Sexually Transmissible Infections in Clinical Practice

29. A Pregnant Woman with Genital Herpes

Alexander McMillan1, 2  

(1)

Department of Genitourinary Medicine, NHS Lothian, Edinburgh Royal Infirmary, Edinburgh, Uk

(2)

University of Edinburgh, Edinburgh, Uk

Alexander McMillanFormerly, Consultant Physician, part-time Senior Lecturer

Email: a.amcmm@btinternet.com

Abstract

Samantha is a 28-year-old woman who presents to a Sexual Health clinic with a 3 day history of painful swelling and ulceration of the vulva. She has felt unwell with fever for a few days. She is 37 weeks pregnant to her husband who has a history of recurrent genital herpes. They had unprotected sexual intercourse about 1 week before the onset of her symptoms; her husband had no obvious signs of recurrent herpes at that time. Physical examination confirms the presence of multiple ulcers on the labia majora, labia minora, and at the introitus (Fig. 29.1). She also has bilateral tender inguinal lymph node enlargement.

Samantha is a 28-year-old woman who presents to a Sexual Health clinic with a 3 day history of painful swelling and ulceration of the vulva. She has felt unwell with fever for a few days. She is 37 weeks pregnant to her husband who has a history of recurrent genital herpes. They had unprotected sexual intercourse about 1 week before the onset of her symptoms; her husband had no obvious signs of recurrent herpes at that time. Physical examination confirms the presence of multiple ulcers on the labia majora, labia minora, and at the introitus (Fig. 29.1). She also has bilateral tender inguinal lymph node enlargement.

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Figure 29.1.

Multiple vulval ulcers in a pregnant woman.

29.1 How Would You Manage This Case?

Samantha should be treated with either oral or intravenous aciclovir (see Case 16 for information on oral aciclovir).

Herpes simplex virus can be transmitted to the neonate from a mother with primary or initial genital herpes at term. It has been estimated that the risk of neonatal herpes developing after vaginal delivery to a mother with primary or initial genital herpes simplex virus (HSV) infection is about 40%. The neonate may develop disseminated infection, affecting particularly the liver and adrenal glands, or localized infection affecting the central nervous system, eye, skin, or oral cavity. The mortality rate for infants with disseminated or central nervous system disease is high.

Mothers with symptomatic primary or initial herpes at term or within 6 weeks of expected delivery should be delivered by Caesarean section before the membranes have ruptured or within 4 h of their rupture. Performing a Caesarean section beyond this time is not likely to protect the fetus. If vaginal delivery is performed, or if the membranes have been ruptured for more than 4 h, the mother should be treated intra-partum, and subsequently the neonate with intravenous aciclovir. Vaginal procedures such as the application of scalp electrodes are best avoided to reduce the risk of damaging the baby’s skin and allowing viral entry. There should be consultation with a pediatrician.

Note: Primary or initial genital herpes during the first or second trimester should be treated as in the non-pregnant patient (see Case 16). As developmental abnormalities have not been associated with HSV infection, termination of pregnancy is not indicated. Although aciclovir is not licensed for use in pregnancy, there has now been substantial use of the drug by pregnant women, and, in keeping with the results of tests on animals, there has been no evidence of teratogenicity.

Two years later, Samantha who is 3 months pregnant with her second child attends the clinic for advice on the management of symptomatic recurrences during her pregnancy. She also asks if it is necessary to deliver this child by Caesarean section.

29.2 What Advice Would You Give?

Symptomatic recurrences even in pregnant women are likely to be of short duration, and drug therapy is usually unnecessary. If the episodes are severe, however, episodic treatment with aciclovir may be offered.

The risk of transmission of HSV from a woman with recurrent genital herpes to a child at the time of delivery is low. Caesarean section is only recommended for those with lesions at term. There are now good data to show that the prophylactic use of aciclovir or valaciclovir reduces the likelihood of clinical recurrence at the time of delivery and the need for Caesarean section. For this reason, aciclovir, in a dosage of 400 mg three times per day1 by mouth may be offered to women with a history of recurrent genital herpes who wish to avoid delivery by Caesarean section. Treatment should be initiated at 36 weeks' gestation.

Footnotes

1

The higher dose of aciclovir has been recommended because of the altered pharmacokinetics during late pregnancy (2007 National Guideline for the Management of Genital Herpes).