HSV in pregnancy an update on guidelines Joint BASHH and FSRH Meeting 15/01/16 Emily Clarke ST4 GUM, Solent NHS Trust, Portsmouth DIT rep to the BASHH Herpes Advisory Panel
Aims BASHH 2014 herpes guidelines Herpes proctitis Transmission: Key points to cover with patients BASHH/RCOG 2014 herpes in pregnancy guidelines Recurrent HSV / acquisition in 1 st & 2 nd trimesters Primary acquisition in 3 rd trimester Primary lesions in labour HSV in PPROM Preventing maternal HSV acquisition
Herpes proctitisin MSM USA: HSV 16% (3% had HSV + 1 other STI) 1 Australia: 32% had visible external gential ulceration 2 HIV positive HIV negative HSV-1 14.2% 6.5% HSV-2 22.0% 12.3% Total 36.2% 18.8% 1. Klausner et al. Clin Infect Dis 2004;38(2):300-2 2. Bissessor et al. Sex Transm Dis 2013;38:300-2
The case of David Golding
Assumption that best practice had occurred despite lack of documentation The available medical notes were not specific as to advice provided to the appellant. According to [medical expert], he would have expected a full discussion to have taken place at the Genitourinary Clinic following the guideline of the British Association for Sexual Health and HIV. This refers to condom use when lesions are present, the possibility of infectivity even when a person is asymptomatic, and disclosure of the condition to a partner.
Transmission: Key points Abstinence during lesion recurrences / prodromes Transmission may occur due to asymptomatic shedding Male condoms may reduce the risk of transmission, but do not completely prevent it 50% in transmission if using condoms 25-60% of the time Protective effect greater for women 1 Martin et al. Arch Intern Med 2009;169:1233-40
Suppressive antiviral therapy reduces the rate of acquisition of symptomatic HSV Asymptomatic shedding Reduced by ~80-90% by all antivirals Valaciclovir better than famciclovir, aciclovir at least as good as valaciclovir Valaciclovir 500mg OD Reduces the rate of acquistionof HSV-2 & clincially symptomatic HSV in serodiscordant couples MonogomousHIV-negative non-pregnant heterosexual couples
Transmission: Key points Disclosure is advised in all relationships Difficult issue for patients More likely to happen in ongoing relationship Associated with lower transmission risks & may be a protection against legal action Document discussions around disclosure & transmission
Aetiology unknown 8% ~50:50 HSV-1: HSV-2 Most acquired by contact with maternal secretions, 25% possibly postnatal Risks highest: HSV-2 51% Prior to development of maternal antibodies HSV-1 41% New infection (especially within 6/52 of delivery) as viral shedding may persist
Disseminated herpes Infant More common in premature infants Due to primary infection in mother Mother Encephalitis / hepatitis / disseminated skin lesions Rare, but more common in pregnancy (especially if immunocompromised) High maternal mortality
UK incidence Rare in UK in comparison with Europe & USA Active surveillance by BPSU 1986-91 1 76 cases in 5½ years Annual incidence of 1.65/100,000 live births (i.e. 1 in 60,606) 2004-6 2 86 cases in 3 years Approximate doubling of incidence (provisional) No further data published 1. Tookey et al, Paediatr Perinat Epidemiol 1996;10:432-42 2. BPSU 21 st Annual Report 2006-7
Recurrent HSV & primary acquisition in 1 st & 2 nd trimesters managed similarly Recurrent genital HSV Primary acquisition of genital herpes in 1 st or 2 nd trimester Treat primary episode / recurrences (if necessary) with standard doses of aciclovir Consider aciclovir 400mg tds from 36/40 gestation (32/40 if HIV positive)
Recurrent HSV & primary acquisition in 1 st & 2 nd trimesters managed similarly Offer vaginal delivery No genital HSV lesions at delivery Genital HSV lesions at delivery Normal postnatal care Normal postnatal care Discharge home at 24h if baby well Advise patients RE later management if concerns
Your patient asks Will I have a miscarriage? What is the risk of neonatal HSV? Should I have a Caesarean section or a vaginal delivery? Is short course aciclovir safe in early pregnancy? I am taking aciclovir suppression. Should I stop before trying to get pregnant? When should I seek medical help for my baby?
