- Email: [email protected]
Genital herpes during pregnancy: No lesions, no cesarean
Genital Herpes During No Cesarean
Pregnancy: No Lesions,
SCOTT W. ROBERTS, MD, SUSANM. COX, MD, JODY DAX, BSN, GEORGE D. WENDEL, Jr, MD, AND KENNETHJ. LEVENO, MD Objective: To determine the effects at our hospital of adoption of the 1988 guidelines recommended by ACOG for management of genital herpes infections during pregnancy. Methods: Between 1984-1986,96 pregnancies complicated by active genital herpes were delivered at Parkland Hospital. The outcome of these pregnancies were compared with 217 similar pregnancies managed after implementation of the 1988 ACOG herpes guidelines. Results: Adoption of the 1988 ACOG herpes guidelines resulted in a 37% decrease in the use of cesarean delivery for women with genital herpes infections at our hospital. Most of this decrease was because the new guidelines eliminated the need for a confirmatory negative herpes culture before permitting vaginal delivery. No neonatal herpes infections occurred as a result of implementing the ACOG recommendations. Conclusion: The rate of cesarean delivery for women with genital herpes infections during pregnancy declined significantly at our hospital as a result of the adoption of ACOG herpes guidelines, and there were no neonatal consequences, such as increased incidence of neonatal herpes simplex virus infection. (Obstet Gynecol 2995;85:261-4)
In the early and mid-1980s, obstetric practice recommendations for the prevention of intrapartum transmission of herpes virus to the newborn infant were based primarily on virologic culture confirmation that maternal genital herpes infection was absent before parturition.‘-* A liberal policy of delivery by cesarean was advocated if herpes culture results were positive or unavailable when delivery was imminent. Several investigators have reported that such practices reduced the incidence of cesareans without an increase in neonatal morbidity or mortality.3-5 Although obstetric strategies to prevent neonatal herpes have been widely accepted in the United States, this approach has not totally eliminated neonatal herpes
Texas
From
the Department of Obstetrics and Gynecology, Southwestern Medical Center, Dallas, Texas.
VOL.
85, NO.
2, FEBRUARY
1995
University
of
infections because more than 50% of infected newborns are delivered of mothers without known genital herpes infections.6-7 Moreover, some investigators have raised the possibility that cesarean delivery was being overused in the prevention of neonatal herpes, and others note that weekly cultures fail to predict future herpes simplex virus status.’ These considerations and the low risk of herpes shedding and neonatal transmission of the virus in asymptomatic women led to a revision of the recommendations for management of genital herpes In response, ACOG formulated a during pregnancy.‘-” practice guideline in November 1988 that included elimination of weekly antenatal genital cultures and recommended that cesarean delivery be performed only if genital herpes lesions were present when parturition was imminent.13 We report our experiences with the implementation of these guidelines.
