Transcript Rubella in Pregnancy

Herpes in Pregnancy
Max Brinsmead MB BS PhD
May 2015
Genital Herpes
66% caused by H. simplex Type 2
 33% associated with H simplex Type 1
 Is a latent and recurrent infection in up to
1:5 adults
 ~1:50 women have this virus during
pregnancy
 But most are secondary (or recurrent)
infections
 Even if the woman says she has never
had it before
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Neonatal Herpes 1
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Three subgroups of neonatal infection
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Disseminated disease has 80% mortality
(untreated) and 30% with antiviral agents
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Skin, eye and mouth disease
Encephalitis only
Disseminated disease
And 17% risk of morbidity in survivors
Risk of death from skin, eye and mouth disease
is 2%
Neonatal Herpes 2
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Encephalitis alone typically occurs at 10 – 28d of
age
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Mortality risk 6%
Morbidity risk 70%
There are regional variations in the rate of
neonatal Herpes
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1:60,000 UK
1:30,000 Europe and Japan
1:7500 in certain populations of the US
Maternal Herpes
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Primary infection can be disseminated with
encephalitis, hepatitis and skin eruptions
Is more common in pregnancy because of the
mild immunosupression which occurs
Concomitant HIV infection a real problem
Most infections during pregnancy are secondary
But recurrences are more common because of
pregnancy-related immunosupression
Vertical Transmission of Herpes
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Mostly occurs when the fetus contacts infected
genital secretions
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But intrauterine infection and FDIU possible
Neonatal infection is also possible
Disseminated Herpes occurs after primary
maternal infection
 Often
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with premature delivery
Secondary maternal Herpes can cause
 Skin,
eye and mouth disease
 And sometimes isolated neonatal encephalitis
 Because maternal antibodies do not protect the
brain
Risk of Vertical Transmission
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With maternal primary Herpes the risk of
neonatal infection is 26 – 56%
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With maternal secondary Herpes the risk of
neonatal infection is 1 – 3%
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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)
Diagnosis of Genital Herpes
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Often unrecognised in its recurrent form
Typically localised pruritis and pain
Blister and ulceration
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
Viral culture
Maternal Primary Herpes
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Treat according to clinical condition
Consultation with GU-Specialist desirable
IV Acyclovir recommended
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But use with caution <20 weeks gestation
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 is recommended if a primary infection is
clinically diagnosed or confirmed within 6 weeks
Why Caesarean Section?
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)
Maternal Secondary Herpes
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Weekly cultures are not predictive
Daily Acyclovir from 36 weeks reduces the risk
of
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A recurrence at the time of delivery
Asymptomatic virus shedding
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
Herpes visible at the onset of
labour
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If thought to be a secondary infection then CS is
not mandatory
Requires patient counselling and her choice
should be respected
If there are ruptured membranes then delivery
should be expidated
Fetal trauma should be avoided
The neonatal service should be alerted
Other measures
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Women who volunteer a history of genital
herpes at an antenatal visit require counselling
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Women with known carrier partners can be
advised to take precautions against infection
Or tested for HSV antibodies
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Universal serum screening will reduce both
neonatal transmission and the rate of CS but is
not considered cost effective
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Individuals with active Herpes should not care
for neonates
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