Managment of Herpes simplex Virus infection in pregnancy and in ...

Managment of 

Herpes simplex Virus infection 

in pregnancy and in the newborn 

Recommendations of the Swiss 

Herpes Management Forum 

Christian Kind, St. St. 

Gallen 

Ostschweizer Kinderspital

Situation in the delivery room 

• Baby girl, 37 0/7 W GA, BW 2720g 

• Mother 35-y. gravida 1, para 1 

• Delivery by elective cesarean section after development of 

active genital herpes the day before 

• Mother had been treated for genital herpes type 2 twice 

during the preceding years 

• Spontaneous adaptation, adaptation Apgar 5 / 7 / 8 

• At age 1 hour moderate respiratory distress requiring 

fi O 2 of 30% 

• No cutaneous lesions visible 


How do you proceed? proceed 

• Start iv acyclovir immediately and transfer to 

neonatology unit 

• Culture swabs of oropharynx und conjunctiva for 

Herpes simplex 

Proceed according to culture results 

• Base management exclusively on further clinical 

course 


Risk of perinatal HSV transmission 

Seattle: 202 parturients with positive cultures, cultures, 

10 neonatal 

infections 

% infected OR (95% CI) 

• Infection episode 

– Reactivation (antibody ( antibody +) 1.3% 

– First episode (no ( no antibody) antibody 30.8% 33.1 (6.5-168) 

• HSV type 

– HSV-2 2.7% 

– HSV-1 31.3% 16.5 (4.1-65) 

• Mode of delivery 

– Vaginal 7.7% 

– Cesarean section 1.2% 0.14 (0.02-1.08) 

Brown ZR et al JAMA 2003; 289:203-9 


Perinatal risk with 

reactivation of HSV-2 

• Parturients with positive culture at delivery 140 

– Clinical lesions present 50 

• Cesarean section 38 

• Vaginal delivery 12 

– Clinical lesions absent 90 

• Cesarean section 18 

• Vaginal delivery 72 

• Neonatal infection 0 



% NG mit ANS 

8 

7 

6 

5 

4 

3 

2 

1 

0 

Why has the baby 

respiratory distress? distress 

Frequency of RDS in 33 289 term infants in Cambridge 

37 0/7 - 6/7 38 0/7 - 6/7 39 0/7 - 6/7 

Gestationsalter SSW 

Morrison JJ et al Br J Obstet Gynaecol 1995; 102:101-6 

Elektive Sectio 

Sekundäre Sectio 

Vaginale Geburt 


Neonatal 

Herpes simplex infection 

• Three clinical presentations: 

presentations 

– Localised (Skin, eyes, eyes mouth) mouth 

50% 

– CNS – Disseminiated 

33% 

(Hepatitis, DIC, shock, shock pneumonitis) pneumonitis 17% 

• Start of symptoms: symptoms 

– 1. Day of life 9% 

– Day 2-5 30% 

– After 5 days 60% 

Kimberlin DW Pediatrics 2001; 108:223-9 


Symptoms at presentation 

• Skin vesicles 68% 

• Fever 39% 

• Lethargy 38% 

• Seizures 27% 

• Conjunktivitis 19% 

• Pneumonitis 13% 

• DIC 11% 



Progonosis after 

high dose acyclovir 

• Disseminated infection: infection 

– Death 31% 

– Sequelae in survivors 17% 

• Infection of CNS: 

– Death 6% 

– Sequelae in survivors 69% 

• Severe 39% 

• Moderate 15% 

• Mild 15% 

• Average duration of symptoms at start of tx 5.6-7.4 days! days 



Detection of newborns at risk? risk 

• Culture at birth pos 10 202 

neg 6 39821 

• History for genital herpes pos 4 102 

(with with pos. pos culture) culture 

neg 6 100 

• Clinical lesions at delivery ja 0 74 

(with ( with pos. pos culture) culture) 