Materials and Methods All pregnant women or neonates with positive herpes cultures delivered at Parkland Memorial Hospital, Dallas, Texas, between January 1, 1984 and December 31, 1991, were determined by a review of laboratory reports maintained in the virology laboratory at the University of Texas Southwestern Medical Center. Those pregnancies complicated by genital herpes were divided into two time periods corresponding to our obstetric management practices before and after implementation of the 1988 ACOG herpes guidelines. Pregnant women who had proven genital herpes infections and who were delivered between January 1984 and July 1986 were managed with weekly genital cultures commencing at 34 weeks’ gestation. Those women who presented for delivery and whose last herpes culture, obtained within the preceding week, was negative received careful cervical, vaginal, and vulvar examinations and were questioned about prodromal symptoms. A cesarean delivery was performed if negative herpes
0029-7844/95/$9.50 0029-7844(94)00346-F
261
culture results within the preceding week were unavailable, the last herpes culture was positive, or lesions or prodromal symptoms were diagnosed. The period from August 1986 through October 1988 was omitted because obstetric management practices for neonatal herpes prevention were in evaluation at our hospital. The second time period identified for study, and corresponding to the implementation of the ACOG herpes guidelines at our hospital, included November 1, 1988 to December 31, 1991. Pregnancies after 1991 were excluded because most women with gestational herpes have been enrolled in an ongoing investigation of prophylactic acyclovir therapy (Scott L, Jackson G, Sanchez P, Castaneda Y, Hall M, Wendel G. Prevention of cesarean section for recurrent genital herpes simplex virus (HSV) using acyclovir suppressive therapy [abstract 52231. In: Program and abstracts of the 40th Annual Meeting of the Society for Gynecologic Investigation; March 31-April 3, 1993; Toronto, Ontario). Women with known herpes infections were questioned about prodromal symptoms of genital infection when they presented for delivery. Careful visual inspection of the lower genital tract was performed. In the absence of lesions or prodromal symptoms, vaginal birth was permitted. Weekly cultures were not performed during the antenatal course; cultures were performed only to evaluate genital lesions. Herpes virus was identified in the virology laboratory using inoculated cell cultures and observation for cytopathic effect. Cell lines used for these cultures included HEL cells (Whittaker Bioproducts, Inc., Walkersville, MD) before mid-1986 and, subsequently, MRC5 and RK cells (Viromed Laboratories, Inc., Minnetonka, MN). We used Wilcoxon rank-sum or Student t tests for statistical analysis, and analyzed enumeration data using R X C contingency tables and Fisher exact tests.
Results Between 1984-1986,96 women with confirmed antenatal genital herpes were delivered at Parkland Hospital. The total number of women delivered during the same time period was 31,222, resulting in a prevalence of three per 1000 for diagnosed genital herpes. During the second time period (1988-19911, and corresponding to the implementation of ACOG herpes guidelines, 217 women with antenatal herpes were delivered, and the prevalence was 4.6 per 1000 (47,083 women delivered). Selected characteristics of the women delivered during the two time periods are summarized in Table 1. There were no significant differences in maternal age, parity, duration
of pregnancy,
or birth
study groups. The distribution
262
Roberts et al
Genital
Herpes
weight
between
the two
of women according to
and Cesarean
Table
1. Selected Pregnancy Characteristics of Women With Genital Herpes Managed Before and After Implementation of the 1988 ACOG Guidelines Before (1984-1986)
No. of women Age (y) (mean f SD) Parity (median) Race* UV Black White Hispanic Other Duration of pregnancy Birth weight (g) (mean
96 22 t 4 1
(wk) (median) +- SD)
35 (36%) 42 (44%) 19 (20%) 0 39 3240 + 602
After (1988-1991)
P
217 21+5 1
NS NS
131 47 37 2
(60%) (22%) (17%) (1%) 39 3090 k 636
c.01 NS NS
SD = standard deviation; NS = not significant. * 4 x 2 contingency table with Fisher exact test. Racial distribution in general obstetric population during 1984-1988; black 35%, white 27%, Hispanic 36%, other 2%). Racial distribution in general obstetric population during 1988-1991: black 34%, white 22%, Hispanic 42%, other 2%.
race was significantly different when 1984-1986 was compared to 1988 -1991. Black women were more likely than women of other races to be diagnosed with herpes during pregnancy after 1988. The patterns of herpes infection during pregnancy from 1984-1986 compared to those observed from 1988-1991 at our hospital are shown in Table 2. Similar proportions of women in both study groups had their first episode of genital infections during the index pregnancy (42 versus 44%, before and after implementation of the 1988 ACOG herpes guidelines, respectively). The proportion of women with active genital lesions at delivery was also not significantly different (25 versus 1870, for 1984-1986 and 1988-1991, respectively). Table 3 shows the route of delivery and indications for cesarean before and after the 1988 ACOG herpes guidelines were used. Before these guidelines, 57 (59%) of 96 women with genital herpes were delivered by cesarean. In contrast, the overall cesarean rate decreased to 37% (P < .Ol) when cesarean delivery for herpes infection was restricted to those women with lesions or prodromal symptoms. The different cesarean
Table
2. Patterns of Herpes Infection During Pregnancy Before and After Implementation of the 1988 ACOG Guidelines
No. of women First episode, genital herpes during pregnancy Clinical infection at delivery Data did not reach
infection
Before (1984-1988)
After (1988-1991)
96 40 (42%)
217 95 (44%)
24 (25%)
39 (18%)
level of significance.
