When is C-section Required in Pregnant Women with Herpes?

The identification of pregnant women who are carriers of the Herpes Simplex Virus type 2 (HSV-2) is an important concern. Why is genital herpes in pregnancy such a worry? Certainly, this STD can cause the mother distressing symptoms. But the real concern is for the child she is carrying. Infants who are born to women who have ever had genital herpes are at risk of developing neonatal herpes, a potentially lethal condition.

What is neonatal herpes?

There is a spectrum of neonatal disease conditions caused by the herpes simplex virus. This disease spectrum includes:

1. Skin, eye and mouth HSV disease

2. Central nervous system (CNS) HSV disease

3. Disseminated HSV disease

About 45% of infants will develop skin, eye, and mouth herpes lesions. This form of neonatal herpes is the least severe and does not affect the internal organs.

30% of infants with neonatal HSV will develop central nervous system (CNS) disease. Neonatal CNS herpes is manifest by:

-seizures

-lethargy

-irritability

-tremors

-poor feeding

-temperature instability

-a bulging fontanelle

Around 25% of neonatal herpes is of the most severe form, disseminated disease. Infants with disseminated herpes infection have multi-organ involvement. These infants can die from severe coagulopathy (defective blood clotting), liver dysfunction, and/or pulmonary failure.

How can pregnant women with HSV prevent neonatal herpes in their child?

Guidelines have been established in the management of pregnant women who are herpes simplex carriers. These guidelines provide the best chances of preventing neonatal herpes.

Pregnant women who have genital herpes lesions, or prodromal symptoms that suggest a flare is coming on, at the time of labor will require a C-section. This is more effective at preventing neonatal herpes if the C-section is done before the membranes have ruptured (water breaking).

A pregnant woman may have a known third trimester acquisition of genital herpes, in other words, she became infected with herpes for the very first time during the third trimester. In this case, most experts recommend a C-section, whether or not she has signs of infection at the time of labor.

An alternate option is to put the mother on suppressive therapy with acyclovir or valacyclovir. Then type-specific antibodies (which cross the placenta to provide protection to the infant) are checked by the time of delivery.

- If Positive for HSV-2 antibodies a vaginal delivery is possible

- If Negative for HSV-2 antibodies a C-section is required

This alternative option is riskier. The suppressive therapy with acyclovir or valacyclovir may not eliminate viral shedding in the birth canal. Additionally, though antibodies may be present, they may not provide sufficient passive immunity for the infant if the antibody quantities are low.

A pregnant woman who has symptomatic genital herpes at 36 weeks gestational age or has a history of recurrent symptomatic HSV will be put on antiviral suppressive medication at 36 weeks until the baby is delivered. Unless absolutely necessary, the doctor will need to avoid invasive obstetrical procedures such as artificial rupture of membranes (AROM), fetal scalp electrode (FSE), and/or Vacuum or Forceps delivery.