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Publicly Available Published by De Gruyter August 5, 2017

Disseminated genital herpes and mode of delivery

Zdravko Odak, Damir Roje and Marko Vulić

Abstract

Genital herpes in pregnancy is associated with increased perinatal morbidity and mortality. Maternal primary infection with herpes simplex virus (HSV) prior to labor usually does not affect the fetus (1/200,000 deliveries) The greatest risk associated with intrapartum HSV exposure is neonatal herpes infection. Neonatal risk occurs in the case of a primary or reccurent HSV infection. The risk of neonatal HSV infection in case of non-genital herpes is low. The American Congress of Obstetricians and Gynecologists (ACOG) recommends elective cesarean delivery for women with demonstrable genital herpes or prodromal symptoms in labor.

Introduction

Genital herpes in pregnancy is associated with increased perinatal morbidity and mortality. Maternal primary infection with herpes simplex virus (HSV) prior to labor usually does not affect the fetus (1/200,000 deliveries) [1]. The greatest risk associated with intrapartum HSV exposure is neonatal herpes infection. Neonatal risk occurs in the case of a primary or recurrent HSV infection. The risk of neonatal HSV infection in case of non-genital herpes is low. The American Congress of Obstetricians and Gynecologists (ACOG) recommends elective cesarean delivery for women with demonstrable genital herpes or prodromal symptoms in labor.

Case report

We report a case of 24-year-old multipara presented to our department at [39+(4/7)]th weeks of gestation due to skin changes which began to show 10 days before admission. Obstetric history reviled two vaginal deliveries. Her medical history revealed an appendectomy 8 years prior and laparoscopic cholecystectomy 4 years prior.

In the perineal area and throughout her body, there were lesions appearing as shallow eroded ulcers suggesting herpetic infection. There were no painful vesicles or dry crust forms. She was not aware of any herpetic infection or skin changes which could point to it. The infectologist described skin changes typical for herpetic infection (Figure 1 and Figure 2). Suggested therapy was Acyclovir tablet 400 mg for [3×(1/5)] days forthwith along with preoperative prophylactic antibiotic therapy. Due to current recommendations, the mode of delivery was elective cesarean section. Cesarean delivery was performed under general anesthesia because of skin changes on her back. There were no affected parts of skin with herpetic changes near the incision site (Figure 3). A live 4000 g and 52 cm male infant was delivered with an APGAR score of 10. Neonatal inspection revealed no skin changes which could point to possible herpetic infection. He was transferred to the Department of Neonatology and isolated from other newborns for further inspection. Serologic testing, viral culture and polymerase chain reaction (PCR) were all made at the Department of Neonatology and there were no traces of HSV infection.

Figure 1: 
Skin changes typical for herpetic infection.

Figure 1:

Skin changes typical for herpetic infection.

Figure 2: 
Skin changes typical for herpetic infection.

Figure 2:

Skin changes typical for herpetic infection.

Figure 3: 
No herpetic skin changes near incision site.

Figure 3:

No herpetic skin changes near incision site.

Placenta was disposed of according to epidemiological regulations. Pathohistological diagnosis showed no morphological signs of HSV infection.

During puerperium, acyclovir therapy was continued. Usually the dose is 60 mg/kg/day in three divided doses administered every 8 h, assuming that renal function is normal. Treatment duration should be 14 days if the disease is limited to the skin, eyes or mouth, and a minimum of 21 days if the infection involves the central nervous system (CNS) or is disseminated [1]. After negative results of serologic testing and viral culture, we discontinued therapy. Patient recovered and was discharged after 3 days.

Discussion

The incidence of intrauterine HSV infection is 1/20,000 births, which is rare. Prospective data suggest the incidence of neonatal HSV disease to be 1 case in 3200 deliveries, though ranges for incidence span from 1 in 1400 to 1 in 30,000 deliveries [2]. But when it does occur, there are cases of increased perinatal morbidity, preterm labor and low birthweight, together with stillbirth of newborns whose mothers had disseminated genital herpes [3]. It must be noted that the association of HSV in the third trimester and intrauterine growth restriction (IUGR) is confirmed, but on a sample of five [4] pregnant women. The fact that mothers with HSV infection give birth to children with lower birth weight is a result of shorter duration of pregnancy in these women [5]. Management of the patient should be in line with its clinical condition and will usually involve the use of intravenous Acyclovir in standard doses (400 mg 3 times daily, usually for 5 days). In the third trimester, treatment will usually continue with daily suppressive Acyclovir 400 mg 3 times daily until delivery [3], [4]. We acted as suggested, and followed guidelines.

Transmission of the virus from mother to fetus typically occurs by direct contact with the virus in the genital tract during birth. In primary HSV infection, the chance of transmission of the virus during vaginal birth is about 50% and about 3% in recurrent infection. The Royal College of Obstetricians and Gynecologists (RCOG) suggests that cesarean section should be the recommended mode of delivery for all women developing first episode genital herpes in the third trimester, particularly those developing symptoms within 6 weeks of expected delivery [5]. It can be difficult to distinguish clinically between primary and recurrent genital HSV infections. Some of the diagnostic tests that are used are serology, Tzanck test, cell culture and PCR. In general, recurrent infections are less intense, have fewer skin lesions and viruses replicate less. One third of the infected patients do not have recurrent infections, one third up to three per year and the rest have more than three infections. The presence of antibodies of the same type as the HSV isolated from genital swabs would confirm this episode to be a recurrence rather than a primary infection and elective cesarean section would not be indicated to prevent neonatal transmission [3], [6]. However, it should be noted that it may take 2–3 weeks for the results of this test to become available. It is therefore recommended that an initial plan of delivery should be based on the assumption that all first episode lesions are primary genital herpes [3]. In our case, necessary serology tests were done; they were positive on IgG and IgM antibodies for both HSV-1 and HSV-2. We were unable to do serology IgG avidity which would help us in differentiating primary from recurrent infection. So we acted as if all lesions were primary genital herpes. Unfortunately, 60%–80% of neonatal infections occur in the case of asymptomatic or subclinical primary HSV infection when serology is positive and there is absence of clinical manifestations of infection [6], [7], [8]. In the context of the previously mentioned statement, it is proven that 1580 elective cesarean section have to be performed to prevent one neonatal HSV infection [5], [7]. There is no contraindication for breastfeeding during puerperium unless there are lesions on the breast [9].

Conclusion

Educating gravidas on genital herpes and herpes virus screening might reduce the probability of transmitting HSV infections to neonates and reduce the number of cesarean sections performed on those patients. In addition, educating gravidas on HSV infections could facilitate sexually transmitted disease screening and appropriate treatment.

Author’s Statement

  1. Conflict of interest: Authors state no conflict of interest.

Material and Methods

  1. Informed consent: Informed consent has been obtained from all individuals included in this study.

  2. Ethical approval: The research related to human subject use has complied with all the relevant national regulations, and institutional policies, and is in accordance with the tenets of the Helsinki Declaration, and has been approved by the authors’ institutional review board or equivalent committee.

References

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Received: 2016-11-30
Accepted: 2017-02-22
Published Online: 2017-08-05

©2017 Walter de Gruyter GmbH, Berlin/Boston

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