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Herpes in Pregnancy

Herpes in Pregnancy. Max Brinsmead PhD FRANZCOG March 2010. Genital Herpes. 66% caused by H. simplex Type 2 33% associated with H simplex Type 1 Is a latent and recurrent infection in up to 1:5 adults ~1:50 women have this virus during pregnancy

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Herpes in Pregnancy

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  1. Herpes in Pregnancy Max Brinsmead PhD FRANZCOG March 2010

  2. Genital Herpes • 66% caused by H. simplex Type 2 • 33% associated with H simplex Type 1 • Is a latent and recurrent infection in up to 1:5 adults • ~1:50 women have this virus during pregnancy • But most are secondary (or recurrent) infections • Even if the woman says she has never had it before

  3. Neonatal Herpes 1 • Three subgroups of neonatal infection • Skin, eye and mouth disease • Encephalitis only • Disseminated disease • Disseminated disease has 80% mortality (untreated) and 30% with antiviral agents • And 17% risk of morbidity in survivors • Risk of death from skin, eye and mouth disease is 2%

  4. Neonatal Herpes 2 • Encephalitis alone typically occurs at 10 – 28d of age • Mortality risk 6% • Morbidity risk 70% • There are regional variations in the rate of neonatal Herpes • 1:60,000 UK • 1:30,000 Europe and Japan • 1:7500 in certain populations of the US

  5. Maternal Herpes • Primary infection can be disseminated with encephalitis, hepatitis and skin eruptions • Is more common in pregnancy because of the mild immunosupression which occurs • Concomitant HIV infection a real problem • Most infections during pregnancy are secondary • But recurrences are more common because of pregnancy-related immunosupression

  6. Vertical Transmission of Herpes • Mostly occurs when the fetus contacts infected genital secretions • But intrauterine infection and FDIU possible • Neonatal infection is also possible • Disseminated Herpes occurs after primary maternal infection • Often with premature delivery • Secondary maternal Herpes can cause • Skin, eye and mouth disease • And sometimes isolated neonatal encephalitis • Because maternal antibodies do not protect the brain

  7. Risk of Vertical Transmission • With maternal primary Herpes the risk of neonatal infection is 26 – 56% • With maternal secondary Herpes the risk of neonatal infection is 1 – 3% • This means that it would require 1583 Caesarean sections of patients with secondary Herpes to prevent one case of neonatal Herpes (with mortality or morbidity)

  8. Diagnosis of Genital Herpes • Often unrecognised in its recurrent form • Typically localised pruritis and pain • Blister and ulceration • PCR is a sensitive and specific test if appropriate material is collected • Serum IgG and IgM can be useful in distinguishing primary and secondary infection • Viral culture

  9. Maternal Primary Herpes • Treat according to clinical condition • Consultation with GU-Specialist desirable • IV Acyclovir recommended • But use with caution <20 weeks gestation • Use blood IgG and IgM to help distinguish true primary from secondary infection • CS not required if there are type specific IgG antibodies present • CS is recommended if a primary infection is clinically diagnosed or confirmed within 6 weeks

  10. Why Caesarean Section? A prospective study of 58,000 women in Washington USA identified 202 of whom 117 delivered vaginally and 85 by CS. The risk of neonatal sepsis was reduced by 86% by CS but the RR confidence intervals were wide (0.02 – 1.12)

  11. Maternal Secondary Herpes • Weekly cultures are not predictive • Daily Acyclovir from 36 weeks reduces the risk of • A recurrence at the time of delivery • Asymptomatic virus shedding • The chance of CS • And should be offered to women who would elect CS if there was a Herpes outbreak at the time of labour

  12. Herpes visible at the onset of labour • If thought to be a secondary infection then CS is not mandatory • Requires patient counselling and her choice should be respected • If there are ruptured membranes then delivery should be expidated • Fetal trauma should be avoided • The neonatal service should be alerted

  13. Other measures • Women who volunteer a history of genital herpes at an antenatal visit require counselling • Women with known carrier partners can be advised to take precautions against infection • Or tested for HSV antibodies • Universal serum screening will reduce both neonatal transmission and the rate of CS but is not considered cost effective • Individuals with active Herpes should not care for neonates

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