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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2]
Synonyms and keywords:
Overview
Historical Perspective
- In 1935, the first case resembling neonatal HSV, was described with the presence of intranuclear inclusion bodies in a premature infant in the liver and the adrenals.[1]
Classification
Neonatal Herpes Simplex Classification
Neonatal herpes simplex is classified based on the organ system involvement in the neonate into the following:
- Disseminated herpes simplex: Involving visceral organs such as lung, liver, adrenal glands, skin, eye, and/or brain
- Central nervous system disease: Involvement of the CNS with or without skin lesions
- Disease limited to the involvement of skin, eye and mouth (SEM)
Maternal Genital Herpes Classification
Maternal genital herpes is classified based on HSV type and maternal serology. It is essential to distinguish the type of maternal infection, as the type of infection has influence on the management approach.
| Classification of maternal infection | PCR / Culture from the genital lesion | Maternal HSV-1/ HSV-2 Antibody status |
|---|---|---|
| First episode primary infection | Positive for either virus | Negative for both |
| Recurrent infection | Positive for HSV-1 | Positive for HSV-1 |
| Positive for HSV-2 | Positive for HSV-2 |
Pathophysiology
Pathogenesis
- The risk of transmission of infection to the neonate from an infected mother is high (30-50%) who have genital herpes at term and low (<1%) in mothers with prenatal history of recurrent herpes or who have genital HSV during the first and second trimester.[2][3][4]
Timing of infection
- Exposure to the fetus from active genital herpes lesions during delivery, accounts for majority of neonatal herpes simplex cases. [5]
- Intrauterine infection accounts for 5% of cases with neonatal herpes simplex.
- Postnatal trasmission by contact with HSV shed from infected patients. It accounts for 10% of the cases.
Factors that influence transmission of HSV from the mother to the neonate
The factors which influence the transmission of infection include:
- Women with primary infection have higher rate of infection transmission when compared to women with recurrent infection.
- Maternal HSV antibody status
- Prolonged duration of rupture of membranes increases the risk of infection transmission.
- Use of scalp electrodes can breech the integrity of mucocutaneous barrier increasing the risk of transmission.
- Vaginal delivery has a higher risk of transmission of infection compared to cesarean section.
Epidemiology and Demographics
- The annual incidence of neonatal herpes is estimated to be 10 cases per 100,000 livebirths.
Causes
- 85% of cases are caused by HSV type 1
- 15% of cases are caused by HSV type 2
Differentiating Neonatal Herpes Simplex From Other Diseases
The most important congenital infections, which can be transmitted vertically from mother to fetus are the TORCH infections. These infections have overlapping features and hence, must be differentiated from Congenital Varicella Syndrome:[6][7]
| Congenital Infection | Cardiac Findings | Skin Findings | Ocular Findings | Hepatosplenomegaly | Hydrocephalus | Microcephaly | Intracranial Calcifications | Hearing deficits |
|---|---|---|---|---|---|---|---|---|
| Congenital Varicella Syndrome | -
|
|
✔ | ✔ | ✔ | |||
| Toxoplasmosis | ✔ | ✔ | ✔ | Diffuse intracranial calcifications | ||||
| Congenital Syphils | ✔ | |||||||
| Rubella | ✔ | ✔ | ✔ | ✔ | ||||
| Cytomegalovirus (CMV) | ✔ | ✔ | ✔ | Periventricular calcifications | ✔ | |||
| Herpes simplex virus (HSV) | ✔ | ✔ | ✔ | ✔ | ||||
| Parvovirus B19 | ✔ |
Natural History, Prognosis and Complications
Natural History
Complications
Diagnosis
History and Symptoms
Physical Examination
Laboratory Findings
Treatment
Medical Therapy
Surgical Therapy
Prevention
Primary Prevention
- Women without known genital herpes should be counseled to abstain from vaginal intercourse during the third trimester with partners known or suspected of having genital herpes.
- Pregnant women without known orolabial herpes are advised to abstain from receptive oral sex during the third trimester with partners known or suspected to have orolabial herpes.
