#220 Management of Genital Herpes in Pregnancy

Question 1

What is the prevalence of HSV-2 infection in 14- to 49-year-old females?

Answer 1

15.9%

Question 2

What type of virus is HSV?

Answer 2

Double-stranded DNA virus

Question 3

What differentiates HSV 1 and 2?

Answer 3

Glycoproteins in the lipid bilayer envelope. Glycoprotein G1 (HSV1) and G2 (HSV2)

Question 4

What is HSV 1 the primary etiologic agent of?

Answer 4

Herpes labialis, gingivostomatitis, and keratoconjunctivitis. Increasingly common cause of oral and genital infections

Question 5

What does HSV2 cause?

Answer 5

genital herpes

Question 6

How is HSV transmitted?

Answer 6

Person to person through direct contact

Question 7

What is the incubation period after acquisition of HSV1 or HSV2?

Answer 7

2 days to 12 days

Question 8

Where does HSV remain latent?

Answer 8

In sensory nerves

Question 9

When do type-specific antibodies to HSV viral proteins develop after infection?

Answer 9

2-3 weeks after infection

Question 10

How do you determine a primary HSV outbreak?

Answer 10

HSV1 or HSV2 is detected from a lesion in an individual with no evidence of antibodies to either viral type in the serum

Question 11

How do you determine a nonprimary first-episode infection of HSV?

Answer 11

When one viral type is detected in lesions from individual with evidence of antibodies to the other viral type in serum

Question 12

How do you determine a recurrent HSV infection?

Answer 12

When HSV is detected in lesions from individuals with evidence of antibodies to the same viral type in the serum

Question 13

Approximately what % of patients with infections report recognition of their infections?

Answer 13

5-15%

Question 14

Approximately what % of US women have serologic evidence of HSV2?

Answer 14

~21%

Question 15

Among women susceptible to HSV infection, what is the incidence of new HSV infection during pregnancy?

Answer 15

Approximately 2%

Question 16

When is a woman during pregnancy more likely to be infected with HSV?

Answer 16

Timing of infection is relatively evenly distributed

Question 17

Among women with recurrent genital HSV, approximately what % will have at least one recurrence during pregnancy?

Answer 17

Approximately 75%

Question 18

Among women with recurrent genital HSV, approximately what % will have prodromal symptoms or clinical recurrence at delivery?

Answer 18

Approximately 14%

Question 19

When is neonatal herpes usually acquired?

Answer 19

During intrapartum period through exposure to the virus in the maternal genital tract

Question 20

Approximately how many cases of neonatal herpes occur annually in the US?

Answer 20

1,200-1,500

Question 21

What fraction of neonatal herpes cases are caused by HSV-1?

Answer 21

1/3 to 1/2

Question 22

What types of neonatal HSV infection are there?

Answer 22

Disseminated disease (25%), CNS disease (30%), and disease limited to the skin, eyes or mouth (45%)

Question 23

What is the risk of mortality for disseminated neonatal HSV?

Answer 23

30%

Question 24

What is the mortality risk for CNS neonatal HSV?

Answer 24

4%

Question 25

What % of survivors of neonatal herpes have long-term neurologic sequelae?

Answer 25

~20%

Question 26

What is the preferred method of testing for patients who present with genital vesicles, ulcers, or other mucocutaneous lesions?

Answer 26

Virologic tests - include viral culture and HSV antigen detection by PCR

Question 27

How should you collect a genital specimen for HSV culture?

Answer 27

Unroof the vesicle, if present, and vesicular fluid should be collected

Question 28

How is the sensitivity of viral culture for HSV?

Answer 28

Low. 80% for primary lesions, 40% for recurrent lesions

Question 29

How does the sensitivity of an HSV PCR compare to culture?

Answer 29

PCR is 3-5x more likely to be positive

Question 30

Up to what % of first-episode infections during pregnancy are recurrent HSV infections?

Answer 30

15%

Question 31

What is a primary outbreak of HSV in the first trimester of pregnancy associated with?

Answer 31

Neonatal chorioretinitis, microcephaly, and skin lesions

Question 32

Is routine HSV screening recommended in pregnant women?

Answer 32

No

Question 33

What are the three common oral antiviral agents used to treat HSV infections?

Answer 33

Acyclovir, valacyclovir, and famciclovir

Question 34

True or false, acyclovir is considered safe in the first trimester?

Answer 34

True

Question 35

How does acyclovir work?

