HSV Serotesting in pregnancy.
Genital herpes is primarily transmitted to other adults or newborns from people who are unaware of their infection. Approximately 90% of individuals who have antibodies to herpes simplex virus (HSV)-2 are unaware of their infection and are experiencing recurrent genital symptoms that are often attributed to other problems such as a genital yeast infections, recurrent urinary tract infections, or semen or condom allergies.
Unrecognized genital ulceration with subclinical viral shedding may occur during as many as 20% of days in women who are HSV-2 seropositive but unaware of their infection.
As a predominantly subclinical genital ulcerative disease, genital herpes is a major risk factor for the acquisition of HIV infection. It is likely that control of the HIV epidemic will not be possible without first controlling the HSV epidemic. Not only does herpes cause unrecognized recurrent ulcers on the mucosal surfaces of the female genitalia that serve as portals of entry for HIV, but it draws to the environment of the ulcers those cells that are the primary target for HIV.
Neonatal herpes is the most devastating complication of genital herpes. Despite strategies designed to prevent perinatal transmission, the number of cases of neonatal HSV infection continues to rise, mirroring the rising prevalence of infection in women of childbearing age. About one-half to two-thirds of cases of neonatal herpes are a consequence of a mother acquiring a new infection in the third trimester of pregnancy and shedding virus in her genital secretions at the time of labor. Approximately two-thirds to three-quarters of new infections during pregnancy go unrecognized by either the patient or her provider, because she is either asymptomatic at the time of the infection or her symptoms are attributed to another organism such as yeast.
Pregnant women who are shown by serologic testing to be susceptible for acquiring genital herpes--those who are HSV seronegative or HSV-1 seropositive--should be cautioned about having unprotected intercourse in the third trimester of pregnancy. This is the simplest and most cost effective algorithm because it does not directly involve the male partner.
If abstinence or the use of a condom for the duration of pregnancy is impossible or unacceptable to a susceptible woman, then her partner can be tested. If her partner is amenable to be serotested and is shown to be concordant with the woman, no further intervention is required. If the woman and her partner are shown to be discordant, he should be placed on suppressive antiviral therapy for the duration of her pregnancy, and they should be counseled to observe safe sexual practices in the third trimester.
If a patient is found to be HSV-2 seropositive when tested during pregnancy, she should be placed on suppressive antiviral chemotherapy from 36 weeks to the time of labor. In addition, her provider should artificially rupture the membranes and use fetal scalp electrodes only for rigorous obstetrical indications. Following pregnancy, the HSV-2 seropositive patient could be maintained on a suppressive antiviral to reduce the risk of HSV transmission to sexual partners and reduce her risk of acquiring HIV injection.
The two main concerns that have been raised over instituting universal HSV serologic testing in pregnant women are the cost to the health care system and family disruption.
With respect to cost, type-specific HSV serologic screening of pregnant women was recently shown via an extensive decision-analysis model to be a cost effective intervention for preventing neonatal herpes.
As for familial impact, although universal HSV serologic screening of pregnant women represents a potential risk for marital disruption, the health benefits of such screening far outweigh the risks. At the University of Washington, we have screened more than 30,000 couples since the early 1980s, and there have been few if any marital disruptions as a consequence of the screening.
DR. ZANE A. BROWN is professor of perinatal medicine in the department of obstetrics and gynecology, University of Washington, Seattle.
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|Title Annotation:||Guest Editorial|
|Author:||Brown, Zane A.|
|Publication:||OB GYN News|
|Date:||Jan 15, 2004|
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