Management of Genital Herpes in Pregnancy
(RCOG/BASHH Oct 2014)

Neonatal Herpes

3 subgroups depending on site of infection

  1. Disease localised to skin, eye, and/or mouth alone
  2. Local CNS disease (encephalitis alone)
  3. Disseminated infection with multiple organ involvement

1. Disease localised to skin, eye, or mouth alone (best prognosis)

  • Approximately 30% of neonatal herpes infections
  • Neurological and/or ocular morbidity: <2%

2. Local CNS disease / 3. Disseminated infection

  • Approximately 70% of neonatal herpes infections
  • 60% will present without skin, eye, or mouth infection
  • Often present late (between 10 days and 4 weeks)
  • Mortality: 6% (local CNS disease); 30% (disseminated disease)
  • Neurological morbidity: 70% (local CNS disease); 17% (disseminated disease)

Aetiology

Herpes simplex virus type I (HSV-1): 50%
Herpes simplex virus type II (HSV-2): 50%

Incidence: Approximately 3.3/100,000 live births

Majority due to direct contact with infected maternal secretions; 25% of cases postnatal infection (usually close relative of the mother)

Factors associated with transmission

  • Type of maternal infection (primary or recurrent)
  • Presence of transplacental maternal neutralising antibodies
  • Duration of rupture of membranes before delivery
  • Use of fetal scalp electrodes
  • Mode of delivery

Management of 1st Episode

Greatest risk: Aquiring a new infection (primary genital herpes) in the 3rd trimester, particularly within 6 weeks of delivery, as viral shedding may persist and the baby is likely to be born before the development of protective maternal antibodies

Congenital herpes: Occurs as a result of transplacental intrauterine infection (transfer of infection in utero). Affects skin, eyes, and CNS, and may cause fetal growth restriction or death.

Disseminated Herpes Infection in the Mother

Commonly reported in pregnancy, particularly in the immunocompromised (e.g.: HIV)

Disseminated herpes: More common in preterm infants and occurs almost exclusively as a result of primary infection in the mother

Recurrent genital herpes at time of delivery (often asymptomatic): May cause localised forms of neonatal herpes (local CNS disease or skin, eye, or mouth infection)

Transplacentally acquired HSV antibodies do not prevent the herpes virus from spreading to the brain of the neonate

Associated with high mortality rates

Clinical presentation: Encephalitis, hepatitis, disseminated skin lesions, or combination

Co-infection with HSV and HIV results in increased replication of both viruses. All immunocompromised women, are at increased risk of more severe and frequent symptomatic recurrent episodes of genital herpes during
pregnancy and of asymptomatic shedding of HSV at term.

1st or 2nd Trimester (<28 weeks)

3rd Trimester Acquisition (From 28 Weeks)

Management of Recurrent Genital Herpes

No evidence

  • Increased risk of spontaneous miscarriage in the 1st trimester
  • Increased incidence of congenital abnormalities

Refer women with suspected genital herpes to a GUM clinic for diagnosis by viral PCR, advice on management, and STI screening

Treatment with aciclovir (immediate)

  • Oral aciclovir 400mg TDS for 5 days
  • IV aciclovir if disseminated HSV
  • Associated with reduction in duration and severity of symptoms and decrease in duration of viral shedding
  • May cause transient neonatal neutropenia

Recommended mode of delivery (not within 6 weeks)

  • Manage pregnancy expectantly and aim for vaginal delivery

Treatment with aciclovir (prophylactic from 36 weeks)

  • Daily suppressive aciclovir 400mg TDS from 36 weeks
  • Reduces HSV lesions at term, asymptomatic viral shedding, and need for Caesarean section

Treatment with aciclovir

  • Oral aciclovir 400mg TDS for 5 days
  • IV aciclovir if disseminated HSV
  • Daily suppressive aciclovir 400mg TDS until delivery

Risk of neonatal herpes is low, even if lesions are present at the time of delivery (0-3% for vaginal delivery)

Symptomatic relief

  • Paracetamol and topical lidocaine 2% gel

Recommended mode of delivery

  • Caesarean section, particularly those developing symptoms within 6 weeks of expected delivery
  • Risk of neonatal transmission of HSV is very high at 41% if primary genital herpes lesions are present at the time of delivery and the baby is delivered vaginally

Difficult to distinguish clinically between primary and recurrent genital HSV infections, as in up to 15% of cases where a woman presents with a first episode of clinical HSV infection, it will actually be a recurrent infection

HSV antibody testing

  • Type-specific HSV antibody testing (IgG antibodies to HSV-1 and HSV-2) is advisable
  • Presence of antibodies of the same type as the HSV isolated from genital swabs would confirm this episode to be a recurrence rather than a primary infection and elective Caesarean section would not be indicated to prevent neonatal transmission

Mode of delivery

  • Aim for vaginal delivery in the absence of other obstetric indications for Caesarean section

Majority of recurrent episodes of genital herpes are short-lasting and resolve within 7–10 days without antiviral treatment. Supportive treatment measures using saline bathing and analgesia with standard doses of paracetamol alone will usually suffice.

