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%
% risk of neonatal herpes following vaginal birth during an episode of recurrent HSV
0–3%
management of primary genital herpes in preterm prelabour rupture of membranes (PPROM)
limited evidence
MDT discussion
depend on the gestation that PPROM occurred
If decision is for immediate delivery then CS will likely be beneficial
If initial conservative management - start maternal IV aciclovir 5 mg/kg every 8 hours.
+/- prophylactic corticosteroids
special consideration for HIV-positive women with HSV infection in pregnancy
some evidence - HIV positive F with genital HSV ulceration in pregnancy are more likely to transmit HIV infection - independent of other factors
Offer daily suppressive aciclovir 400 mg TDS from 32/40 to reduce risk of transmission of HIV
Esp if VD planned
Management of babies born by CS in mothers with primary HSV infection in the third trimester
Low risk of vertically transmitted HSV
Conservative management recommended
● Liaise with the neonatal team
● Swabs from the neonate NOT indicated.
● No active treatment for baby
● Normal postnatal care of the baby is advised with a neonatal examination at 24 hours, then can be discharged from hospital if well and feeding established
● Parents educated re hand hygiene and care to reduce risk of postnatal infection.
● advised to seek medical help if any concerns - advised to look for: skin, eye and mucous membrane lesions, lethargy / irritability, poor feeding
Management of babies born by spontaneous VD in mothers with primary HSV infection in the previous 6 weeks
At high risk of vertically transmitted HSV
● Liaise with the neonatal team.
If the baby is well:
● Swabs of the skin, conjunctiva, oropharynx and rectum sent for herpes simplex PCR.
● lumbar puncture NOT necessary.
● Empirical treatment - IV aciclovir (20 mg/kg 8 hourly) - initiated until evidence of active infection ruled out
● Strict infection control procedures for both mother and baby.
● Breastfeeding is recommended unless the mother has herpetic lesions around the nipples.
● Parents report any early signs of infection such
as poor feeding, lethargy, fever or any suspicious lesions.
If baby unwell or has skin lesions -
Also do LP - even if CNS features are not present
Why is the risk low for babies born to mothers with recurrent HSV infection in pregnancy
Maternal IgG will be protective in the baby
Prevention of postnatal transmission of HSV
Good hand hygiene - for all people with herpetic lesions who have contact with the baby
People with oral herpes (cold sores) should not kiss the baby
What are the 3 subgroups of Neonatal herpes
● localised to skin, eye and/or mouth
● local central nervous system (CNS) disease (encephalitis alone)
● disseminated infection with multiple organ involvement
Which type of neonatal herpes has the best prognosis
Disease localised to skin, eye and/or mouth
30% of neonatal herpes infections
antiviral treatment means neurological and/or ocular morbidity is less than 2%
What proportion of infants with neonatal herpes have disseminated and/or CNS infection
70%
and 60% of infants with local CNS and/or disseminated disease will present without skin, eye and/or mouth infection
What is the mortality rate and neurological morbidity rate from neonatal herpes of the local CNS
6% mortality
70% - Neurological morbidity (may be lifelong)
Infants with local CNS disease often present late (generally between 10 days and 4 weeks of age)
What is the mortality rate and neurological morbidity rate from disseminated neonatal herpes
with appropriate antiviral treatment
30% - mortality
17% long-term neurological sequelae
What is the difference between neonatal herpes and congenital herpes
Neonatal herpes = result of infection at the time of birth
Congenital herpes = transfer of infection in utero - extremely rare
Incidence of neonatal herpes in the UK
Neonatal herpes is rare in the UK
1.65 / 100,000 live births
Aetiology of neonatal herpes
50% due to HSV-1
50% due to HSV-2
Most cases occur due to direct contact with infected maternal secretions
Postnatal infection can occur from oro-labial herpes
what may disseminated herpes present with
encephalitis
hepatitis
disseminated skin lesions
rare in adults
more common in pregnancy
high maternal mortality
Management of LGV in pregnancy
Erythromycin 500mg QDS PO 21 days
Alternative: Azithromycin 1g weekly for 3 weeks
AVOID doxycycline
TOC in pregnancy
Treatment of gonorrhoea in pregnancy / breastfeeding
Ceftriaxone 1g IM STAT
(or Spectinomycin 1g IM STAT
or Azithromycin 2g PO STAT)
