivery and planning
●Vaginal delivery should be anticipated in the absence of other obstetric indications for caesarean section.
●Daily suppressive aciclovir 400 mg three times daily should be considered from 36 weeks of gestation
●This increase from the standard suppressive dose of 400 mg twice daily is recommended in view of the greater volume of distribution of the drug
during pregnancy.
how to identify women who are asymptomatically shedding HSV,
● Sequential PCR culture during late gestation to predict viral shedding at term, or at delivery to identify women who are asymptomatically shedding HSV, is not indicated.
MX of primary or recurrent genital lesions at onset of labour
General management
● Management be based on clinical assessment as there will not be time for confirmatory laboratory testing.
- The clinician must take a history in order to ascertain
whether this is a primary or recurrent episode. - A viral swab from the lesion(s) should nonetheless be taken, since the result may influence management of the neonate.
● The neonatologist should be informed.
MX of primary or recurrent genital lesions at onset of labour
Primary episode
Mode of delivery
● CS should be recommended to all women presenting with primary episode genital herpes lesions at the time of delivery, or within 6 weeks of the expected date of delivery, in order to reduce exposure of fetus to HSV which may be present in maternal genital secretions.
MX of primary or recurrent genital lesions at onset of labour
Primary episode
if the membranes have been ruptured for greater than 4 hours.
●There is some evidence to suggest that the benefit of caesarean section reduces if the membranes have been ruptured for greater than 4 hours.
-However, there may be some benefit in performing a caesarean section even after this time interval.
MX of primary or recurrent genital lesions at onset of labour
Primary episode
If deliver vaginally in the presence of primary genital herpes lesions
●Although vaginal delivery should be avoided if possible, in women who deliver vaginally in presence of primary genital herpes lesions, invasive procedures (application of fetal scalp electrodes, fetal blood sampling, ARM and/or instrumental deliveries) should be avoided.
Third trimester acquisition (from 28 weeks of gestation)
HSV preterm birth, LBW and still birth
● There is some evidence of increased perinatal morbidity (preterm labour and low birthweight), together with stillbirth, however the data are conflicting, so no additional monitoring of such pregnancies is recommended.
- There is insufficient evidence to suggest association between HSV and stillbirth as cause of fetal death with some studies demonstrating no association
