Genital Infections In Pregnancy Flashcards
Problems with bacterial vaginosis in pregnancy
In 1st Trimester can lead to second trimester miscarriages or preterm labour
Treat with metronidazole
Presentation of disseminated herpes in pregnancy
Encephalitis
Hepatitis,
Disseminated skin lesions
Advice re miscarriage risk with primary genital herpes in the first trimester
No evidence of an increased risk of miscarriage
Management of primary genital herpes in the first trimester
Oral aciclovir 400 mg TDS, 5 days
(IV aciclovir for disseminated HSV)
Paracetamol
Topical lidocaine 2% gel
Aciclovir is not licensed in pregnancy - considered safe
What is the impact of using aciclovir for primary genital herpes
A reduction in the duration and severity of symptoms
A decrease in the duration of viral shedding.
When is daily suppressive therapy for HSV offered in pregnancy
From 36 weeks
Following first or second trimester acquisition of HSV
Aciclovir 400 mg TDS
Reduces HSV lesions at term and the need for delivery by caesarean section
+ reduces asymptomatic viral shedding (similar results have been seen with valaciclovir, although valaciclovir is not recommended for use in pregnancy in view of lack of experience with its use).
Risks re third trimester acquisition of HSV (from 28 weeks of gestation)
Some evidence of increased perinatal morbidity
- preterm labour
- low birthweight
- stillbirth
Conflicting data
No additional monitoring required
Treatment of newly acquired HSV in the third trimester (from 28/40)
Treatment should not be delayed.
Oral aciclovir (or IV for disseminated HSV) 400mg TDS usually for 5 days
In the third trimester treatment usually continues with daily suppressive aciclovir 400 mg TDS until delivery
Request type- specific HSV antibody testing (IgG)
Recommended mode of delivery of newly acquired HSV in the third trimester (from 28/40)
CS recommended for all women developing first episode HSV in the 3rd trimester
Esp if developing within 6 weeks of EDD as risk of neonatal transmission of HSV is very high at 41%
For women with HSV in the 3rd trimester how can we determine if it is a primary infection or a recurrence?
Request type- specific HSV antibody (IgG) serology
Antibodies of the same type as the HSV isolated from genital swabs confirms this episode is a recurrence
May take 2–3 weeks for results to be available so initial plan for delivery is based on assuming all 1st episode lesions are primary HSV
Advice for women with recurrent HSV re risk of neonatal herpes
low risk
even if lesions are present at the time of delivery = 0–3% for vaginal delivery
Treatment advice for women with recurrent HSV in pregnancy
No evidence that aciclovir is unsafe in early pregnancy
BUT most recurrent episodes of HSV are short-lasting + resolve in 7–10 days without antiviral treatment
Supportive measures - saline bathing + analgesia
Consider daily suppressive aciclovir 400mg TDS from 36/40 - reduces viral shedding and recurrences at delivery
Why is the suppressive dose of aciclovir increased for HSV prevention during pregnancy
Aciclovir 400 mg BD is the standard dose of HSV prophylaxis
In pregnancy the daily suppressive aciclovir dose is 400 mg TDS
due to the greater volume of distribution of the drug during pregnancy
Management of women with HSV lesions detected at the onset of labour
Management based on clinical assessment - no time for confirmatory laboratory testing
Use history to ascertain if primary or recurrent HSV
Send viral swab from the lesion(s)
inform the neonatologist
CS if suspected primary HSV
Benefit from CS may be reduced if membranes ruptured >4 hours
Consider IV aciclovir intrapartum to mother and then to neonate if VD
% risk of neonatal herpes following vaginal birth during an episode of primary HSV
estimated 41%
