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Sepsis > HSV > Flashcards

HSV Flashcards

1
Q

What are the manifestations of disseminated maternal herpes?

A

Encephalitis, hepatitis, disseminated skin lesions or a combination

Rare, but more common in pregnancy, particularly if immunocompromised

High maternal mortality

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2
Q

Co-infection with HSV and HIV results in…

A

Increased replication of both viruses

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3
Q

If HIV positive with history of HSV, management:

A

Daily suppressive Aciclovir 400mg tds from 32/40
Reduce risk of transmission of HIV, especially if VD is planned
Start early if possibility of PTL

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4
Q

What are the manifestations of congenital herpes?

A

Skin, eyes, CNS involvement
IUGR
IUFD

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5
Q

What proportion of neonatal herpes is HSV1 vs HSV2

A

50%

50%

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6
Q

What are factors that increase the risk of HSV transmission in labour?

A

Primary infection
New infection in third trimester, particularly within 6 weeks of delivery
- viral shedding may persist
- baby is likely to be born before the development of protective maternal antibodies

Duration of ROM before delivery
FBS
Mode of delivery

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7
Q

In maternal HSV, what is the risk of neonatal transmission in

  • primary episode in labour
  • primary episode in trimester 3, from 28/30
A

41% with vaginal delivery

Therefore CS recommended

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8
Q

In maternal HSV, what is the risk of neonatal transmission in

  • recurrent episode antenatally
  • recurrent episode in labour
A

0-3%
If antenatal: aim vaginal delivery
If antenatal or in labour: offer VS or CS, maternal decision but VD is safe
I

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9
Q

In maternal HSV, what are the recommendations re breastfeeding?

A

Continue

Unless herpetic lesions around nipple

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10
Q

HSV-1 accounts for what % of genital herpes?

A

35%

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11
Q

What is the HSV-2 seroprevalence in adult female population?

A

16%

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12
Q

HSV-1 compared with HSV-2 is:

  • Associated with ____ frequent recurrences
  • _____ risk of transmission to the neonate at delivery
A

HSV-1 compared with HSV-2 is:

  • Associated with LESS frequent recurrences
  • HIGHER risk of transmission to the neonate at delivery
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13
Q

What % of neonates acquire HSV:

  • At delivery?
  • In-utero?
  • Postpartum?
A
  • At delivery 90%
  • In utero 5%
  • Postpartum 5%
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14
Q

What are potential sources of postnatal HSV transmission to newborn?

A
  • Breast milk
  • Skin and oral lesions
  • SHV lesions from caregivers, family members or medical staff with close contact.
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15
Q

What is the mortality rate of disseminated neonatal HSV infection?

A
  • 90% if untreated

- 20-30% if treated

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16
Q

What is the indications for Caesarean section delivery to prevent neonatal HSV infection?

A
  • Primary genital HSV during pregnancy particularly third trimester.
  • Primary genital HSV diagnosed in labour.
  • Active genital herpes lesions and membranes ruptured <6 hours.
  • Poor seroconversion following primary HSV infection in first and second trimesters.
17
Q

When is it safe to offer vaginal delivery when a mother has a history of HSV?

What precautions should you still take in labour?

A
  • History of genital herpes with no active lesions in labour.
  • Seroconversion following primary infection in first and second trimesters.
  • Avoid trauma to fetal scalp: no FSE, FBS, forceps or ventouse.
  • Follow-up neonate
18
Q

What neonate cares are needed if baby is inadvertently delivered vaginally when there are active genital herpes lesions or following a primary genital herpes episode in the third trimester?

A
  • Empiric IV aciclovir for neonate.
19
Q

What precautions should be taken when a pregnant seronegative woman has a partner with a history of genital herpes?

A
  • Use condoms.
  • Suppressive antiviral therapy for partner.
  • Avoid oral sex if partner has oral herpes and HSV type is unknown.
  • Abstinence whe symptomatic and during third trimester.
20
Q

What is the mortality rate of disseminated neonatal HSV infection?

A
  • 90% if untreated

- 20-30% if treated

21
Q

What is the indications for Caesarean section delivery to prevent neonatal HSV infection?

A
  • Primary genital HSV during pregnancy particularly third trimester.
  • Primary genital HSV diagnosed in labour.
  • Active genital herpes lesions and membranes ruptured <6 hours.
  • Poor seroconversion following primary HSV infection in first and second trimesters.
22
Q

When is it safe to offer vaginal delivery when a mother has a history of HSV?

What precautions should you still take in labour?

