Genital Herpes; Clinical Features, Diagnosis and Treatment

During pregnancy, the major concern of maternal Genital herpes infection is transmitted to the fetus, as neonatal infection can result in serious morbidity and mortality.

Clinical features of Genital Herpes

Primary genital infection – 

• The patient has the first occurrence of a genital HSV lesion and no pre-existing herpes simplex virus type 1 (HSV-1) or herpes simplex virus type 2 (HSV-2) antibodies. 
• initial presentation can be severe, with painful genital ulcers, pruritus, dysuria, fever, tender inguinal lymphadenopathy, and headache. However, most patients have only mild symptoms or remain asymptomatic.

Nonprimary first-episode genital infection- 

• The patient has the first occurrence of a genital HSV lesion but has pre-existing HSV antibodies that are different from the HSV type recovered from the genital lesion 
• milder than in primary infection

Recurrent infections-

• HSV type recovered from the genital lesion is the same type as pre-existing antibodies in the serum. 
• Prodromal symptoms, such as pruritus, burning, or pain before lesions are visible.
• mild localized symptoms with few lesions and lack systemic findings.
• The lesions may be non-tender or atypical in appearance (eg, fissure, vulvar irritation)
• The duration of lesions and viral shedding is shorter than during a primary episode.

Accurate classification is particularly important during pregnancy because a newly acquired genital infection (primary or nonprimary first-episode) near the time of delivery is a major risk factor for transmission (30%–50%) to the neonate. The risk of neonatal transmission at delivery is much lower (<1%) in patients with recurrent genital infection

Complications in pregnancy

• Transmission of HSV to the neonate (usually occurs during labor and delivery). Use of invasive fetal monitoring and preterm birth increase the risk of neonatal infection in patients with viral shedding
• In utero infection acquired transplacentally or transcervically (across the amniochorionic membranes) has been reported anecdotally in women with primary HSV infection, and could result in miscarriage, congenital anomalies, preterm birth, and/or intrauterine growth restriction 
• Recurrent HSV has not been associated with these

Neonatal Herpes

 Screening 

• Evidence does not support routine HSV-2 serologic screening among asymptomatic pregnant women.
•  type-specific serologic tests might be useful for identifying pregnant women at risk for HSV 
• In the absence of lesions, routine serial cultures for HSV are not indicated for women in the third trimester who have a history of recurrent genital herpes

Diagnosis

• Clinical diagnosis
• Serology — Type-specific antibodies to HSV
• Tzanck smear-multinucleate giant cells
• Direct viral test
•  PCR
• Viral culture 
• Direct fluorescent antibody 

Treatment 

Antiviral medications and doses for genital herpes in pregnancy

Treatment may be extended if healing is incomplete after 10 days.
Suppressive therapy is offered to women who have had a genital HSV lesion (whether a first-episode or recurrent infection) any time during the pregnancy.

Analgesia with acetaminophen and sitz baths help to relieve fever, vulvar pain, dysuria, and other local symptoms.

Route of delivery 

Cesarean delivery as soon as possible after the onset of labor/rupture of membranes to women with a history of genital HSV and either of the following:

• Active genital lesions (including those that have crusted)
• Prodromal symptoms (eg, pain, burning)
• first-episode genital herpes infection in the third trimester, particularly those who develop symptoms within six weeks of the expected delivery

For women with no active lesions or prodromal symptoms but a primary or nonprimary first-episode genital infection during the current pregnancy, the decision depends heavily on the woman’s preferences and values

For women with a history of recurrent HSV but no active lesions or prodromal symptoms, the risk for neonatal HSV is too low to warrant cesarean delivery

Treatment of Neonate

Disease is limited to the skin and mucous membranes

• Acyclovir 20 mg/kg IV every8 hours for 14 days 

Disseminated disease and that involving the central nervous system

• Acyclovir 20 mg/kg IV every8 hours for 21 days