In the name of GOD

Herpes simplex virus and pregnancy

Virology Alpha herpes viruses: Herpes simplex virus type 1 (HSV-1) Herpes simplex virus type 2 (HSV-2) Varicella zoster virus (VZV)

Virology HSV-1 HSV-2 The incidence of antibodies specific for HSV-2 increases with age. 20% of women have antibody to type HSV-2 virus. The risk for type 2 antibody were greatest among blacks and previously married women.

Pathology Nuclear hyperchromatosis Intranuclear basophilia Acidophilic inclusions Nonspecific changes (gliosis , vasculitis )

Clinical Infection

First episode infection: It is frequently symptomatic. Some first episodes are mild due to cross reacting antibody from childhood acquired type 1 infection. Prior orolabial infection with type 1 virus may modify an initial type 2 genital infection .

Typical incubation period of 3-6 days. Popular eruption with tingling which then become painful and vesicular. Painful perineal lesions that may coalesce. Inguinal adenopathy Influenza-like symptom Occasionally hepatitis ,encephalitis ,or pneumonia Urinary retention due to sacral nerve involvement Cervical involvement

Recurrent infection Lesions are fewer in number, less tender ,shed virus for shorter periods (2-5 days). Typically recur at same sites. Cervical involvement is less frequent. Sub clinical shedding often followed symptomatic recurrence.

Diagnosis Tissue culture(95% sensitive) optimal for clinically or asymptomatic recurrence . Cytological examination, specific for cervical infection and sensitive for for genital ulcer disease PCR(8 times higher detection rate) Antibodies

Treatment: No effective treatment In first episode infections: Acyclovir: -Topically -Oral 400 mg orally TDS(?) -Parenteral Analgesics or topical anesthetics Indwelling catheter in severe urinary retention . In HIV patient ,increasing the dose of Acyclovir In recurrent infections: Acyclovir :Reduce recurrence in pregnancy Decrease rate of C/S due to recurrent herpes 200-400 mg TDS is well tolerated in late of pregnancy

Clinical course during pregnancy 0.2-0.3 pregnant women in early labor has HSV infection, most of them are recurrent infection. Baschat AA, determined this prevalence in asymptomatic patients . Forty-four (6.4%) amniotic fluid samples were positive for viral genome . Viral genome is commonly found in amniotic fluid with a sonographically normal fetus, and the prevalence follows a seasonal pattern . (J Matern Fetal Neonatal Med. 2003 Jun;13(6):381-4).

80% of women with recently acquired HSV-2 genital infection will have an average of 2-4 symptomatic recurrence during pregnancy. Concomitant cervical shedding is identified in about 15% of women with clinically evident vulvular recurrence.

10% of recurrence in pregnancy will be asymptomatic. Clinical recurrence appear to be slightly more common in late pregnancy ,asymptomatic cervical shedding of herpes virus is unaffected by the duration of pregnancy.

Routine sero screaning of pregnant patient is not recommended Exceptions: Maternal anxiety High risk patients

Cherpes TL ,determined that, attributable risk of bacterial vaginosis for HSV-2 seroconversion was 21%. ( Clin Infect Dis. 2003 Aug 1;37(3):319-25. Epub 2003 Jul 15).

Consideration should be given To use of antiviral therapy in selected patient Elective C/S delivery for high risk deliveries

Neonatal disease Vertically transmission: Trans placental (in uteri transmission) Retrograde (Ascending) Immediate postnatal period (Breastfeeding)

Neonatal disease HSV Newborn infection can have devastating consequences. Even with therapy , risk of morbidity, specially CNS morbidity is significant. In USA Neonatal HSV infection occur in up to 1 in 2500 birth ,which can be cause by both HSV-1 and HSV-2 infection.

Newborn infection has three form: Disseminated Localized (CNS, eyes, skin, mucosa) Asymptomatic 50% risk of neonatal infection with primary maternal infection, but only 4-5 %percent with recurrent infection.

Effect on pregnancy outcome Adverse outcome is most likely when initial outbreak of genital herpes is during pregnancy. These risks are greatest when there is first episode none primary infections and no cross reacting antibody to HSV-1 . First episode infection in early pregnancy is probably associated with increased rate of abortion. Late pregnancy primary infection results in an increased incidence of preterm labor.

Antepartum Management Culture are taken to confirm the diagnosis when a pregnant woman has lesions suggestive of HSV. If there are no visible lesions at the onset of labor then vaginal delivery is acceptable. Weekly surveillance cultures of woman with a history of HSV but without lesion are not necessary and NVD is acceptable. Amniocentesis is not recommended.

Prophylactic acyclovir beginning at 36 weeks' gestation reduces the risk of clinical HSV recurrence at delivery, cesarean delivery for recurrent genital herpes, and the risk of HSV viral shedding at delivery. (Sheffield JS, Obstet Gynecol. 2003 Dec;102(6):1396-403).

Significant experience has been gained with the use of acyclovir in pregnancy and it is recommended for both episodic and suppressive therapy in pregnant women. Its use has been demonstrated to be cost-effective in suppressive therapy, although issues regarding compliance and the potential for neonatal neutropenia need to be addressed. (Leung DT, Sacks SL . Expert Opin Pharmacother. 2003 Oct;4(10):1809-19).

Thus C/S is performed when : Primary or recurrent lesions are visualized near the time of labor When the membrane are ruptured. If there are prodromal symptoms of recurrence.

No lesions No C/S

Care of the neonate Known or suspected : should be isolated and taken culture. Should be tested for liver function and spinal fluid for up to two weeks. Unnecessary to separate baby and mother. Breast feeding has been allowed.