Herpes Simplex Virus Infections in Pregnant Women and Neonates

1
Herpes Simplex Virus Infections in Pregnant Women
and Neonates
2
Primary maternal HSV infection

• Disseminated or presumed maternal primary
  infection should be treated with aciclovir
  (Category 2 recommendation).
• For a woman presenting with a first episode in
  the third trimester, every effort should be made
  to characterize it serologically (e.g. primary vs
  non-primary)
• In women with a primary HSV infection after 34
  weeks, delivery by elective Caesarean section and
  the use of suppressive aciclovir should be
  considered (Category 2 recommendation).

3
Maternal HSV infection - recurrence at delivery

• In the past, Caesarean section has been used
  widely but is not justified in the era of
  evidence-based medicine (Category 3
  recommendation)
• Caesarean section and other management options
  should be discussed with the patient (Category 3
  recommendation)
• Controlled trials of management policies to
  reduce the use of Caesarean section are required
  (Research recommendation)
• Mode of delivery may be based on clinical
  findings at the time of delivery. (Category 2
  recommendation) The presence of obvious herpetic
  lesions is a relative indication for Caesarean
  section

4
Maternal recurrent HSV infection - prophylaxis

• Aciclovir prophylaxis in late pregnancy for women
  with known recurrences is not recommended
  (Category 2 recommendation).
• Additional studies are underway so this
  recommendation should be reviewed as results
  become available (Research recommendation)

5
Maternal HSV infection - invasive monitoring

• Invasive monitoring should only be used for
  defined obstetrical indications (Category 3
  recommendation)

6
Maternal HSV infection - type-specific
serological testing

• Type-specific serological testing may have value
  in the management of the pregnant woman and her
  partner. Depending on local epidemiology and test
  performance, it has the potential to identify
• previously infected individuals
• those who seroconvert, if serial samples are
  taken
• Type-specific serological testing alone will not
  differentiate genital HSV-1 infection and
  orolabial HSV-1 infection

7
Investigation of suspected neonatal herpes
simplex virus infection

• The poor prognosis associated with neonatal HSV
  infection means that every effort should be
  employed to secure a diagnosis as early as
  possible
• Neonatal herpes may occur in the absence of skin
  lesions. Thus, other diagnostic methods are
  required
• Acquisition of material (for culture, PCR
  serology etc) of sites such as the eye and
  throat, and of lesions (when present) should be
  done (Category 1 recommendation)
• Viral cultures, liver function tests, PCR and CSF
  should be used to assess the extent of disease
  (Category 1 recommendation)

8
Neonatal herpes simplex virus infection -
diagnosis

• PCR analysis of the CSF for HSV DNA should be
  used to diagnose neonatal herpes (Category 2
  recommendation)
• PCR of peripheral blood mononuclear cells and
  plasma may also be a useful diagnostic tool
  (Research recommendation)
• PCR to detect HSV DNA in dried blood spots on
  Guthrie cards may also be useful for detection of
  HSV infection (Research recommendation)

9
Neonatal herpes simplex virus infection -
treatment

• Intravenous aciclovir (20 mg/kg every 8 hours)
  decreases the mortality and morbidity of neonatal
  herpes (Category 2 recommendation). Early therapy
  improves long-term neurological outcome (Category
  1 recommendation)
• Aciclovir dose is 60 mg/kg/day for 14 days (SEM
  disease) or 21 days (CNS or disseminated disease)
  (1/2)
• The value of suppressive therapy for neonatal
  herpes is not established (Category 2
  recommendation)

10
Neonatal herpes simplex virus infection -
monitoring treatment

• In infants in whom there is persistence of HSV
  DNA in the CSF following completion of antiviral
  therapy are more likely to die or suffer serious
  neurological impairment than infants whose
  post-therapy CSF specimens are PCR negative
  (Category 3 recommendation)
• Quantitative PCR testing of serial CSF samples
  may also help monitor the progress of treatment
  of neonatal herpes simplex infection and may be
  useful as a prognostic tool (Research
  recommendation)

11
Infant born to mother with clinically apparent
first episode genital herpes

• Ideally, the infant should be examined by a
  paediatrician experienced at identifying the
  signs of neonatal herpes
• Educate parents to be aware of signs of neonatal
  herpes
• Collect material including CSF for virology
  studies (e.g. culture, PCR)
• Prophylactic therapy with intravenous aciclovir
• if CSF normal 60 mg/kg/day in three divided
  doses x 14 days (Category 2 recommendation)
• if CSF abnormal same dose for 21 days (Category
  2 recommendation)
• If CSF not obtainable - same dose for 21 days

12
Infant born to mother with clinically apparent
recurrent genital herpes at delivery

• Ideally, the infant should be examined by a
  paediatrician experienced at identifying the
  signs of neonatal herpes
• Collect specimens from any lesions for routine
  culture
• The value of CSF for virology studies needs to
  be established (Research recommendation)
• Educate parents to be aware of signs of neonatal
  herpes
• Treat with iv aciclovir if infant develops
  evidence of neonatal infection
• if CSF normal 60 mg/kg/day in three divided
  doses x 14 days
• if CSF abnormal same dose for 21 days.

13
Infant born to mother with history of genital
herpes but no obvious lesions at delivery

• Educate parents to be aware of signs of neonatal
  herpes
• Collect material for diagnosis of neonatal herpes
  (e.g. culture, PCR) if symptoms develop
• Treat with iv aciclovir if infant develops
  evidence of neonatal infection
• if CSF normal 60 mg/kg/day in three divided
  doses x 14 days
• if CSF abnormal same dose for 21 days

14
Neonatal herpes simplex virus infection -
research initiatives

• It is important to prospectively evaluate
• PCR detection of HSV DNA in the CSF and blood
  (Research recommendation)
• family counselling (Research recommendation)
• controlled trials of suppressive therapy are in
  progress (Research recommendation)
• A vaccine able to prevent neonatal herpes is
  desirable