Management of Genital Herpes In Pregnancy Flashcards
How is neonatal herpes classified?
1- localized to skin + ( eye and/ or mouth) 30 % of the cases
2- local CNS disease ( encephalitis)
3- disseminated infection with multiple organ involvement
2 + 3 : 70 % of the cases
What is the mortality & morbidity rate in each subgroup of neonatal herpes with antiviral treatment ?
1- localized to skin / eye- mouth
Morbidity < 2%
2- local CNS ( encephalitis)
Mortality 6% neurological morbidity 70 %
3- disseminated infection
Mortality 30 %
What is the route of infection in neonatal herpes?
Infection at the time of delivery
What is the incidence of neonatal herpes in USA / UK ?
In USA 1 / 15,000
in UK 50 % of that ( 1/ 30,000)
What is the aetiology of neonatal herpes?
Herpes simplex type 1(50%)
+ type 2 (50%)
♤ Most of the cases is a result if direct contact with infected maternal secretions
What are the factors associated with transmission of HSV & cause neonatal herpes?
1- type of maternal infection ( primary/ recurrent)
2- presence of transplacental maternal antibodies
3- duration of membranes rupture before delivery
4- use fetal scalp electrodes
5- mode of delivery
What are the factors that have the greatest risk of neonatal herpes?
1- primary genital herpes
2- 3rd trimester ( particularly within [6] weeks of delivery
What are the risk factors for disseminated neonatal herpes?
1- preterm infants
2- EXCLUSIVE for primary infection
What causes congenital herpes?
Transplacental intrauterine infection
RARE
What is the management in a pregnant woman with first episode genital herpes in 1st / 2nd trimester?
1- NO increased risk of miscarriage
2- referral to genitourinary physician: confirm the diagnosis by PCR / screen for other STD
3- obstetrician should be informed
4 - ACYCLOVIR: 400 mg 1×3 for 5d
5- paracetamol + lidocaine gel
6- delivery doesn’t ensue within 6w
7- acyclovir 400 mg 1×3 from 36w of gestation reduce HSV lesions at term to alow vaginal delivery
What is the adverse neonatal effect of acyclovir antenatally?
Transient neonatal neutropenia
What is the management of a pregnant woman with first episode genital herpes in the 3rd trimester (>28w) ?
1- no additional fetal monitoring
2- ACYCLOVIR: 400 mg 1×3 /d & continued until delivery
3- CS should be recommended particularly if the symptoms develop within 6 w of expectant delivery
What is the risk of neonatal transmission if the delivery occurs within 6 w of the first episode of maternal genital herpes ?
41 %
What is the risk of neonatal herpes in women with recurrent genital herpes?
Very low( 0- 3%), even if the lesions are present at the time of delivery
What is the management of pregnant women with recurrent genital herpes?
1- supportive treatment & analgesia
2- no need for acyclovir
3- from 36w of gestation: suppressive acyclovir 400 mg 1×3/d
4- vaginal delivery should be anticipated
In a pregnant woman with recurrent genital herpes, what are the adverse obstetric outcomes?
🚩NO increase in : preterm birth/ preterm rupture of membranes/ FGR
🚩 NO increase risk of congenital abnormalities
What is the role of PCR during late gestation to predict the viral shedding?
NOT recommended
What is the general management of women with primary or recurrent lesions of herpes at the onset of the labour?
1- history: ( primary or recurrent)
2- viral swab from the lesions
3- inform the neonatologist
What is the management of women with primary genital lesions at the onset of labour ( or within 6w before)?
CS [ even if the membranes have been ruptured > 4 h ( may reduce the benefit of CS) ]
In women opting for vaginal birth with primary genital lesions at the onset of the labour, what is the management?
🚩IV ACYCLOVIR ( 5 mg / kg) / 8h to the mother
+ ( 20 mg / kg ) / 8h to the neonate
🚩 AVOID: invasive procedures: fetal blood sampling - artificial rupture of membranes - instrumental delivery
What is the management of women with recurrent genital lesions at the onset of the labour?
1-Vaginal birth should be offered: since the risk of neonatal herpes is low ( 0-3%)
2- invasive procedures may increase the risk of neonatal HSV: may be used if required
3- spontaneous rupture of membranes 👉 expedite delivery
How to manage women with primary genital herpes in preterm prelabour rupture of membranes ( < 37w) ?
1- MDT
2- ACYCLOVIR IV : 5 mg / kg / 8h
3- steroids: ( fetal lungs)
4- if the delivery is indicated within 6w of primary herpes 👉 CS
How to manage women with recurrent genital herpes in preterm prelabour rupture of membranes ( < 37w) ?
PPROM < 34 w 👉 expectant management: acyclovir 400 mg 1×3
PPROM > 34 W 👉 antenatal steroids ( fetal lungs)
[ neonatal mortality is not influenced by the recurrent herpes lesions]
Pregnant / HIV+/ with primary genital HSV , how to manage?
As for women with primary genital HSV: - 1st & 2nd trimester: oral acyclovir 5 days
Then oral acyclovir from 32w
- 3rd trimester: oral acyclovir until delivery + CS ( if the infection within 6 w of the delivery)
