herpes in pregnancy

Question 1

what type of virus is HSV? how long is incubation period?

Answer 1

ds DNA

incubation period 2-12 d

Question 2

how to diagnose:

• primary infection
• non-primary, 1st episode
• recurrent

Answer 2

• primary: Ab neg
• Ab Pos but does not match clinical type (i.e. HSV 1 and 2)
• Ab Pos: AB and clinical type do match

Question 3

diagnostic testing options?

Answer 3

• culture of lesion: high false negative rate (20% false negative rate for primary infection, and 40% for recurrent)
• clinical assessment: high false positive rate
• serology with PCR is test of choice for confirmation

Question 4

vertical transmission rates (primarily at time of delivery)

• primary infection
• non-primary first episode
• recurrent infection

Answer 4

• primary: 50%
• non-primary, first episode: 33%
• recurrent infection: 3%

Question 5

what are medication options and how do they work?

Answer 5

• acyclovir - inhibits viral kinase and therefore viral replication
• famciclovir - converted to pencyclovir in liver (increase bioavail compared to acyclovir)
• valacyclovir - converted to acyclovir in liver (greater bio avaial than acyclovir)

Question 6

treatment regimens:

Answer 6

valacyclovir:

• primary: 1000 mg BID x 7-10 days
• recurrent: 500 mg BID x 3 days or 1 g qday x 5 days
• suppression: 500 mg BID

acyclovir:

• primary: 400 mg TID x 7-10 days
• recurrent: 400 mg TID x 5 days or 800 mg BID x 5 days
• suppression: 400 mg TID

Question 7

what is treatment for systemic/disseminated HSV?

Answer 7

acyclovir: IV 5-10 mg/kg q8hr x 2-7d, then PO treatment for primary infection to complete a total of 10 days

Question 8

when/why to start ppx in pregnancy

Answer 8

36 weeks, reduces risk of recurrence and need for CD

Question 9

delivery scenarios:

• active lesions
• ROM and active lesions

Answer 9

• active genital lesions - CD
• active non-genital lesions (buttock/back/thigh) - cover and VD
• ROM at term - CD ASAP; benefits persist even with delay though
• PPROM - expectant management/ANC/antivirals/CD if lesions present

Question 10

what does neonatal hsv look like?

Answer 10

• skin/cutaneus manifestations: 45%
• neurologic: 30% (4% mortality)
• sytemic: 25% (30% mortality)
  20% of those who survive neonatal HSV have long term neurologic sequelae

Question 11

what’s the deal with breast feeding?

Answer 11

• if there is an active lesion on the breast - no BF

- make sure everyone in household is washing hands– can be transmitted with direct contact even if lesions elsewhere