Treatment of Acute Herpes Infection in Pregnancy

For acute herpes infection during pregnancy, oral acyclovir 400 mg three times daily for 7-10 days is the recommended first-line treatment. 1

First Episode Treatment Options

Treatment may need to be extended if healing is incomplete after 10 days of therapy 1.

The first clinical episode of genital herpes during pregnancy may be treated with oral acyclovir 1
For life-threatening maternal HSV infection (disseminated infection, encephalitis, pneumonitis, or hepatitis), intravenous acyclovir is indicated 1
Current registry findings do not indicate an increased risk for major birth defects after acyclovir treatment compared with the general population 1

Registry data does not show increased risk of major birth defects with valacyclovir 2
The Valacyclovir Pregnancy Registry documented outcomes of 111 infants exposed to valacyclovir during pregnancy with 3.9% occurrence of major birth defects during any trimester of exposure 2
Valacyclovir has been shown to reduce clinical recurrences when used as suppressive therapy in late pregnancy 3, 4

Available data from pharmacovigilance reports with famciclovir use in pregnant women have not identified a drug-associated risk of major birth defects 5
However, prenatal exposure to famciclovir is too limited to provide useful information on pregnancy outcomes 1

The risk for transmission to the neonate is high (30%-50%) among women who acquire genital herpes near the time of delivery 1
Risk is low (≤3%) among women with a history of recurrent herpes at term 1
Most mothers of infants who acquire neonatal herpes lack histories of clinically evident genital herpes 1

At the onset of labor, all women should be examined and questioned regarding symptoms of genital herpes 1
Vaginal delivery is permitted if no clinical recurrence or prodromal symptoms are present 1
Cesarean delivery is indicated for women with active genital lesions or prodromal symptoms at the time of delivery 1

Suppressive acyclovir therapy given to women experiencing a first episode of genital HSV during pregnancy decreases the need for cesarean delivery 6, 7
Valacyclovir suppression (500 mg twice daily) starting at 36 weeks significantly reduces HSV shedding and recurrent genital herpes requiring cesarean delivery 3, 4
Routine administration of suppressive therapy to pregnant women with recurrent genital herpes is not universally recommended, though evidence suggests benefits 1, 8

Immunocompromised patients might have prolonged and/or severe episodes of genital herpes 1
Higher doses of antiviral drugs are often beneficial for HIV-infected patients 1
Acyclovir 400 mg orally three to five times a day is recommended for immunocompromised patients 1

If lesions persist during acyclovir treatment, resistance should be suspected 1
All acyclovir-resistant strains are also resistant to valacyclovir, and most are resistant to famciclovir 1
For severe cases caused by acyclovir-resistant strains, foscarnet 40 mg/kg IV every 8 hours is often effective 1

Explain the risk of neonatal infection to all pregnant women with genital herpes 1
Advise patients to inform healthcare providers who care for them during pregnancy about the HSV infection 1
Counsel women to avoid unprotected genital and oral sexual contact during late pregnancy, especially with partners who have oral or genital HSV infection 1