A
  • History of genital herpes with no active lesions in labour.
  • Seroconversion following primary infection in first and second trimesters.
  • Avoid trauma to fetal scalp: no FSE, FBS, forceps or ventouse.
  • Follow-up neonate
23
Q

What neonate cares are needed if baby is inadvertently delivered vaginally when there are active genital herpes lesions or following a primary genital herpes episode in the third trimester?

A
  • Empiric IV aciclovir for neonate.
24
Q

What precautions should be taken when a pregnant seronegative woman has a partner with a history of genital herpes?

A
  • Use condoms.
  • Suppressive antiviral therapy for partner.
  • Avoid oral sex if partner has oral herpes and HSV type is unknown.
  • Abstinence whe symptomatic and during third trimester.
25
Q

What precautions should be taken when a pregnant woman has RECURRENT symptomatic genital HSV?

A
  • Aciclovir suppressive therapy from 36 weeks (or earlier if symptomatic).
  • Follow-up for neonate.
26
Q

What investigations should you order for a pregnant woman with a first episode of genital herpes in pregnancy/labour?

A
  • Type specific PCR and culture (genital swab)

- HSV type specific serology (blood sample)

27
Q

How would you interpret:

  • HSV detect on genital swab BUT
  • Same serotype antibody not detected in blood
    e. g. HSV1+ swab, HSV1 IgG -ve and HSV2 IgG +ve blood
A

Non-primary first episode (new acquisition of an HSV serotype with evidence of exposure (IgG +ve) to the other serotype).

Still considered high risk if doesn’t seroconvert prior to 3-34 weeks

28
Q

How would you interpret:

  • Genital swab HSV +ve BUT
  • Seronegative for both HSV1 and HSV2 IgG in blood?
A

Primary first episode.

New acquisition of either HSV serotype without prior exposure (i.e. seronegative in blood to both HSV IgG1 and 2).

29
Q

What can you infer if a patient has HSV1 antibodies on serology?

A

Implies prior infection but does not specify site of infection.

30
Q

How would you interpret:

  • Genital swab HSV +ve AND
  • Seropositive for same HSV type IgG in blood?
A

Recurrent infection

31
Q

What is the effect of prior HSV-1 infection have on acquisition of HSV-2?

A
  • Does not alter risk of acquisition.

- Lessens symptoms of HSV-2

32
Q

What is the effect of prior orolabial HSV1 infection on genital HSV1?

A

Prior orolabial HSV1 is protective against genital HSV1.

33
Q

How to prevent spread of genital herpes

A
  • Condom use (does not eliminate risk).
  • Avoid sexual contact when oral or genital lesions present.
  • Oral suppressive therapy reduces risk of transmission by 80-95%.
34
Q

What investigations can be performed for confirming genital herpes?

Highlight any advantages and disadvantages.

A

Viral PCR swab:

  • Gold standard
  • Low false positive rate
  • Negative test does not rule out HSV.

Viral culture swab:
- High false negative rate.

Type-specific herpes serology (blood):

  • Positive antibodies only indicate past (not current) infection.
  • Cannot distinguish anatomical site of infection
  • No accurate enough.
  • Seroconversion rates highly variable.
  • Indicated if: discordant couple planning pregnancy (male +ve, female -ve); herpes in pregnancy with no previous history; recurrent or atypical genital sx with negative HSV PCR swab.
35
Q

What antiviral therapy would you prescribe for:

  • First episode
  • Recurrent episode
  • Suppressive treatment
A
  • First episode: valaciclovir 500 mg BD 7 days or more.
  • Recurrent episode: valaciclovir 500 mg BD for 3 days.
  • Suppressive treatment: valaciclovir 500 mg OD for 12 months; trial break for 3 months after this.
36
Q

Outline symptomatic management of genital herpes

A
  • Oral analgesia
  • Topical analgesia lignocaine gel 2%
  • Sitz baths
  • Micturating sitting in bath/bowl of water
  • Suprapubic catheter
  • Dry lesions with lowest setting of a hair dryer
37
Q

What are the three subgroups of neonatal HSV?

A
  1. Skin, eye and/or mouth
  2. Local CNS: encephalitis alone
  3. Disseminated infection with multiple organ involvement
38
Q

For a woman who has primary episode of HSV diagnosed after 28/40, how long should she take antiviral therapy for?

A

Aciclovir 400mg tds
UNTIL DELIVERY

Treat without waiting for results

39
Q

What is a neonatal side effect of mum taking Aciclovir antenatally?

A

Transient neonatal neutropenia

NO clinically significant adverse effects

Sepsis (6 decks)

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