Obstetrics
6 Gynecology
Table
3.
Route of Delivery and Parturition Before and 1988 ACOG Guidelines
Herpes After
Symptoms Implementation
Before (1984-1986)
at
After (1988-7991)
of the
P
No. of women No. of cesarean deliveries Type of cesarean delivery*
96 57 (59%)
217 81 (37%>)
<.Ol
Primary Repeat Indications
46 (48) 11 (11%)
60 (28%) 21 (10%)
1.01
22 (23%>)
37 (17%‘)
NS
26 (27%) 9 (9%) 34 (35%)
N/AI 44 (20%) N/A*
for cesarean
delivery Herpes lesions or symptoms No negative herpes culture’ Obstetric reasons Vaginal delivery with herpes
negative
culture*
N/A = not applicable; NS = not significant. * 2 X 2 contingency table with Fisher exact test. ’ Negative genital culture within 7 days of labor. * See ACOG guidelines.
rates were not attributable to repeat procedures (Table 3). Herpes-related problems were the indication for cesarean in 48 (50%) women with these infections before the ACOG guidelines and in only 37 of 217 (17%) women subsequently. Further analysis of these pregnancies suggests that active herpes infections at delivery were not significantly different between the two study groups (Table 3); the difference was attributable to abandonment of the requirements for negative culture evidence before permitting a vaginal delivery. Approximately one-fourth of women were delivered by cesarean for herpes between 1984-1986 because a negative herpes result was not available. Conversely, when weekly cultures were required, only one-third of the women met this requirement and could “safely” anticipate vaginal birth. In contrast, use of ACOG guidelines resulted in 83% of our patients being candidates for vaginal delivery because they did not have active lesions or prodromal symptoms. Between 1984-1991, three infants delivered at our hospital developed neonatal herpes infections, for a rate of three per 100,000 births. None of these infants were delivered to women diagnosed with herpes during pregnancy. Indeed, one of these three infected infants was delivered via cesarean with intact fetal membranes. From 1984-1986, two infants were delivered vaginally of mothers who had culture-proven genital herpes at delivery. One of these women had a first episode and the other a recurrent genital herpes infection, and both delivered shortly after arriving at the hospital. In addition, two infants were exposed to herpes virus during the second study period. None of these four infants suffered from neonatal herpes.
VOL.
85, NO.
2, FEBRUARY
1995
Discussion We analyzed data collected over more than 6 years; during this time, more than 79,000 women were delivered at our hospital. Herpes infection during pregnancy was diagnosed in only 313 women. Our objective was to evaluate management strategies for the prevention of neonatal herpes. We are pleased to report that the 1988 ACOG guidelines for herpes management during pregnancy not only simplifies treatment but is effective in significantly reducing the need for cesarean delivery without causing neonatal infections. The primary reason for the decreased cesarean rate was that more women (83 versus 35%, for 1984-1986 and 1988-1991, respectively) were eligible for vaginal delivery when weekly genital herpes cultures were no longer mandatory. Although fewer cesarean deliveries were performed as a result of the recent improvement in herpes management during pregnancy, our results do not prove that restricting cesareans to women with lesions or prodromal symptoms is absolutely safe for the infant.13 For example, the rate of neonatal infection is three per 100,000 births, but we analyzed only 313 pregnant women with herpes. It is possible that no infants developed herpes because of the condition’s statistical improbability, not because of our management. Thus, although we have shown that the adoption of ACOG guidelines for herpes management is not unsafe, we do not believe that we have proven its safety.
