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

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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

Ostschweizer Kinderspital


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

Ostschweizer Kinderspital


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

Ostschweizer Kinderspital


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

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

Ostschweizer Kinderspital


% 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

Ostschweizer Kinderspital


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

Ostschweizer Kinderspital


Symptoms at presentation

• Skin vesicles 68%

• Fever 39%

• Lethargy 38%

• Seizures 27%

• Conjunktivitis 19%

• Pneumonitis 13%

• DIC 11%

Kimberlin DW Pediatrics 2001; 108:223-9

Ostschweizer Kinderspital


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

Kimberlin DW Pediatrics 2001; 108:223-9

Ostschweizer Kinderspital


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

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

newborn infected exposed

Ostschweizer Kinderspital


Ostschweizer Kinderspital


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

Ostschweizer Kinderspital


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

Ostschweizer Kinderspital


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

Ostschweizer Kinderspital


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

Ostschweizer Kinderspital


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

Ostschweizer Kinderspital


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

Ostschweizer Kinderspital


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

Kimberlin DW Pediatrics 2001; 108:230-8

Ostschweizer Kinderspital


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

Ostschweizer Kinderspital

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