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Herpes Simplex in Pregnancy

Compiled by Suzanne Garland

and no lesions are evident at delivery the pregnancy should be managed expectantly with vaginal delivery anticipated. Primary HSV less than 34 weeks and with lesions in labour and ruptured membranes for less than 6 hours should be managed with Caesarean section. Providing that delivery does not ensue. HSV genital culture and ideally test the serum in parallel with first antenatally collected sample to define the episode as primary (no previous HSV infection) or first episode. Aciclovir should be commenced immediately should any cultures become positive. That is. primary HSV at less than 34 weeks with no lesions at the time of labour should be managed by vaginal delivery. The neonatal attack rate for those exposed before development of maternal seroconversion is in the order of 30 to 50%. If aciclovir is not started immediately the neonate should be closely monitored for signs of lethargy. Intravenous aciclovir 20mg/kg/tds should be commenced and continued dependent upon cultures/pcr (14 days treatment or 21 days if the CSF is found to be abnormal.000 live births. In addition EDTA blood for HSV PCR should be taken. .Neonatal herpes is a very rare. 1 AUSTRALIAN HERPES MANAGEMENT FORUM Third trimester acquisition Apart from aciclovir treatment. the infant should be treated with IV aciclovir. poor feeding. Caesarean section should be considered for all women. Management of the neonate Babies born to mothers with first episode genital herpes at the onset of labour To allow early identification of infected babies. but serious infection with high morbidity and mortality. For diagnosis late in pregnancy where there is a high risk of neonatal HSV. one should consider maternal suppressive oral aciclovir . Continuous suppressive aciclovir in the last four weeks of pregnancy may be indicated for the patient with multiple clinical recurrences to prevent recurrences at delivery and hence the need for Caesarean section. surface swabs should be taken from the oropharynx. culture or antigen detection). fever. urine as well as collecting CSF for identification of HS V (by PCR. First and second trimester acquisition Management of the woman should be in line with the clinical HSV presentation and may involve the use of either oral or intravenous (IV) aciclovir in standard doses.9/ 100. particularly those developing symptoms within 6 weeks of delivery as their infants are at greatest risk of viral transmission due to the lack of time for development of maternal neutralizing antibodies and their lack of transplacental passage. or lesions consistent with neonatal HSV infection.Herpes Simplex in Pregnancy Management of pregnant women with first episode genital herpes Obtain HSV serology (type specific). eyes. Where infants are born via vaginal delivery with active disease and no maternal treatment. Neonatal Herpes . The incidence in Australia is – 3.

2 AUSTRALIAN HERPES MANAGEMENT FORUM Management of pregnant women with recurrent genital herpes Sequential third trimester cultures to predict viral shedding at term are NOT indicated. Management of women with genital lesions at onset of labour • Current practice is for delivery by Caesarean section. For those with multiple recurrences in pregnancy and in order to avoid a Caesarean section. Use of invasive monitoring (foetal scalp electrode. For those with recurrent lesions and vaginal delivery (shedding risk by culture is 20%) and the risk of neonatal HSV is < –1%.4% and the risk of neonatal HSV is 0. Maternal specimens for HSV culture (sweep genital swab) are advised at delivery if the baby is delivered vaginally. • There is evidence that the risks of viral transmission to the neonate following vaginal delivery are small and must be weighed against risks of Caesarean section to the mother. particularly if the membranes have been ruptured for less than six hours. forceps and vacuum delivery) are advised against. Recurrent HSV No lesions and vaginal delivery.Herpes Simplex in Pregnancy Risk of neonatal HSV and delivery mode: Primary Initial episode with seroconversion prior to delivery (prior to 30-34 weeks) – 3%. consider suppressive aciclovir treatment at 400mg tds.02 to 3% (non-shedding vs HSV shedding respectively). and should be used only for de ned obstetric indications. in order to identify the babies exposed to women asymptomatically shedding HSV. the shedding risk is 7% and neonatal HSV risk is < With a primary/initial episode less than 6 weeks before delivery the risk of neonatal HSV is 30-50%. Caesarean section to prevent neonatal herpes is only indicated for women who have genital lesions evident at delivery. • . Risk of asymptomatic HSV shedding is in the order of 1. Symptomatic recurrences of genital herpes during the third trimester will be brief and vaginal delivery is appropriate if no lesions are present at delivery.

Parents should be advised to report early signs of infection (lethargy. poor feeding or lesions). Parents should be advised to report early signs of infection (lethargy. Prevention of acquisition of infection (continued) Pregnant women should be advised of the risk of acquiring genital HSV-1 as a result of oro-genital contact.5% and HSV 1 of 80% reported. Prevention of acquisition of infection There is a dearth of evidence on which to formulate guidelines for prevention. should undergo careful genital inspection at the onset of labour to look for clinical signs of herpes infection. Identifying susceptible women by means of type-speci c antibody testing has been evaluated in Australia with a seroprevalence of HSV 2 of 12. Conscientious use of condoms throughout pregnancy may diminish the risk of acquisition. Women without a history of genital herpes. recurrence of genital herpes). aciclovir treatment of the infant is advised. fever. none seroconverted to HSV 1 and no cases of neonatal HSV were seen. . poor feeding or lesions). Babies born to asymptomatic mothers with a history of genital herpes Routine viral culture is not recommended. it is not cost e ective to o er type speci c serology to pregnant women and their partners. All women should be asked at their first antenatal visit if they or their partner have ever had genital herpes. Fetal scalp electrode. Whilst 3% acquired HSV 2 during pregnancy. sta and other relatives/friends with active oral lesions should be advised about the risk of post-natal transmission. Type specific serology may help confirm risk of primary infection and identify potential risk of asymptomatic shedding in those women already infected but undiagnosed. not just those with a history of genital herpes.Herpes Simplex in Pregnancy Management of the neonate Babies born to mothers with recurrent genital herpes at the onset of labour One set of specimens for viral culture should be collected after delivery for early identification of infection. Mothers. If cultures are positive. fever.e. Aciclovir is excreted in breast milk but its use is not contra-indicated as it does not cause harm to the infant. forceps and vacuum delivery should be avoided. Any strategy for prevention of neonatal herpes needs to involve both parents. Therefore it was concluded in low prevalence communities. whose partners have genital herpes should be strongly advised not to have sex when genital lesions are present (i. All women. Post-natal care of mother and child 3 AUSTRALIAN HERPES MANAGEMENT FORUM Breastfeeding is recommended unless the mother has lesions around the nipples.

