Master the board step 3

Obstetrics
Treatment
··
Antiviral therapy with ganciclovir or foscarnet prevents viral shedding and
prevents hearing loss but does not cure the infection.
··
CMV hyperimmune globulin may reduce the risk of congenital infection in
pregnant women with primary CMV infection.
Herpes Simplex Virus (HSV)
A 21-year-old multipara is admitted to the birthing unit at 39 weeks gestation in
active labor at 6 cm dilation. Membranes are intact. She has a history of genital herpes
preceding the pregnancy. Her last outbreak was 8 weeks ago. She now complains
of pain and pruritus. On examination, she had localized, painful, ulcerative lesions
on her right vaginal wall. Which of the following is the next step in management?
a. Administer IV acyclovir
b. Administer terbutaline
c. Obtain culture of ulcer
d. Proceed with vaginal delivery
e. Schedule cesarean section
Answer: E. Active genital herpes is an indication for cesarean section.
The most common cause of transmission is contact with maternal genital
lesions during an active HSV episode. Transplacental infection can also occur
with primary infections during pregnancy (50 percent risk). Greatest risk is
primary infection in the third trimester. Suspect primary HSV infection if the
case describes fever, malaise, and diffuse genital lesions during pregnancy.
Neonatal infection acquired during delivery has 50 percent mortality rate.
Surviving infants develop meningoencephalitis, mental retardation, pneumonia,
hepatosplenomegaly, jaundice, and petechiae.
Diagnostic Testing
··
(+) HSV culture from vesicle fluid or ulcer or HSV PCR
Prevention
··
Perform c-section in women with lesions suspicious for active genital HSV
at the time of labor.
··
Do not use fetal scalp electrodes for monitoring (increased risk of HSV
transmission if mother has active HSV lesion).
··
Advise standard precautions (avoid intercourse if partner has active lesions,
avoid oral sex in presence of oral lesions, avoid kissing neonate in presence
of oral lesions).
Treatment
··
Acyclovir to patient for primary infection during pregnancy
429