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Management of Genital Herpes in Pregnancy (RCOG/BASHH Oct 2014) - Coggle…
Management of Genital Herpes in Pregnancy
(RCOG/BASHH Oct 2014)
Neonatal Herpes
3 subgroups depending on site of infection
Disease localised to skin, eye, and/or mouth alone
Local CNS disease (encephalitis alone)
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)
Incidence
: Approximately 3.3/100,000 live births
Aetiology
Herpes simplex virus type I (HSV-1): 50%
Herpes simplex virus type II (HSV-2): 50%
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
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
: 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
Management of 1st Episode
1st or 2nd Trimester (<28 weeks)
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
Symptomatic relief
Paracetamol and topical lidocaine 2% gel
3rd Trimester Acquisition (From 28 Weeks)
Treatment with aciclovir
Oral aciclovir 400mg TDS for 5 days
IV aciclovir if disseminated HSV
Daily suppressive aciclovir 400mg TDS until delivery
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
Disseminated Herpes Infection in the Mother
Commonly reported in pregnancy, particularly in the immunocompromised (e.g.: HIV)
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.
Management of Recurrent Genital Herpes
Risk of neonatal herpes is low, even if lesions are present at the time of delivery
(0-3% for vaginal delivery)
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
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
Recurrent Herpes
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
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
PPROM
Primary Herpes
Immediate delivery
: Caesarean section recommended
Initial conservative management
: IV aciclovir 5 mg/kg TDS
Corticosteroids
: Consider to reduce implications of preterm delivery
Recurrent Herpes
Before 34 weeks
: Oral aciclovir 400mg TDS
After 34 weeks
: No difference in management
HIV with HSV Infection
Primary HSV
3rd trimester acquisition
: Manage according to recommendations for all women with primary genital HSV infection
Recurrent HSV
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