Ashley RL. Cunningham A. Mohan K.316:240-244. New England Journal of Medicine 1997.16:152-156. Obstetrics and Gynecology 1993.315:796-800. Lancet 1988. Marian Villa. Nail ZN. et al. et al. Westmead NSW 2145 Australia Telephone +61 2 8230 3843 Facsimile +61 2 9845 6287 www. The management of pregnancies complicated by genital infections with herpes simplex virus. Di erence between herpes simplex virus type 1 and type 2 neonatal herpes encephalitis in neurological outcome. • Brown lA. 1998 First Printed 2002 Re-Printed 2004 Revised and Re-Printed 2006 Revised and Re-Printed 2009 Revised e-publication 2011 Re-edited e-publication Disclaimer The AHMF have made considerable e orts to ensure the information upon which this guideline is based reproduces the evidence as accurately as possible. Effect of serologic status and caesarean delivery on transmission rates of herpes simplex virus from mother to infant. Australasian Society for Infectious Disease. Kirk JK.STIRC. National Surveillance for neonatal herpes simplex virus infection. Vontver LA. Benedetti J.317:1246-1251. Neonatal herpes simplex virus infection in relation to asymptomatic maternal infection at the time of labor. Jackson GL.38:186-191.289(2). Brooks CA. • Brown ZA. Selke S. • Chuang Westmead Hospital. Jones C. New England Journal of Medicine 1991. Astruc D. Neonatal herpes: incidence. Clinical Infectious Diseases 1992. Stone EF. Neonatal herpes simplex pneumonia. • Randolph AR. Langer B. New England Journal of Medicine 1987. • Nahmias AJ. http://www. especially drug indications. • Prober CG. Corey L.82:102-104. American Journal of Obstetrics and Gynecology 1971. Neonatal herpes simplex virus infection. Perinatal risk associated with maternal genital herpes simplex infection. • Stone KM. American Journal of Preventive Medicine. Acyclovir suppression to prevent Caesarean deliver y after first-episode genital herpes. Failure of antepartum maternal cultures to predict the infants risk of exposure to herpes simplex virus at delivery. Prober CG. Low risk of herpes simplex virus infections in neonates exposed to the virus at the time of vaginal delivery to mothers with recurrent genital herpes. as this guideline does not indicate an exclusive course of action or serve as a standard of medical care. • Corey L. 2002. Lokiec F.336:756. Josey WE. Messer J. Neonatal herpes simplex virus infection in the British Isles. is correct by way of independent sources. Garland S. • Stray-Pederson B. et al. Journal of the American Medical Association 1993. Hensleigh PA. P. The acquisition of herpes simplex virus during pregnancy. et al. Genital herpes simplex virus infection and incide nce of neonatal disease in Sweden.15:1031-1038. Journal of Family Practice 1994. • Mindel A. • Forsgren M. McIntyre P. et al.10:432-442. Alexander ER. Knudson MP. • Prober CG. Caesarean deliver y for woman presenting with genital herpes lesions: efficacy. • Spangler JG. Journal of the American Medical Association 2003.110:825-834. Tenth Annual Report of the Australian Paediatric Surveillance Unit.337:509. Washington E.htm. Yasukawa LL.324:1247-1252. Users of this guideline are strongly recommended to con rm that the information contained within it. et al. Neonatal herpes prevention: a minor public health problem in some . The AHMF accepts no responsibility for any inaccuracies. • Tookey PA. Wald A. Acyclovir in late pregnancy to prevent neonatal herpes simplex (letter). New England Journal of Medicine 1986. Tideman RL.59(7):668-670. Prober CC.racp. • Brown ZA. Isaacs D. prevention and consequences.87:69-73. Sanchez PJ. Brown lA. et al. 2002. et al. information perceived as misleading. • Palasanthiran. Effects on infants of a first episode of genital herpes during pregnancy.8575-6:1-4. Sexually Transmitted Infections 2000. 1988. Taylor J. 4 AUSTRALIAN HERPES MANAGEMENT FORUM Australian Herpes Management Forum (AHMF) C/. Ashley R. (Editors) “Management of Perinatal Infections”.Herpes Simplex in Pregnancy Bibliography • Arvin A.270:77-82. Oral acyclovir and recurrent genital herpes during late pregnancy. Sexually Transmitted Diseases 1989. Shaw PJ. Sullender WM. Uses and safety of acyclovir in pregnancy. Zeh J. New England Journal of Medicine 1987.76(4):287-91.. • Scott LL. et al.203-209. Underhill G.69:37-41. risks and costs. et al. • Jones CA. or success of any treatment regime detailed in this guideline. Whitley • Lissauer T J. Peckham CS. Starr M. Benedetti J. Lancet 1990. Arch Dis Child 1984. Scandinavian Journal of Infections 1994. • Haddad J. Pediatric and Perinatal Epidemiology 1996. • Brown ZA. Guinan ME. Obstetrics and Gynecology 1996.ahmf.