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A positive diagnosis with HSV-2 in an expectant mother can be a major source of concern. With neonatal herpes being potentially fatal, how likely is it that they will contract it in the womb and how can we best prevent it?

A lot of people may suffer some embarrassment when suffering from a sexually transmitted disease. Genital herpes during pregnancy makes the situation a little more complicated; you will suffer from the painful red sores, the discomfort from urination and the knowledge that there is no real cure for the disease, meaning that a recurrence may arise when your body is at its weakest. 

An overview on genital herpes

Genital herpes is caused by two types of Herpes Simplex Virus (HSV), type 1 (HSV-1) and type 2 (HSV-2). HSV-2 causes genital sores and is the most common cause of what we call genital herpes. The time between transmission of the virus to a new host and the onset of symptoms is between 2 to 14 days in adults. However, most infections with HSV-2 occur with some mild tingling or itching in the genital area or without the presentation of any symptoms at all, resulting in many being unaware that they have contracted the illness. The disease lives on indefinitely in the body in the nerves near the spinal cord, regardless of whether a person received any treatment for it. As a result, once contracted, genital herpes is always waiting to strike when you are at your most vulnerable, such as during illness or stress. [1]

The odds of transmission of genital herpes in pregnancy

The risk of passing an HSV-2 infection to an unborn child is dependent on a few factors:

  • stage of the pregnancy the infection takes place  
  • whether it is the mother’s first encounter with the disease
  • whether it is a recurrent infection 

If the first time the mother is infected is prior to pregnancy, she has a 75% chance of at least one recurrence of the disease, and 14% will experience minor symptoms and sores at the time of delivery. [2] The rates of transmission of the herpes virus to the child vary, but the risk is much lower (1.3%) if you have already suffered from the disease.

If the first infection is during pregnancy in the first trimester, the risk of transmission of the infection to the child is relatively low (less than 1%). These infections, while quite rare, carry very serious consequences for the child as they can result in poor development of the brain, premature birth, restriction of growth and even miscarriage. These cases account for only 5% of the situations where HSV is transmitted to the child. [3]

If the primary infection arises in the third trimester, where 30% to 50% of newborns are infected; however the majority (85%) of these infections arise during the birthing process. This is because the mother has not had the time required to produce antibodies that neutralize the viral particles, preventing the spread of the disease. These antibodies are passed on to the child which helps prevent them from becoming infected by HSV-2. Being infected in the third trimester is too short a period to produce the antibodies, which can take up to 8 weeks. The child's immune system is vulnerable as a result to assault by the herpes virus particles. [4]

How can we reduce the odds of transmission?

The use of antiviral medications, such as acyclovir or valacyclovir, can be used to decrease the transmission risk in late pregnancy primary infections with genital herpes, as these drugs work by suppressing the replicative processes of the virus, preventing the development of outbreaks and shortening the duration of any symptoms present. [5] These medications are safe for use in all stages of pregnancy and are used for the treatment of HSV-2 infection in the newborn if deemed necessary. 

How can we detect genital herpes?

As we have many presentations of the infection that are completely asymptomatic, studies show an increase in the number of people testing positive for HSV, especially among women, [6] meaning that an increase in neonatal herpes is inevitable unless steps are taken to try and identify at-risk mother and provide them with the appropriate therapy. This can be accomplished by swabbing areas where symptoms appear, such as the birth canal and any potential herpetic lesions that are present and send the samples to a laboratory to test for the presence of viral DNA. [7] This is trickier in asymptomatic patients as they might not have enough viral particles being produced to be able to be detected by this method, which leads us to a more precise means of detecting HSV. By collecting a blood sample from a patient, we can perform a test to detect the presence of specific markers to herpes virus, which would indicate a prior infection. [8

How do we treat it?

As mentioned earlier, we can employ the use of acyclovir and its derivatives to treat genital herpes during pregnancy by suppressing flare ups (recurrences) if present till delivery of the child. Otherwise, antiviral therapy in the absence of outbreaks is not recommended as there is little evidence to suggest that it has a significant impact on the risk of transmission. [9] The mother should be educated on the symptoms to pay attention to in the lead up to a recurrence so that she may receive the appropriate treatment in a timely manner.

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