Management of Genital Herpes In Pregnancy

Question 1

How is neonatal herpes classified?

Answer 1

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

Question 2

What is the mortality & morbidity rate in each subgroup of neonatal herpes with antiviral treatment ?

Answer 2

1- localized to skin / eye- mouth
Morbidity < 2%
2- local CNS ( encephalitis)
Mortality 6% neurological morbidity 70 %
3- disseminated infection
Mortality 30 %

Question 3

What is the route of infection in neonatal herpes?

Answer 3

Infection at the time of delivery

Question 4

What is the incidence of neonatal herpes in USA / UK ?

Answer 4

In USA 1 / 15,000
in UK 50 % of that ( 1/ 30,000)

Question 5

What is the aetiology of neonatal herpes?

Answer 5

Herpes simplex type 1(50%)
+ type 2 (50%)
♤ Most of the cases is a result if direct contact with infected maternal secretions

Question 6

What are the factors associated with transmission of HSV & cause neonatal herpes?

Answer 6

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

Question 7

What are the factors that have the greatest risk of neonatal herpes?

Answer 7

1- primary genital herpes
2- 3rd trimester ( particularly within [6] weeks of delivery

Question 8

What are the risk factors for disseminated neonatal herpes?

Answer 8

1- preterm infants
2- EXCLUSIVE for primary infection

Question 9

What causes congenital herpes?

Answer 9

Transplacental intrauterine infection
RARE

Question 10

What is the management in a pregnant woman with first episode genital herpes in 1st / 2nd trimester?

Answer 10

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

Question 11

What is the adverse neonatal effect of acyclovir antenatally?

Answer 11

Transient neonatal neutropenia

Question 12

What is the management of a pregnant woman with first episode genital herpes in the 3rd trimester (>28w) ?

Answer 12

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

Question 13

What is the risk of neonatal transmission if the delivery occurs within 6 w of the first episode of maternal genital herpes ?

Answer 13

41 %

Question 14

What is the risk of neonatal herpes in women with recurrent genital herpes?

Answer 14

Very low( 0- 3%), even if the lesions are present at the time of delivery

Question 15

What is the management of pregnant women with recurrent genital herpes?

Answer 15

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

Question 16

In a pregnant woman with recurrent genital herpes, what are the adverse obstetric outcomes?

Answer 16

🚩NO increase in : preterm birth/ preterm rupture of membranes/ FGR
🚩 NO increase risk of congenital abnormalities

Question 17

What is the role of PCR during late gestation to predict the viral shedding?

Answer 17

NOT recommended

Question 18

What is the general management of women with primary or recurrent lesions of herpes at the onset of the labour?

Answer 18

1- history: ( primary or recurrent)
2- viral swab from the lesions
3- inform the neonatologist

Question 19

What is the management of women with primary genital lesions at the onset of labour ( or within 6w before)?

Answer 19

CS [ even if the membranes have been ruptured > 4 h ( may reduce the benefit of CS) ]

Question 20

In women opting for vaginal birth with primary genital lesions at the onset of the labour, what is the management?

Answer 20

🚩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

Question 21

What is the management of women with recurrent genital lesions at the onset of the labour?

Answer 21

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

Question 22

How to manage women with primary genital herpes in preterm prelabour rupture of membranes ( < 37w) ?

Answer 22

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

Question 23

How to manage women with recurrent genital herpes in preterm prelabour rupture of membranes ( < 37w) ?

Answer 23

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]

Question 24

Pregnant / HIV+/ with primary genital HSV , how to manage?

Answer 24

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)

Question 25

Pregnant HIV+ with recurrent HSV infection, how to manage?

Answer 25

Daily suppressive
acyclovir 400 mg 1×3 /d from 32 w
● increased possibility of preterm labour in HIV +women

Question 26

Why it is important to offer suppressive daily acyclovir earlier (32w) in pregnant women with recurrent HSV infection ?

Answer 26

They are more likely to transmit HIV infection in the presence of genital HSV ulceration

Question 27

If the HIV+pregnant with sero positive HSV 1/2 with no history of genital herpes, what is the recommendations about suppressive treatment?

Answer 27

NO evidence to recommend daily suppressive treatment

Question 28

When to recommend conservative management for babies of mothers with genital herpes?

Answer 28

1- babies born by CS in mothers with primary infection in 3rd trimester
2- babies born to mothers with recurrent HSV infection with or without active lesions at the time of delivery

Question 29

What is the conservative management for babies of mothers with genital herpes?

Answer 29

1- swabs : not indicated
2- active treatment: not required
3- normal postnatal care : discharge after 24h if the baby is well
4- parents should be advised: good hygiene

Question 30

What is the management of babies born by VB in mothers with primary HSV within the previous 6w ,if the baby is well?

Answer 30

1- SWABS : skin, rectum, conjunctiva, oropharynx
2- IV ACYCLOVIR: 20mg/kg/8h
3- breastfeeding is recommended
4- lumbar puncture: NOT necessary

Question 31

What is the management of babies born by VB in mothers with primary HSV within the previous 6w ,if the baby is unwell ?

Answer 31

1- SWABS : skin, rectum, oropharynx, conjunctiva for PCR
2- LUMBAR PUNCTURE: even if CNS features are not present
3- IV ACYCLOVIR: 20mg/kg/8h

Question 32

What is the percentage of postnatal transmission of neonatal herpes?

Answer 32

25%
Usually a close relative of the mother