Neonatal Herpes Infection: A Review

Leslie A. Parker, MSN, RNC, NNP; Sheryl J. Montrowl, MSN, RNC, NNP

Disclosures

NAINR. 2004;4(1) 

In This Article

Prevention

The prevention of HSV infection in the newborn has received considerable attention. In 1999 the American College of Obstetricians and Gynecologists (ACOG) developed a practice model for the management of herpes in pregnancy.[55] Universal screening is not recommended as this is inaccurate and not cost effective. The ACOG recommendations included the following points:

  • Primary infection during pregnancy should be treated with antivirals; this reduces viral shedding and promotes healing of lesions

  • Cesarean delivery for those with primary infection and lesions at delivery

  • Treatment for pregnant women beyond 36 weeks' gestation with a primary infection

  • Cesarean delivery for recurrent HSV infections with lesions or prodromal symptoms at delivery

  • Expectant management of patients with preterm labor or prolonged premature rupture of membranes and lesions may be warranted

  • Consider treatment for women at or beyond 36 weeks' gestation with recurrent HSV infection; this will decrease clinical occurrences and possibly the need for cesarean section (C/S)

Even though these recommendations increase the likelihood of cesarean section from 23 to 85%, their use decreases vertical transmission of HSV to the newborn by 50%.[16] Treatment with acyclovir in pregnancy is a reasonable option as several studies have suggested it is free of teratogenic effects.[46,56] Acyclovir is concentrated in the amniotic fluid but does not accumulate in the fetus.[57,58]

No single method has proven effective in preventing transmission of genital herpes to newborns. Several studies have looked at various methods to predict which women were at highest risk. Attempts at using antenatal viral cultures to predict the exposure from asymptomatic viral shedding, suppressive acyclovir therapy during the last weeks of pregnancy, or universal screening of all pregnant women for HSV-2 have been either unsuccessful or too costly.[59,60,61]

In 1996, Randolph and associates studied, from a health care payer's perspective, four methods to prevent vertical transmission of HSV from pregnant women to infants.[62] The four methods were A, C/S if lesions were present; B, acyclovir prophylaxis in late pregnancy and C/S if lesions were present; C, acyclovir prophylaxis in late pregnancy and vaginal delivery if lesions were present but with screening and follow up of exposed infants; and D, no intervention. This study showed that acyclovir prophylaxis late in pregnancy to prevent genital herpes outbreaks in women with recurrent infection would prevent more neonatal herpes infections and save money over the current strategy at that time of no acyclovir and C/S when lesions were present. Although this strategy may reduce the number of neonatal HSV infections in women with recurrent HSV, it may not change the overall incidence of neonatal herpes, as most infections are acquired from women with primary herpes.

Barnabas and associates[12] in 2002 reported the results of a health care economic analysis evaluating the use of prophylactic acyclovir on reducing neonatal HSV infection. In the first group (P1) no intervention other than normal pregnancy costs were employed; the second group (P2) followed the ACOG guidelines; and the third group (P3) consisted of treating partners with acyclovir, counseling and screening all pregnant women and their partners, and performing C/S for women with herpes at time of delivery. For this study the estimated yearly number of neonatal cases of HSV for group P1 was 169. This number was reduced to 155 in group P2 and to 31 in group P3. Screening and therapy (P3) prevents 80% of cases compared with the existing ACOG guidelines but was shown not to be cost effective. This study using the human capital approach, which uses estimates of lost wages to evaluate morbidity and mortality, found that, while group P3 had the greatest impact on neonatal herpes incidence, it was not cost effective. This approach, however, does not account for neonatal mortality and the value of an infant's life.

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