HSV

Question 1

What are the manifestations of disseminated maternal herpes?

Answer 1

Encephalitis, hepatitis, disseminated skin lesions or a combination

Rare, but more common in pregnancy, particularly if immunocompromised

High maternal mortality

Question 2

Co-infection with HSV and HIV results in…

Answer 2

Increased replication of both viruses

Question 3

If HIV positive with history of HSV, management:

Answer 3

Daily suppressive Aciclovir 400mg tds from 32/40
Reduce risk of transmission of HIV, especially if VD is planned
Start early if possibility of PTL

Question 4

What are the manifestations of congenital herpes?

Answer 4

Skin, eyes, CNS involvement
IUGR
IUFD

Question 5

What proportion of neonatal herpes is HSV1 vs HSV2

Answer 5

50%

50%

Question 6

What are factors that increase the risk of HSV transmission in labour?

Answer 6

Primary infection
New infection in third trimester, particularly within 6 weeks of delivery
- viral shedding may persist
- baby is likely to be born before the development of protective maternal antibodies

Duration of ROM before delivery
FBS
Mode of delivery

Question 7

In maternal HSV, what is the risk of neonatal transmission in

• primary episode in labour
• primary episode in trimester 3, from 28/30

Answer 7

41% with vaginal delivery

Therefore CS recommended

Question 8

In maternal HSV, what is the risk of neonatal transmission in

• recurrent episode antenatally
• recurrent episode in labour

Answer 8

0-3%
If antenatal: aim vaginal delivery
If antenatal or in labour: offer VS or CS, maternal decision but VD is safe
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Question 9

In maternal HSV, what are the recommendations re breastfeeding?

Answer 9

Continue

Unless herpetic lesions around nipple

Question 10

HSV-1 accounts for what % of genital herpes?

Answer 10

35%

Question 11

What is the HSV-2 seroprevalence in adult female population?

Answer 11

16%

Question 12

HSV-1 compared with HSV-2 is:

• Associated with ____ frequent recurrences
• _____ risk of transmission to the neonate at delivery

Answer 12

HSV-1 compared with HSV-2 is:

• Associated with LESS frequent recurrences
• HIGHER risk of transmission to the neonate at delivery

Question 13

What % of neonates acquire HSV:

• At delivery?
• In-utero?
• Postpartum?

Answer 13

• At delivery 90%
• In utero 5%
• Postpartum 5%

Question 14

What are potential sources of postnatal HSV transmission to newborn?

Answer 14

• Breast milk
• Skin and oral lesions
• SHV lesions from caregivers, family members or medical staff with close contact.

Question 15

What is the mortality rate of disseminated neonatal HSV infection?

Answer 15

• 90% if untreated

- 20-30% if treated

Question 16

What is the indications for Caesarean section delivery to prevent neonatal HSV infection?

Answer 16

• Primary genital HSV during pregnancy particularly third trimester.
• Primary genital HSV diagnosed in labour.
• Active genital herpes lesions and membranes ruptured <6 hours.
• Poor seroconversion following primary HSV infection in first and second trimesters.

Question 17

When is it safe to offer vaginal delivery when a mother has a history of HSV?

What precautions should you still take in labour?

Answer 17

• History of genital herpes with no active lesions in labour.
• Seroconversion following primary infection in first and second trimesters.
• Avoid trauma to fetal scalp: no FSE, FBS, forceps or ventouse.
• Follow-up neonate

Question 18

What neonate cares are needed if baby is inadvertently delivered vaginally when there are active genital herpes lesions or following a primary genital herpes episode in the third trimester?

Answer 18

• Empiric IV aciclovir for neonate.

Question 19

What precautions should be taken when a pregnant seronegative woman has a partner with a history of genital herpes?

Answer 19

• Use condoms.
• Suppressive antiviral therapy for partner.
• Avoid oral sex if partner has oral herpes and HSV type is unknown.
• Abstinence whe symptomatic and during third trimester.

Question 20

What is the mortality rate of disseminated neonatal HSV infection?

Answer 20

• 90% if untreated

- 20-30% if treated

Question 21

What is the indications for Caesarean section delivery to prevent neonatal HSV infection?

Answer 21

• Primary genital HSV during pregnancy particularly third trimester.
• Primary genital HSV diagnosed in labour.
• Active genital herpes lesions and membranes ruptured <6 hours.
• Poor seroconversion following primary HSV infection in first and second trimesters.

Question 22

When is it safe to offer vaginal delivery when a mother has a history of HSV?

What precautions should you still take in labour?