References 1. Whitley mortality
R, Arvin A, Prober in neonates with
C, et al. Predictors of morbidity herpes simplex virus infections.
and The
National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group. N Engl J Med 1991;324:450-4. 2. Committee on Fetus and Newborn, Committee on Infectious Diseases. Perinatal 1980;66:147-9.
herpes
simplex
virus
infections.
Pediatrics
3. Grossman JH 3d, Wallen WC, Sever JL. Management of genital herpes simplex virus infection during pregnancy. Obstet Gynecol 1981;58:1-4. 4. Harger JH, Pazin GJ, Armstrong JA, Breinig MC, Ho M. Characteristics and management of pregnancy in women with genital herpes simplex virus infection. Am J Obstet Gynecol1983;145:78491. 5. Vontver
LA,
Hickok
DE,
Brown
Z, Reid
L, Corey
L. Recurrent
genital herpes simplex virus infection in pregnancy: Infant outcome and frequency of asymptomatic recurrences. Am J Obstet Gynecol 1982;143:75-84. 6. Whitley RJ, Nahmias AJ, Visintine AM, Fleming CL, Alford CA. The natural history newborn. Pediatrics
of herpes simplex 1980;66:489 -94.
virus
infection
of mother
and
7. Yeager AS, Arvin AM. Reasons for the absence of a history of recurrent genital infections in mothers of neonates with herpes simplex virus. Pediatrics 1984;73:188-93. 8. Binkin NJ, Kaplan JP, Cates W. Preventing neonatal herpes. The
Roberts
et al
Genital
Herpes
and
Cesarean
263
value of weekly viral cultures in pregnant women with recurrent genital herpes. JAMA 1984;251:2816-21. 9. Arvin AM, Hensleigh PA, Prober CG, et al. Failure of antepartum maternal cultures to predict the infant’s risk of exposure to herpes simplex virus at delivery. N Engl J Med 1986;315:796-800. 10. Prober CG, Hensleigh PA, Boucher FD, Yasukawa LL, Au DS, Arvin AM. Use of routine viral cultures at delivery to identify neonates exposed to herpes simplex virus. N Engl J Med 1988;318: 887-91. 11. Gibbs RS, Amstey MS, Sweet RL, Mead PB, Sever JL. Management of genital herpes infection in pregnancy. Obstet Gynecol 1988;71:
779-80. 12. Hankins
GDV, Cunningham FG, Luby II’, Butler SL, Stroud J, Roark M. Asymptomatic genital excretion of herpes simplex virus during early labor. Am J Obstet Gynecol 1984;150:100-1. 13. American College of Obstetricians and Gynecologists. Perinatal herpes simplex virus infections. ACOG technical bulletin no. 122, Washington, DC American College of Obstetricians and Gynecologists.
Address reprint requests to: Scoff W. Roberts, MD University of Kansas School of Medicine-Wichita Department of Obstetrics and Gynecology Division of Maternal-Fetal Medicine 3243 East Murdock, Suite 201 Wichita, KA 67208
Received May 10, 1994. Received in revised form August 29, 1994. Accepted September 21,1994.
Copyright 0 1995 by The Gynecologists.
American
College
of Obstetricians
and
FOURTH ANNUAL COMPREHENSIVE WORKSHOP FOR RESIDENTS,FELLOWS, AND O.R. PERSONNEL March H-22,1995 The American Association of Gynecologic Laparoscopists is sponsoring a workshop, to be held at The Doubletree at Lincoln Centre in Dallas, Texas. This course has been approved for 11 cognate hours (Formal Learning) by The American College of Obstetricians and Gynecologists. For further information, contact the Registration Desk, The American Association of Gynecologic Laparoscopists, 13021 East Florence Avenue, Sante Fe Springs, CA 90670-4505; 0300) 554-2245.
