Herpes in pregnancy

Question 1

Why is neonatal herpes considered a serious viral infection?

Answer 1

High MORBIDITY and MORTALITY

Question 2

What sites of infection with herpes affect the neonate?

Answer 2

localised to skin, eye, mouth
local CNS disease eg encephalitis
disseminated with multiple organ involvement

Question 3

What is the proportion of disseminated or CNS infection in neonatal herpes?

Answer 3

70% of all cases

30% localised skin, eye, mouth

Question 4

What is the mortality and the morbidity associated wit disseminated neonatal herpes?

Answer 4

MORTALITY 30%

Neurological MORBIDITY 17%

Question 5

What is the typical route of transmission of neonatal herpes?

Answer 5

Vertical at time of birth

Question 6

What is the incidence of neonatal herpes in UK?

Answer 6

1.65/100 000 live births

Question 7

What is the proportion of HSV-1 vs HSV-2 in neonatal herpes infection?

Answer 7

50:50

Question 8

What factors are associated with transmission of maternal-neonate herpes?

Answer 8

Primary > recurrent infection
presence of transplacental maternal neutralising antibodies
duration of rupture of membranes before delivery
use of foetal scalp electrodes
mode of delivery

Question 9

When is the risk greatest of transmission of herpes to neonate?

Answer 9

PRIMARY infection in THIRD trimester

last SIX weeks

Question 10

If a mother acquires genital herpes during pregnancy in her first or second trimester - what guidance should be given?

Answer 10

Manage episode as per usual guidance for first episode
No risk to pregnancy or neonate as long as no delivery within 6 weeks
DAILY suppressive therapy from 36 weeks
Vaginal delivery possible

Question 11

What risk is associated with acquiring genital herpes in third trimester?

Answer 11

PRETERM labour

LOW birthweight

Question 12

If first infection with genital herpes occurs in last 6 weeks of pregnancy what is risk of neonatal transmission?

Answer 12

41%

Question 13

What management can be offered to reduce risk of neonatal transmission of herpes?

Answer 13

Start treatment for first episode and continue until delivery
Recommend C-section, especially if episode <6 weeks from delivery
Check type- specific HSV antibody testing (to quantify if first infection or past infection, first episode)

Question 14

What treatment is offered to all mothers with past or recent genital herpes from week 36 of pregnancy?

Answer 14

Acyclovir 400mg THREE times daily

Increased dose suppressive therapy as greater volume distribution in pregnancy

Question 15

Is there any increased risk of perinatal morbidity if mother is seropositive for HSV?

Answer 15

NO increased risk of
preterm labour
PPROM
Foetal growth restriction
congenital abnormalities

Question 16

If a mother opts for vaginal delivery despite first infection with herpes within 6 weeks of delivery what treatment can be considered with an aim to reduce risk of maternal-neonate transmission?

Answer 16

IV aciclovir for mother and neonate

although unclear if risk transmission reduced

Question 17

What interventions should be avoided during vaginal delivery in a women with herpes infection < 6 weeks from delivery?

Answer 17

Invasive procedures
-application of fetal scalp electrodes
-fetal blood sampling
-artificial rupture of membranes
instrumental deliveries

Question 18

In women with recurrent genital herpes at onset of labour - can they opt for vaginal delivery?

Answer 18

Vaginal delivery offered - low risk transmission 0-3%

final choice mother’s

Question 19

Primary herpes infection + PPROM - what to do?

Answer 19

MDT discussion
Delivery via C-section
If delay delivery, IV aciclovir
consider corticosteroid

Question 20

Recurrent herpes infection + PPROM - what to do?

Answer 20

<34 weeks -
suppressive therapy acyclovir 400mg THREE x daily
>34 weeks follow general PPROM guidance

Question 21

Women who are HIV antibody positive and have a history of genital herpes - what advice?

Answer 21

32 weeks

-daily suppressive aciclovir 400 mg three times daily reduce the risk of transmission of HIV infection

Question 22

Why does administration of acyclovir reduce risk of HIV transmission in pregnancy+past infection herpes?

Answer 22

some evidence that HIV antibody positive women with genital HSV ulceration in pregnancy are more likely to transmit HIV infection independent of other factors

Question 23

Management of neonate - C-section - primary HSV infection - third trimester?

Answer 23

Liase with neonatal team
Conservative management
Counsel parents on signs of HSV infection

Question 24

Management of neonate - spontaneous vaginal delivery - primary HSV infection - <6weeks?

Answer 24

Liase with neonatal team
Swab skin, eye, oropharynx, rectum HSV PCR
IV acyclovir 20mg/kg 8 hourly until active infection ruled out

Question 25

What percentage of neonatal herpes infection occurs in the postnatal period?

Answer 25

25%