Complications of Pregnancy

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Herpes Simplex Virus Infections in Pregnancy

 

Herpes simplex virus (HSV) is a major source of morbidity and mortality for newborns infected with HSV. HSV-2 is primarily responsible for genital HSV disease. Spread is principally through sexual contact.

The majority of cases are asymptomatic or symptoms are unrecognized. HSV-1 infection generally involves the mucosal surfaces of the mouth, pharynx, lips and eyes, but the virus can also be recovered from genital lesions.

Clinical presentation

Primary genital episode genital HSV is characterized by multiple painful vesicles in clusters. They may be associated with pruritus, dysuria, vaginal discharge, and tender regional adenopathy. Fever, malaise, and myalgia often occur one to two days prior to the appearance of lesions. The lesions may last four to five days prior to crusting. The skin will reepithelialize in about 10 days. Viral shedding may last for 10 to 12 days after reepithelialization.

Nonprimary first-episode genital HSV refers to patients with preexisting antibodies to one of the two types of virus who acquire the other virus and develop genital lesions. Nonprimary disease is less severe with fewer systemic symptoms, and less local pain.

Recurrent HSV episodes are characterized by local pain or paresthesia followed by vesicular lesions. Lesions are generally fewer in number and often unilateral but may be painful.

Diagnosis

PCR to detect HSV DNA from lesions or genital secretions is recommended for diagnosis. The gold standard for diagnosis of acute HSV infection is viral culture. Although the highest yield is from vesicular fluid of skin lesions, cultures may be obtained from the eyes, mouth, cerebral spinal fluid, rectum, urine, and blood.

Clinical Designation of Genital Herpes Simplex Virus Infection

Primary genital HSV infection
Antibodies to both HSV-1 and HSV-2 are absent at the time the patient acquires genital HSV due to HSV-1 or HSV-2

Nonprimary first episode genital HSV infection
Acquisition of genital HSV-1 with pre-existing antibodies to HSV-2 or acquisition of genital HSV-2 with pre-existed antibodies rto HSV-1

Recurrent genital HSV infection
Reactivation of genital HSV in which the HSV type recovered from the lesion is the same type as antibodies in the serum.

Maternal treatment
Recurrent infection. Women with one or more HSV recurrence during pregnancy benefit from suppression given at 36 weeks of gestation through delivery.

Cesarean delivery
should be offered to women who have active lesions or symptoms of vulvar pain or burning at the time of delivery in those with a history of genital herpes. However, delivery by cesarean birth does not prevent all infections.

Approximately 20 to 30 percent of HSV-infected infants are born by cesarean. Prophylactic cesarean delivery is not recommended for women with recurrent HSV and no evidence of active lesions at the time of delivery. Lesions which have crusted fully are considered healed and not active.

Prevention

Nongenital invasive procedures (eg, amniocentesis) should be delayed if there is evidence of systemic disease. Use of fetal scalp electrodes should be avoided among women who are known to have recurrent HSV, and who are in labor.

Mothers with active lesions should cover their lesions, and hands should be washed before touching the baby. Breastfeeding is not contraindicated as long as there are no breast lesions.