264 Roberts
et al
Genital Herpes and Cesarean
Obstetrics b Gynecology
Pregnancy: No Lesions,
SCOTT W. ROBERTS, MD, SUSANM. COX, MD, JODY DAX, BSN, GEORGE D. WENDEL, Jr, MD, AND KENNETHJ. LEVENO, MD Objective: To determine the effects at our hospital of adoption of the 1988 guidelines recommended by ACOG for management of genital herpes infections during pregnancy. Methods: Between 1984-1986,96 pregnancies complicated by active genital herpes were delivered at Parkland Hospital. The outcome of these pregnancies were compared with 217 similar pregnancies managed after implementation of the 1988 ACOG herpes guidelines. Results: Adoption of the 1988 ACOG herpes guidelines resulted in a 37% decrease in the use of cesarean delivery for women with genital herpes infections at our hospital. Most of this decrease was because the new guidelines eliminated the need for a confirmatory negative herpes culture before permitting vaginal delivery. No neonatal herpes infections occurred as a result of implementing the ACOG recommendations. Conclusion: The rate of cesarean delivery for women with genital herpes infections during pregnancy declined significantly at our hospital as a result of the adoption of ACOG herpes guidelines, and there were no neonatal consequences, such as increased incidence of neonatal herpes simplex virus infection. (Obstet Gynecol 2995;85:261-4)
In the early and mid-1980s, obstetric practice recommendations for the prevention of intrapartum transmission of herpes virus to the newborn infant were based primarily on virologic culture confirmation that maternal genital herpes infection was absent before parturition.‘-* A liberal policy of delivery by cesarean was advocated if herpes culture results were positive or unavailable when delivery was imminent. Several investigators have reported that such practices reduced the incidence of cesareans without an increase in neonatal morbidity or mortality.3-5 Although obstetric strategies to prevent neonatal herpes have been widely accepted in the United States, this approach has not totally eliminated neonatal herpes
Texas
From
the Department of Obstetrics and Gynecology, Southwestern Medical Center, Dallas, Texas.
VOL.
85, NO.
2, FEBRUARY
1995
University
of
infections because more than 50% of infected newborns are delivered of mothers without known genital herpes infections.6-7 Moreover, some investigators have raised the possibility that cesarean delivery was being overused in the prevention of neonatal herpes, and others note that weekly cultures fail to predict future herpes simplex virus status.’ These considerations and the low risk of herpes shedding and neonatal transmission of the virus in asymptomatic women led to a revision of the recommendations for management of genital herpes In response, ACOG formulated a during pregnancy.‘-” practice guideline in November 1988 that included elimination of weekly antenatal genital cultures and recommended that cesarean delivery be performed only if genital herpes lesions were present when parturition was imminent.13 We report our experiences with the implementation of these guidelines.