Answer 22

• History of genital herpes with no active lesions in labour.
• Seroconversion following primary infection in first and second trimesters.
• Avoid trauma to fetal scalp: no FSE, FBS, forceps or ventouse.
• Follow-up neonate

Question 23

What neonate cares are needed if baby is inadvertently delivered vaginally when there are active genital herpes lesions or following a primary genital herpes episode in the third trimester?

Answer 23

• Empiric IV aciclovir for neonate.

Question 24

What precautions should be taken when a pregnant seronegative woman has a partner with a history of genital herpes?

Answer 24

• Use condoms.
• Suppressive antiviral therapy for partner.
• Avoid oral sex if partner has oral herpes and HSV type is unknown.
• Abstinence whe symptomatic and during third trimester.

Question 25

What precautions should be taken when a pregnant woman has RECURRENT symptomatic genital HSV?

Answer 25

- Aciclovir suppressive therapy from 36 weeks (or earlier if symptomatic). - Follow-up for neonate.

Question 26

What investigations should you order for a pregnant woman with a first episode of genital herpes in pregnancy/labour?

Answer 26

- Type specific PCR and culture (genital swab) | - HSV type specific serology (blood sample)

Question 27

How would you interpret: - HSV detect on genital swab BUT - Same serotype antibody not detected in blood e. g. HSV1+ swab, HSV1 IgG -ve and HSV2 IgG +ve blood

Answer 27

Non-primary first episode (new acquisition of an HSV serotype with evidence of exposure (IgG +ve) to the other serotype). Still considered high risk if doesn't seroconvert prior to 3-34 weeks

Question 28

How would you interpret: - Genital swab HSV +ve BUT - Seronegative for both HSV1 and HSV2 IgG in blood?

Answer 28

Primary first episode. New acquisition of either HSV serotype without prior exposure (i.e. seronegative in blood to both HSV IgG1 and 2).

Question 29

What can you infer if a patient has HSV1 antibodies on serology?

Answer 29

Implies prior infection but does not specify site of infection.

Question 30

How would you interpret: - Genital swab HSV +ve AND - Seropositive for same HSV type IgG in blood?

Answer 30

Recurrent infection

Question 31

What is the effect of prior HSV-1 infection have on acquisition of HSV-2?

Answer 31

- Does not alter risk of acquisition. | - Lessens symptoms of HSV-2

Question 32

What is the effect of prior orolabial HSV1 infection on genital HSV1?

Answer 32

Prior orolabial HSV1 is protective against genital HSV1.

Question 33

How to prevent spread of genital herpes

Answer 33

- Condom use (does not eliminate risk). - Avoid sexual contact when oral or genital lesions present. - Oral suppressive therapy reduces risk of transmission by 80-95%.

Question 34

What investigations can be performed for confirming genital herpes? Highlight any advantages and disadvantages.

Answer 34

Viral PCR swab: - Gold standard - Low false positive rate - Negative test does not rule out HSV. Viral culture swab: - High false negative rate. Type-specific herpes serology (blood): - Positive antibodies only indicate past (not current) infection. - Cannot distinguish anatomical site of infection - No accurate enough. - Seroconversion rates highly variable. - Indicated if: discordant couple planning pregnancy (male +ve, female -ve); herpes in pregnancy with no previous history; recurrent or atypical genital sx with negative HSV PCR swab.

Question 35

What antiviral therapy would you prescribe for: - First episode - Recurrent episode - Suppressive treatment

Answer 35

- First episode: valaciclovir 500 mg BD 7 days or more. - Recurrent episode: valaciclovir 500 mg BD for 3 days. - Suppressive treatment: valaciclovir 500 mg OD for 12 months; trial break for 3 months after this.

Question 36

Outline symptomatic management of genital herpes

Answer 36

- Oral analgesia - Topical analgesia lignocaine gel 2% - Sitz baths - Micturating sitting in bath/bowl of water - Suprapubic catheter - Dry lesions with lowest setting of a hair dryer

Question 37

What are the three subgroups of neonatal HSV?

Answer 37

1. Skin, eye and/or mouth 2. Local CNS: encephalitis alone 3. Disseminated infection with multiple organ involvement

Question 38

For a woman who has primary episode of HSV diagnosed after 28/40, how long should she take antiviral therapy for?

Answer 38

Aciclovir 400mg tds UNTIL DELIVERY Treat without waiting for results

Question 39

What is a neonatal side effect of mum taking Aciclovir antenatally?

Answer 39

Transient neonatal neutropenia NO clinically significant adverse effects