1. Herpes in Pregnancy Max Brinsmead MB BS PhD May 2015

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

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

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

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

6. Vertical Transmission of Herpes Mostly occurs when the fetus contacts infected genital secretions Mostly occurs when the fetus contacts infected genital secretions But intrauterine infection and FDIU possible But intrauterine infection and FDIU possible Neonatal infection is also possible Neonatal infection is also possible Disseminated Herpes occurs after primary maternal infection Disseminated Herpes occurs after primary maternal infection Often with premature delivery Often with premature delivery Secondary maternal Herpes can cause Secondary maternal Herpes can cause Skin, eye and mouth disease Skin, eye and mouth disease And sometimes isolated neonatal encephalitis And sometimes isolated neonatal encephalitis Because maternal antibodies do not protect the brain 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 primary Herpes the risk of neonatal infection is 26 – 56% With maternal secondary Herpes the risk of neonatal infection is 1 – 3% 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) 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 Often unrecognised in its recurrent form Typically localised pruritis and pain Typically localised pruritis and pain Blister and ulceration Blister and ulceration PCR is a sensitive and specific test if appropriate material is collected 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 Serum IgG and IgM can be useful in distinguishing primary and secondary infection Viral culture Viral culture

9. Maternal Primary Herpes Treat according to clinical condition Treat according to clinical condition Consultation with GU-Specialist desirable Consultation with GU-Specialist desirable IV Acyclovir recommended IV Acyclovir recommended But use with caution <20 weeks gestation But use with caution <20 weeks gestation Use blood IgG and IgM to help distinguish true primary from secondary infection 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 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 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. 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) 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 Weekly cultures are not predictive Daily Acyclovir from 36 weeks reduces the risk of Daily Acyclovir from 36 weeks reduces the risk of A recurrence at the time of delivery A recurrence at the time of delivery Asymptomatic virus shedding Asymptomatic virus shedding The chance of CS 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 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 If thought to be a secondary infection then CS is not mandatory Requires patient counselling and her choice should be respected Requires patient counselling and her choice should be respected If there are ruptured membranes then delivery should be expidated If there are ruptured membranes then delivery should be expidated Fetal trauma should be avoided Fetal trauma should be avoided The neonatal service should be alerted The neonatal service should be alerted

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

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