Materials and Methods All pregnant women or neonates with positive herpes cultures delivered at Parkland Memorial Hospital, Dallas, Texas, between January 1, 1984 and December 31, 1991, were determined by a review of laboratory reports maintained in the virology laboratory at the University of Texas Southwestern Medical Center. Those pregnancies complicated by genital herpes were divided into two time periods corresponding to our obstetric management practices before and after implementation of the 1988 ACOG herpes guidelines. Pregnant women who had proven genital herpes infections and who were delivered between January 1984 and July 1986 were managed with weekly genital cultures commencing at 34 weeks’ gestation. Those women who presented for delivery and whose last herpes culture, obtained within the preceding week, was negative received careful cervical, vaginal, and vulvar examinations and were questioned about prodromal symptoms. A cesarean delivery was performed if negative herpes
0029-7844/95/$9.50 0029-7844(94)00346-F
261
culture results within the preceding week were unavailable, the last herpes culture was positive, or lesions or prodromal symptoms were diagnosed. The period from August 1986 through October 1988 was omitted because obstetric management practices for neonatal herpes prevention were in evaluation at our hospital. The second time period identified for study, and corresponding to the implementation of the ACOG herpes guidelines at our hospital, included November 1, 1988 to December 31, 1991. Pregnancies after 1991 were excluded because most women with gestational herpes have been enrolled in an ongoing investigation of prophylactic acyclovir therapy (Scott L, Jackson G, Sanchez P, Castaneda Y, Hall M, Wendel G. Prevention of cesarean section for recurrent genital herpes simplex virus (HSV) using acyclovir suppressive therapy [abstract 52231. In: Program and abstracts of the 40th Annual Meeting of the Society for Gynecologic Investigation; March 31-April 3, 1993; Toronto, Ontario). Women with known herpes infections were questioned about prodromal symptoms of genital infection when they presented for delivery. Careful visual inspection of the lower genital tract was performed. In the absence of lesions or prodromal symptoms, vaginal birth was permitted. Weekly cultures were not performed during the antenatal course; cultures were performed only to evaluate genital lesions. Herpes virus was identified in the virology laboratory using inoculated cell cultures and observation for cytopathic effect. Cell lines used for these cultures included HEL cells (Whittaker Bioproducts, Inc., Walkersville, MD) before mid-1986 and, subsequently, MRC5 and RK cells (Viromed Laboratories, Inc., Minnetonka, MN). We used Wilcoxon rank-sum or Student t tests for statistical analysis, and analyzed enumeration data using R X C contingency tables and Fisher exact tests.
Results Between 1984-1986,96 women with confirmed antenatal genital herpes were delivered at Parkland Hospital. The total number of women delivered during the same time period was 31,222, resulting in a prevalence of three per 1000 for diagnosed genital herpes. During the second time period (1988-19911, and corresponding to the implementation of ACOG herpes guidelines, 217 women with antenatal herpes were delivered, and the prevalence was 4.6 per 1000 (47,083 women delivered). Selected characteristics of the women delivered during the two time periods are summarized in Table 1. There were no significant differences in maternal age, parity, duration
of pregnancy,
or birth
study groups. The distribution
262
Roberts et al
Genital
Herpes
weight
between
the two
of women according to
and Cesarean
Table
1. Selected Pregnancy Characteristics of Women With Genital Herpes Managed Before and After Implementation of the 1988 ACOG Guidelines Before (1984-1986)
No. of women Age (y) (mean f SD) Parity (median) Race* UV Black White Hispanic Other Duration of pregnancy Birth weight (g) (mean
96 22 t 4 1
(wk) (median) +- SD)
35 (36%) 42 (44%) 19 (20%) 0 39 3240 + 602
After (1988-1991)
P
217 21+5 1
NS NS
131 47 37 2
(60%) (22%) (17%) (1%) 39 3090 k 636
c.01 NS NS
SD = standard deviation; NS = not significant. * 4 x 2 contingency table with Fisher exact test. Racial distribution in general obstetric population during 1984-1988; black 35%, white 27%, Hispanic 36%, other 2%). Racial distribution in general obstetric population during 1988-1991: black 34%, white 22%, Hispanic 42%, other 2%.
race was significantly different when 1984-1986 was compared to 1988 -1991. Black women were more likely than women of other races to be diagnosed with herpes during pregnancy after 1988. The patterns of herpes infection during pregnancy from 1984-1986 compared to those observed from 1988-1991 at our hospital are shown in Table 2. Similar proportions of women in both study groups had their first episode of genital infections during the index pregnancy (42 versus 44%, before and after implementation of the 1988 ACOG herpes guidelines, respectively). The proportion of women with active genital lesions at delivery was also not significantly different (25 versus 1870, for 1984-1986 and 1988-1991, respectively). Table 3 shows the route of delivery and indications for cesarean before and after the 1988 ACOG herpes guidelines were used. Before these guidelines, 57 (59%) of 96 women with genital herpes were delivered by cesarean. In contrast, the overall cesarean rate decreased to 37% (P < .Ol) when cesarean delivery for herpes infection was restricted to those women with lesions or prodromal symptoms. The different cesarean
Table
2. Patterns of Herpes Infection During Pregnancy Before and After Implementation of the 1988 ACOG Guidelines
No. of women First episode, genital herpes during pregnancy Clinical infection at delivery Data did not reach
infection
Before (1984-1988)
After (1988-1991)
96 40 (42%)
217 95 (44%)
24 (25%)
39 (18%)
level of significance.