nein 10 128 

• Serology neg 6 11115 

pos HSV-1 6 23480 

pos HSV-2 2 5761 

pos both 1 8034 


newborn infected exposed 



Members of the Swiss Herpes 

Management Forum 

• Dermatology: S. Büchner, Basel, W. Kempf, Zürich, 

S. Lautenschlager, Zürich 

• Internal medicine:H. H. Hirsch, Basel, P. P. Reusser, 

Porrentruy 

• Microbiology: P. Meylan, Lausanne, W. Wunderli, Genève 

• Neonatology: C. Kind 

• Obstetrics: S. Gerber, Lausanne, U. Lauper, Zürich 

• Ophthalmology: J. Garweg, Bern 

• Pediatrics: D. Nadal, Zürich 

• Sponsor: GlaxoSmith Kline, Münchenbuchsee 


Guidelines endorsed by 

• Swiss Society for Dermatology and Venerology 

• Swiss Society for Urology 

• Swiss Society for Allergology and Immunology 

• Swiss Society for Gynaecology and Obstetrics 

• Swiss Society of Ophthalmology 

• Swiss Society of Paediatrics 

• Swiss Society of Neonatology 

• Swiss Society for Infectious diseases 

• Swiss Society of Haematology 

• Swiss Society for Oncology 

• Swiss Society of Internal Medicine 

• Swiss Society of General Practice Medicine 

• Swiss Society for Microbiology 


Recommendations for pregnancy 

• No serological or virological screening 

• Treat clinical episodes with acyclovir 

• Use suppressive treatment from 36 weeks of pregnancy in 

case of high risk of recurrence 

• Deliver by cesarean section if active clinical lesions or 

prodromal pain at time of presentation for labor 

• Do not perform c-sectionc- section for 

– History of genital herpes in absence of lesions 

– Clinical lesions in the absence of labor or rupture of 

membranes before 39 weeks 


Rupture of membranes in the 

presence of herpes lesions 

• If pulmonary maturity is probable 

– perform cesarean section as soon as possible (no ( no later 

than 4-6 hours) hours 

• If lungs immature 

– low risk with expectant management in the case of 

recurrent maternal herpes (Major CA et al, al, 

Am J 

Obstet Gynecol 2003; 188:1551-1555) 

– very difficult situation in the case of known maternal 

primary infection 


Management of the 

exposed neonate 

• If clinically active lesions or positive cultures at birth 

→ 

culture swabs from conjunctiva, conjunctiva oropharynx and rectum 

between 24 and 48 hours of life 

• Observe for clinical symptoms, symptoms, 

also after discharge (4-6 

weeks) weeks) 

→ instruction of parents 

• Antiviral therapy only for symptomatic infants or with 

positive cultures 


Think herpes! herpes 

• The majority of neonatal herpes infections occur after no 

known exposure 

• 1/3 of infected infants have no vesicles 

• Consider herpes infection in any case of 

– Cutaneous, Cutaneous mucosal and conjunctival lesions 

– Seizures; Seizures lethargy 

– Fever or other systemic symptoms 

Without any other explanation 


Management of suspected 

neonatal herpes infection 

• Culture swabs from vesicles, vesicles conjunctiva, conjunctiva oropharynx 

ev. ev stools/rectal stools rectal swab, swab urine, urine blood 

• LP for PCR 

• Chemistry incl. incl transaminases and coagulation studies 

• Acyclovir iv 60 mg/kg/d in 3 x 

• For 2 weeks in localised infection 

• For 3 weeks in CNS or disseminated infection 

(ev ev. Repeat LP for PCR after discontinuation) 

discontinuation 

• Cutaneous recurrences possible für months 

(ev ev. suppression with acyclovir po) po 



Preventive measures 

• Isolate newborn with neonatal herpes and avoid direct 

contact with lesions and body fluids 

• Protect healthy newborns from direct contact with herpes 

lesions in adults (on ( on lips, lips fingers, fingers nipples) nipples by sealed 

covering of lesions 

• Medical staff with oral herpes need not be suspended 

from caring for neonates

Managment of Herpes simplex Virus infection in pregnancy and in ...

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