From the Guidelines
A cesarean section is not indicated for a pregnant patient with a history of herpes who is experiencing burning sensations but has no active lesions and is already on prophylactic acyclovir. According to the 1998 guidelines for treatment of sexually transmitted diseases by the Centers for Disease Control and Prevention 1, prophylactic cesarean section is not indicated for women who do not have active genital lesions at the time of delivery. Key points to consider in this scenario include:
- The patient's history of herpes and current prophylactic treatment with acyclovir, which reduces the risk of viral shedding and outbreaks near delivery
- The absence of active genital lesions, which is the primary indication for cesarean delivery in herpes cases to prevent neonatal herpes transmission
- The burning sensation without visible lesions, likely representing prodromal symptoms, but with antiviral suppression, the risk of viral shedding is minimized
- The importance of continuing antiviral medication through delivery and performing a thorough genital examination at the onset of labor to confirm the absence of lesions. If lesions appear during labor despite prophylaxis, then a cesarean section would become indicated to prevent neonatal herpes infection, which can cause severe neurological damage or death in newborns.
From the Research
Indications for Cesarean Section
- A cesarean section is generally recommended in cases of primary genital herpes infection in the third trimester 2.
- For women with recurrent herpes, vaginal delivery is often permitted as the risk of neonatal infection is low 2.
- However, the decision to perform a cesarean section should be based on individual patient circumstances, including the presence of symptoms or lesions at the time of delivery.
Management of Recurrent Genital Herpes
- Antiviral therapy, such as valacyclovir or acyclovir, is commonly used to suppress recurrent genital herpes in pregnancy 3, 4, 5, 6.
- Suppressive therapy has been shown to reduce the incidence of recurrent genital herpes and the need for cesarean delivery 3, 5, 6.
- In the absence of active lesions, the risk of neonatal herpes is low, and vaginal delivery may be considered 2.
Specific Considerations
- The patient in question is being treated with valacyclovir prophylactically and has no active lesions, but is experiencing burning sensations.
- Based on the available evidence, a cesarean section may not be indicated in this case, as the risk of neonatal infection is low and the patient is receiving suppressive therapy 3, 2.