Your patient asks Will I have a miscarriage? No evidence of an increased risk of spontaneous miscarriage with primary HSV in 1 st trimester What is the risk of neonatal HSV? Risk of neonatal HSV is low even if lesions are present at delivery (0-3% for vaginal delivery)
Should I have a Caesarean section or a vaginal delivery? Offer vaginal delivery but final decision by woman Risk of neonatal HSV transmission versus risks of Caesarean section to mother & future pregnancies With small risk of transmission, invasive procedures can be used if required
Is short course aciclovir safe in early pregnancy? Not licensed in pregnancy Well tolerated in pregnancy Considered safe Pregnancy register Standard animal studies Mechanism of action of the drug Used to treat acquisitions in early pregnancy Category B classification by FDA Transient neonatal neutropenia reported
I am taking aciclovir suppression. Should I stop before trying to get pregnant? No advice included in BASHH/RCOG guidelines Tolerable symptoms: advise stop Reduce transmission risk to male partner: consider artificial insemination Severe symptoms: encourage immediate stop on pregnancy If insists on continuing Warn patient Give the lowest effective dose Do not use aciclovir 400mg tds (as used from 36/40)
When should I seek medical help for my baby? Any concerns but especially: Skin / eye / mucous membrane lesions Lethargy / irritability Poor feeding Fever Avoid postnatal transmission Hand hygiene Cold sores
Primary acquisition of genital HSV in 3 rd trimester Treat primary episode with standard doses of aciclovir Consider aciclovir 400mg tds until delivery Recommend planned Caesarean section (especially if within 6/52 of delivery Inform neonatologist Normal postnatal care Discharge home if baby well at 24 hours Advise patients regarding later management if any concerns
A woman has primary genital lesions at onset of labour. She asks I really want to have a vaginal delivery. What is the risk? Is there any way to reduce that risk? What will happen to my baby after delivery?
I really want to have a vaginal delivery. What is the risk? 41% risk of neonatal HSV Disease localised to skin/eye/mouth(30%) Neuro/ocular morbidity <2% with treatment Local CNS disease Mortality 6%, neurological morbidity70% Disseminated disease Mortality 30%, chronic neurological morbidity 17%
Is there any way to reduce that risk? IV aciclovir intrapartum to mother (5mg/kg every 8h) unknown whether reduces risk Avoid invasive procedures (fetal scalp electrodes, fetal blood sampling, artificial ROM, instrumental deliveries)
What will happen to my baby after delivery? Liaison with neonatal team HSV PCR swabs from skin, conjunctiva, oropharynx & rectum LP if unwell or skin lesions Empirical treatment with IV aciclovir (20mg/kg every 8h for 10d) until infection ruled out
Primary genital HSV in PPROM (<37+0) Limited evidence MDT decision Depends on gestation If for immediate delivery: as for management of primary HSV in labour If for conservative management IV aciclovir 5mg/kg every 8h Consider prophylactic steroids If delivery within 6/52 of primary infection, Caesarean section may still offer some benefit
Recurrent genital HSV in PPROM Risks of premature delivery likely to outweigh risks of HSV as transmission risk very small If PPROM <34/40 consider expectant management & start aciclovir 400mg tds After this follow RCOG guidelines on PPROM & consider antenatal steroids: not really influenced by presence of recurrent HSV lesions
Preventing HSV acquisition by pregnant women A women is 8 weeks pregnant & has negative HSV serology. Her husband has a known diagnosis of HSV-2 & has occasional symptomatic recurrences. What would you advise (in addition to normal advice on abstaining during recurrences / prodromes)? 1. No sex once pregnant 2. Conscientious use of condoms, & no sex in the last 6 weeks of pregnancy 3. Conscientious use of condoms, especially in the 3 rd trimester 4. No additional precautions
Prevention of HSV transmission to pregnant women Could also consider aciclovir suppression for male partner What about oral sex? 44-51% of neonatal HSV of known type due to HSV-1 Consider recommending avoiding receptive orogenital sex if known oro-labial HSV in partner, especially in 3 rd trimester BASHH HSV guidelines
Thank you Acknowledgements BASHH guidelines: Raj Patel, John Green, Kanchana Senviratne, Naomi Abbt, Ceri Evans, Jane Bickford, Marian Nicholson, Nigel O Farrell, Simon Barton, Mark Fitzgerald, Elizabeth Foley BASHH/RCOG guidelines: Elizabeth Foley, Virginia Beckett, Sam Harrison, Anil Pillai, Mark Fitzgerald, Philip Owen, Naomi Low-Beer, Raj Patel