Answer 35

It is a nucleoside analogue that enters virally infected cells and acts specifically to inhibit the viral thymidine kinase and, thus, DNA replication

Question 36

How is valacyclovir related to acyclovir?

Answer 36

Prodrug of acyclovir, rapidly converted in the liver.

Question 37

What is the rate of acyclovir resistance in HSV in immunocompetent and immunocompromised patient?

Answer 37

0.3-0.6% in immunocompetent. 6-7% in immunocompromised.

Question 38

When should you offer suppressive therapy for HSV in pregnant women?

Answer 38

At 36wks, if has had outbreak in pregnancy or clinical hx of genital herpes

Question 39

What is the dosing of acyclovir for primary or first-episode HSV infection?

Answer 39

Acyclovir 400mg orally, three times daily, for 7-10days. (may extend if healing incomplete after 10d of therapy)

Question 40

What is the dosing of valacyclovir for primary or first-episode HSV infection?

Answer 40

1g orally, twice daily, for 7-10d (can extend if healing incomplete)

Question 41

What is the dosing of acyclovir for symptomatic recurrent episode of HSV?

Answer 41

400mg orally, three times daily, for 5 days or 800mg orally, twice daily for 5 days

Question 42

What is the dosing of valacyclovir for symptomatic recurrent episode of HSV?

Answer 42

500mg orally, twice daily, for 3 days or 1g orally, daily, for 5 days

Question 43

What is the acyclovir dosing for daily HSV suppression?

Answer 43

400mg orally three times daily, from 36wks until delivery

Question 44

What is the valacyclovir daily suppression dosing for HSV?

Answer 44

500mg orally, twice daily, from 36wk until delivery.

Question 45

What is the acyclovir dosing for severe or disseminated HSV disease?

Answer 45

5-10mg/kg IV every 8 hours for 2-7d, then oral therapy for primary infection to complete 10d

Question 46

What is the risk of vertical HSV transmission when primary outbreak occurs at the time of delivery?

Answer 46

Approx 40-80%

Question 47

Why do neonates have higher risk of vertical transmission of HSV infection if delivery is at time of primary outbreak?

Answer 47

1. Reduced protective HSV-2 specific antibodies that cross the placenta 2. Increased virus exposure in genital tract

Question 48

What is the mean viral shedding length in untreated women with primary herpes infection?

Answer 48

15 days

Question 49

What % of women with primary herpes infection have cervical shedding?

Answer 49

90%

Question 50

True or false, dosing for suppressive HSV therapy is the same in pregnant and nonpregnant individuals?

Answer 50

False. Higher renal clearance means higher doses for pregnant women

Question 51

True or false, cesarean delivery is indicated in women with prodromal HSV symptoms?

Answer 51

True, may indicated viral shedding

Question 52

What is the risk of neonatal herpes in women with HSV isolated from genital secretions at time of delivery for vaginal vs CS delivery?

Answer 52

Vaginal - 1.2% | CS - 7.7%

Question 53

True or false, CS performed before ROM prevents HSV transmission to neonate?

Answer 53

False. Can still have transmission, although decreased risk.

Question 54

Does a primary HSV outbreak during 3rd trimester of pregnancy affect delivery method recommendation?

Answer 54

Can consider CS due to possibility of prolonged viral shedding

Question 55

Is CS recommended for women with recurrent HSV lesions on back, thigh, or buttock?

Answer 55

No. These lesions may be covered with an occlusive dressing and patient may give birth vaginally

Question 56

In a patient with active HSV lesions and ROM at term, should CS be performed?

Answer 56

Yes.

Question 57

In a patient with active HSV lesions and PPROM, should CS be performed?

Answer 57

Risks of prematurity should be weighed against risk of neonatal HSV in considering expectant management.

Question 58

True or false, transabdominal invasive procedures (CVS, amnio, PUBS) should be deferred during active HSV infection?

Answer 58

False. May be performed when genital lesions are present.

Question 59

True or false, transcervical invasive procedures should be deferred during active HSV infection?

Answer 59

True. Seems reasonable to delay procedures until lesions appear to have resolved.

Question 60

Is breastfeeding contraindicated with HSV?

Answer 60

Only if HSV lesions on breast. Should advise women to take special considerations with handwashing

Question 61

True or false, postnatally acquired HSV is less lethal than HSV acquired during delivery?

Answer 61

False. Can be just as lethal.

Question 62

True or false, valacyclovir is safe for breastfeeding women?

Answer 62

True