Should a woman with a history of herpes simplex virus (HSV) infection, currently taking acyclovir (acyclovir), and without visible vaginal lesions, undergo cesarean section (C-section) or vaginal delivery at 39 weeks of gestation?

From the Guidelines

Vaginal delivery is the recommended mode of delivery for a woman at 39 weeks with a history of herpes who has no visible lesions and has been taking acyclovir. According to the 2022 study published in Clinical Infectious Diseases 1, suppressive therapy with acyclovir has been shown to decrease the risk of viral shedding, recurrences, and cesarean deliveries. The study suggests that women with a history of genital herpes who receive suppressive therapy during pregnancy have a lower risk of transmitting the virus to their infant.

Key considerations for this recommendation include:

• The woman has been taking acyclovir, which has been shown to reduce the risk of viral shedding and recurrences 1
• There are no visible vaginal lesions, which reduces the risk of neonatal herpes transmission
• The American College of Obstetrics and Gynecology recommends against routine screening for HSV serostatus during pregnancy, but suggests screening pregnant women for a history of genital herpes 1

It is essential to note that a thorough examination of the genital area should be performed at the onset of labor to confirm the absence of lesions. If lesions appear during labor or if prodromal symptoms develop, then a cesarean section would become indicated to prevent neonatal herpes infection, which can cause serious complications including encephalitis, disseminated disease, and death in newborns. The standard suppressive regimen typically involves acyclovir 400 mg three times daily, valacyclovir 500 mg twice daily, or famciclovir 250 mg twice daily starting at 36 weeks gestation until delivery, as mentioned in the study 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Delivery Options for Women with Herpes

• The American College of Obstetricians and Gynecologists (ACOG) recommends that women with a history of herpes should be offered suppressive antiviral therapy at 36 weeks of gestation to reduce the risk of recurrent genital herpes at delivery 2, 3, 4, 5, 6.
• Studies have shown that suppressive antiviral therapy, such as acyclovir, can reduce the risk of clinical recurrences at delivery, cesarean deliveries for recurrent genital herpes, and the risk of HSV viral shedding at delivery 2, 3, 4, 5, 6.
• A systematic review of five trials with a total enrollment of 799 patients found that acyclovir prophylaxis beginning at 36 weeks' gestation was effective in reducing clinical HSV recurrences at the time of delivery, cesarean deliveries for clinical recurrence genital herpes, total HSV detection at delivery, and asymptomatic HSV shedding at delivery 6.
• In the case of a woman with a history of herpes who is taking acyclovir and has no visible vaginal lesions at 39 weeks of gestation, the risk of transmitting the virus to the baby is low, and a vaginal delivery may be considered 2, 3, 4, 5, 6.
• However, the decision to perform a cesarean delivery should be made on a case-by-case basis, taking into account the individual woman's medical history, the presence of any symptoms or lesions, and the risk of transmission to the baby 2, 3, 4, 5, 6.

Key Findings

• Acyclovir suppression reduces the risk of clinical recurrences at delivery 2, 3, 4, 5, 6.
• Acyclovir suppression reduces the risk of cesarean deliveries for recurrent genital herpes 2, 3, 4, 5, 6.
• Acyclovir suppression reduces the risk of HSV viral shedding at delivery 2, 3, 4, 5, 6.
• The risk of transmitting the virus to the baby is low if the woman is taking acyclovir and has no visible vaginal lesions at delivery 2, 3, 4, 5, 6.