Treatment with aciclovir (prophylactic from 36 weeks)

  • Daily suppressive aciclovir 400mg TDS from 36 weeks

No evidence

  • Increased risk of preterm labour or PPROM
  • Increased risk of fetal growth restriction
  • Incidence of congenital abnormalities

Management at Onset of Labour

Primary Herpes

Recurrent Herpes

General Management

Clinical assessment: No time for confirmatory laboratory testing. Take a history to ascertain primary or recurrent episode.

Viral swab: Result may influence management of neonate

Inform neonatologist

Caesarean section: Recommended to all women presenting with primary genital herpes at time of delivery, or within 6 weeks of expected date of delivery, to reduce exposure of fetus to HSV which may be present in maternal genital secretions

Vaginal delivery (presence of primary genital herpes lesions)

  • IV aciclovir intrapartum for the mother (5 mg/kg TDS) and to the neonate (IV aciclovir 20 mg/kg TDS) may be considered
  • Risk of neonatal herpes is 41%
  • Avoid invasive procedures (FSE, FBS, ARM) and instrumental delivery

Risk of neonatal herpes is low (0-3% for vaginal delivery)

Vaginal delivery

  • Offer to women with recurrent genital herpes lesions
  • Can do invasive procedures (FSE, FBS, ARM) and instrumental delivery

PROM at term: Advise expediting delivery to minimise duration of potential exposure of the fetus to HSV

PPROM

Primary Herpes

Recurrent Herpes

Immediate delivery: Caesarean section recommended

Initial conservative management: IV aciclovir 5 mg/kg TDS

Corticosteroids: Consider to reduce implications of preterm delivery

Before 34 weeks: Oral aciclovir 400mg TDS

After 34 weeks: No difference in management

HIV with HSV Infection

Primary HSV

Recurrent HSV

3rd trimester acquisition: Manage according to recommendations for all women with primary genital HSV infection

Treatment with aciclovir (prophylactic from 32 weeks)

  • HIV and history of genital herpes: Daily suppressive aciclovir 400 mg TDS from 32 weeks
  • HIV and HSV-1/2 seropositive but no history of genital herpes: No evidence to recommend daily suppressive treatment

Mode of delivery: BHIVA HIV in pregnancy guideline recommendations according to obstetric factors and HIV parameters such as HIV viral load

Management of the Neonate

General: Inform neonatologists in all cases

Babies born by Caesarean section in mothers with primary HSV in the 3rd trimester

  • Advise conservative management as low risk of vertically transmitted HSV infection
  • Swabs from baby not indicated
  • No active treatment required for baby
  • Normal postnatal care with NIPE at 24 hours
  • Educate regarding good hand hygiene
  • Observe for: Skin, eye and mucous membrane lesions, lethargy/irritability, poor feeding, fever

Babies born by vaginal delivery in mothers with primary HSV within the previous 6 weeks

  • High risk of vertically transmitted HSV infection

If baby well

  • Send swabs of the skin, conjunctiva, oropharynx and rectum for herpes simplex PCR
  • Empirical treatment with IV aciclovir 20 mg/kg TDS until evidence of active infection excluded
  • Strict infection control measures
  • Breastfeeding is recommended unless the mother has herpetic lesions around the nipples
  • Observe for: Skin, eye and mucous membrane lesions, lethargy/irritability, poor feeding, fever

If baby unwell or presents with skin lesions

  • Perform a lumbar puncture even if CNS features are absent
  • Send swabs of the lesions, skin, conjunctiva, oropharynx and rectum for herpes simplex PCR
  • IV aciclovir 20 mg/kg TDS until evidence of active infection excluded

Babies born to mothers with recurrent HSV infection in pregnancy +/- active lesions at delivery

  • Advise conservative management: Maternal IgG will be protective in the baby. Infection risk is low.
  • Swabs from baby not indicated
  • No active treatment required for baby
  • Normal postnatal care with NIPE at 24 hours
  • Educate regarding good hand hygiene
  • Observe for: Skin, eye and mucous membrane lesions, lethargy/irritability, poor feeding, fever

Concerns about neonate

  • Surface swabs and blood for HSV culture and PCR
  • IV aciclovir 20 mg/kg TDS while awaiting cultures

Postnatal Transmission

In 25% of cases a possible source of postnatal infection is responsible, usually a close relative of the mother

Practice good hand hygiene

Those with oral herpetic lesions (cold sores) should not kiss the neonate