What is the management for a pregnant female with genital herpes who transmits the disease to her neonate during delivery?

Management of Neonatal Herpes Infection Transmitted During Delivery

Immediate intravenous acyclovir treatment is essential for neonates who acquire herpes simplex virus (HSV) infection during delivery, with dosing of 20 mg/kg/dose three times daily for 14-21 days depending on disease classification. 1

Diagnosis and Initial Management

• Immediate evaluation of exposed newborns should include:

  • Surface cultures/PCR from skin, eyes, mouth, and rectum
  • Blood for HSV PCR
  • CSF for HSV PCR and analysis
  • Liver function tests 1

• Treatment initiation: IV acyclovir should be started immediately without waiting for test results in suspected cases 1

Disease Classification and Treatment Duration

Neonatal HSV infection presents in three forms, each requiring specific management:

1. Disseminated Disease (25% of cases)

   • Involves multiple organs
   • High mortality rate despite treatment
   • Treatment: 21 days of IV acyclovir 1

2. CNS Disease (35% of cases)

   • Localized to central nervous system
   • Treatment: 21 days of IV acyclovir
   • Requires repeat CSF HSV PCR at treatment completion 1

3. Skin, Eye, and Mouth (SEM) Disease (40% of cases)

   • Treatment: 14 days of IV acyclovir
   • Monitoring for recurrences during first 6 months 1

Follow-up Management

• After completion of IV therapy, oral suppressive therapy with acyclovir should be continued for 6 months to prevent recurrences 1

• Regular neurological assessments and developmental monitoring are essential, particularly for infants who had CNS involvement

Prevention Strategies for Future Pregnancies

For women with history of genital herpes who have transmitted the infection to their neonate:

• Antiviral suppression in subsequent pregnancies starting at 36 weeks' gestation:

  • Valacyclovir 500 mg twice daily (preferred regimen)
  • Alternative: Acyclovir 400 mg three times daily 1

• Cesarean delivery is recommended for women with active genital lesions or prodromal symptoms at the onset of labor 1

Important Considerations

• The risk of neonatal herpes is significantly higher (25-44%) when a mother has a primary first episode of genital herpes at delivery, compared to only 1% for recurrent episodes 2

• Suppressive therapy starting at 36 weeks significantly reduces viral shedding, clinical recurrences, and need for cesarean deliveries 1

• Acyclovir is considered safe during pregnancy (FDA category B) with no increased risk for major birth defects compared to the general population 3

• Breastfeeding is generally safe unless the mother has cracked nipples with detectable HSV DNA 1

Pitfalls to Avoid

• Delayed treatment: Never wait for confirmatory test results before initiating IV acyclovir in suspected cases, as delayed treatment significantly increases mortality and morbidity

• Inadequate follow-up: Failure to monitor for recurrences after completing initial therapy can lead to missed opportunities for early intervention

• Insufficient treatment duration: Shorter courses of therapy are associated with higher rates of recurrence and poorer outcomes

• Overlooking maternal counseling: Comprehensive education about prevention strategies for future pregnancies is essential to prevent recurrence

By following this evidence-based approach to managing neonatal herpes infection, clinicians can significantly improve outcomes for affected infants while providing appropriate guidance for future pregnancies.