- All pregnant women should be asked about history of genital herpes. At the onset of labor, all women should be questioned carefully about symptoms of genital herpes, including prodromal symptoms, and all women should be examined carefully for herpetic lesions. Women without symptoms or signs of genital herpes or its prodrome can deliver vaginally. Cesarean delivery does not completely eliminate the risk for HSV transmission to the neonate, women with recurrent genital herpetic lesions at the onset of labor should deliver by cesarean delivery to reduce the risk for neonatal HSV infection.
Secondary Prevention
- Suppressive acyclovir treatment late in pregnancy reduces the frequency of cesarean delivery among women who have recurrent genital herpes by reducing the frequency of recurrences at term. However, such treatment may not protect against transmission to neonates in all cases. Recommended Regimen : Acyclovir 400 mg orally three times a day OR Valacyclovir 500 mg orally twice a day, beginning from 36weeks of gestation. [8][9][10]
References
- ↑ Hass GM (1935). "Hepato-Adrenal Necrosis with Intranuclear Inclusion Bodies: Report of a Case". Am J Pathol. 11 (1): 127–142.5. PMC 1910753. PMID 19970188.
- ↑ Brown, ZaneA.; Selke, Stacy; Zeh, Judy; Kopelman, Jerome; Maslow, Arthur; Ashley, Rhoda L.; Watts, D. Heather; Berry, Sylvia; Herd, Millie; Corey, Lawrence (1997). "The Acquisition of Herpes Simplex Virus during Pregnancy". New England Journal ofMedicine. 337 (8): 509–516. doi:10.1056/NEJM199708213370801. ISSN 0028-4793.
- ↑ Pinninti SG, Kimberlin DW (2013). "Maternal and neonatal herpes simplex virus infections". Am J Perinatol. 30 (2): 113–9. doi:10.1055/s-0032-1332802. PMID 23303485.
- ↑ Brown ZA, Benedetti J, Ashley R, Burchett S, Selke S, Berry S; et al. (1991). "Neonatal herpes simplex virus infection in relation to asymptomatic maternal infection at the time of labor". N Engl J Med. 324 (18): 1247–52. doi:10.1056/NEJM199105023241804. PMID 1849612.
- ↑ Brown ZA, Wald A, Morrow RA, Selke S, Zeh J, Corey L (2003). "Effect of serologic status and cesarean delivery on transmission rates of herpes simplex virus from mother to infant". JAMA. 289 (2): 203–9. PMID 12517231.
- ↑ Neu N, Duchon J, Zachariah P (2015). "TORCH infections". Clin Perinatol. 42 (1): 77–103, viii. doi:10.1016/j.clp.2014.11.001. PMID 25677998.
- ↑ Ajij M, Nangia S, Dubey BS (2014). "Congenital rubella syndrome with blueberry muffin lesions and extensive metaphysitis". J Clin Diagn Res. 8 (12): PD03–4. doi:10.7860/JCDR/2014/10271.5293. PMC 4316306. PMID 25654000.
- ↑ Sheffield JS, Hollier LM, Hill JB, Stuart GS, Wendel GD (2003). "Acyclovir prophylaxis to prevent herpes simplex virus recurrence at delivery: a systematic review". Obstet Gynecol. 102 (6): 1396–403. PMID 14662233.
- ↑ Watts DH, Brown ZA, Money D, Selke S, Huang ML, Sacks SL; et al. (2003). "A double-blind, randomized, placebo-controlled trial of acyclovir in late pregnancy for the reduction of herpes simplex virus shedding and cesarean delivery". Am J Obstet Gynecol. 188 (3): 836–43. PMID 12634667.
- ↑ Scott LL, Hollier LM, McIntire D, Sanchez PJ, Jackson GL, Wendel GD (2002). "Acyclovir suppression to prevent recurrent genital herpes at delivery". Infect Dis Obstet Gynecol. 10 (2): 71–7. doi:10.1155/S1064744902000054. PMC 1784606. PMID 12530483.