What is the recommended treatment for a pregnant individual with oral herpes?

Treatment of Oral Herpes in Pregnancy

For pregnant women with oral herpes, treat acute episodes with valacyclovir 1 g orally twice daily for 7-10 days or acyclovir 400 mg orally three times daily for 7-10 days, both of which have established safety profiles with no increased risk of birth defects. 1, 2

Acute Episode Management

First-line treatment options include:

• Valacyclovir 1 g orally twice daily for 7-10 days (preferred for convenience and compliance) 1
• Acyclovir 400 mg orally three times daily for 7-10 days (equivalent efficacy and safety) 1, 2
• For severe cases, consider acyclovir 400 mg orally five times daily, though optimal dosing for oral herpes remains unclear 1

The CDC registry findings provide high-quality evidence showing no increased risk of major birth defects after acyclovir or valacyclovir treatment compared to the general population. 1, 3 Clinical data spanning several decades with both medications in pregnant women have not identified any drug-associated risk of major birth defects. 3

Safety Profile Throughout Pregnancy

Both acyclovir and valacyclovir are considered safe throughout all trimesters of pregnancy. 1 The Acyclovir Pregnancy Registry documented 1,246 exposures with a major birth defect rate of 3.2% (95% CI: 2.0-5.0%) for first-trimester exposure, which does not exceed the general population baseline of 2-4%. 3 The Valacyclovir Pregnancy Registry showed similar reassuring data with 4.5% (95% CI: 0.24-24.9%) for first-trimester exposure. 3

Suppressive Therapy for Recurrent Oral Herpes

For pregnant women with frequent, severe recurrences of oral herpes that significantly impact quality of life:

• Consider suppressive prophylaxis starting at 36 weeks gestation 1
• Valacyclovir 1000 mg orally twice daily, OR 1
• Acyclovir 400 mg orally three times daily 1

This recommendation should be reserved for women with particularly frequent or severe recurrences, as the strength of evidence for suppressive therapy in oral herpes is lower than for genital herpes. 1

Special Populations

Immunocompromised pregnant women (including those with HIV):

• May require higher doses of acyclovir (400 mg orally three to five times daily) 1, 2
• Require close monitoring for treatment response 1
• If lesions persist during standard acyclovir treatment, suspect acyclovir resistance and consider alternative therapy 1, 2

For life-threatening maternal HSV infections (disseminated infection, encephalitis, pneumonitis, or hepatitis), intravenous acyclovir 5-10 mg/kg every 8 hours is definitively indicated, as benefits clearly outweigh any theoretical risks. 4, 2

Critical Counseling Points

Patients should be informed about:

• The chronic nature of HSV infection with potential for recurrent episodes 1
• The importance of avoiding oral-genital contact during active oral herpes outbreaks to prevent transmission to partners 1
• The risk of transmission to the neonate from oral herpes is primarily through postnatal contact rather than during delivery 1

Common pitfall to avoid: Unlike genital herpes at delivery, oral herpes does not necessitate cesarean delivery. The primary concern is postnatal transmission through direct contact with active oral lesions, so mothers with active oral herpes should practice strict hand hygiene and avoid kissing the newborn until lesions have healed. 1