Obstetrics
6 Gynecology
Table
3.
Route of Delivery and Parturition Before and 1988 ACOG Guidelines
Herpes After
Symptoms Implementation
Before (1984-1986)
at
After (1988-7991)
of the
P
No. of women No. of cesarean deliveries Type of cesarean delivery*
96 57 (59%)
217 81 (37%>)
<.Ol
Primary Repeat Indications
46 (48) 11 (11%)
60 (28%) 21 (10%)
1.01
22 (23%>)
37 (17%‘)
NS
26 (27%) 9 (9%) 34 (35%)
N/AI 44 (20%) N/A*
for cesarean
delivery Herpes lesions or symptoms No negative herpes culture’ Obstetric reasons Vaginal delivery with herpes
negative
culture*
N/A = not applicable; NS = not significant. * 2 X 2 contingency table with Fisher exact test. ’ Negative genital culture within 7 days of labor. * See ACOG guidelines.
rates were not attributable to repeat procedures (Table 3). Herpes-related problems were the indication for cesarean in 48 (50%) women with these infections before the ACOG guidelines and in only 37 of 217 (17%) women subsequently. Further analysis of these pregnancies suggests that active herpes infections at delivery were not significantly different between the two study groups (Table 3); the difference was attributable to abandonment of the requirements for negative culture evidence before permitting a vaginal delivery. Approximately one-fourth of women were delivered by cesarean for herpes between 1984-1986 because a negative herpes result was not available. Conversely, when weekly cultures were required, only one-third of the women met this requirement and could “safely” anticipate vaginal birth. In contrast, use of ACOG guidelines resulted in 83% of our patients being candidates for vaginal delivery because they did not have active lesions or prodromal symptoms. Between 1984-1991, three infants delivered at our hospital developed neonatal herpes infections, for a rate of three per 100,000 births. None of these infants were delivered to women diagnosed with herpes during pregnancy. Indeed, one of these three infected infants was delivered via cesarean with intact fetal membranes. From 1984-1986, two infants were delivered vaginally of mothers who had culture-proven genital herpes at delivery. One of these women had a first episode and the other a recurrent genital herpes infection, and both delivered shortly after arriving at the hospital. In addition, two infants were exposed to herpes virus during the second study period. None of these four infants suffered from neonatal herpes.
VOL.
85, NO.
2, FEBRUARY
1995
Discussion We analyzed data collected over more than 6 years; during this time, more than 79,000 women were delivered at our hospital. Herpes infection during pregnancy was diagnosed in only 313 women. Our objective was to evaluate management strategies for the prevention of neonatal herpes. We are pleased to report that the 1988 ACOG guidelines for herpes management during pregnancy not only simplifies treatment but is effective in significantly reducing the need for cesarean delivery without causing neonatal infections. The primary reason for the decreased cesarean rate was that more women (83 versus 35%, for 1984-1986 and 1988-1991, respectively) were eligible for vaginal delivery when weekly genital herpes cultures were no longer mandatory. Although fewer cesarean deliveries were performed as a result of the recent improvement in herpes management during pregnancy, our results do not prove that restricting cesareans to women with lesions or prodromal symptoms is absolutely safe for the infant.13 For example, the rate of neonatal infection is three per 100,000 births, but we analyzed only 313 pregnant women with herpes. It is possible that no infants developed herpes because of the condition’s statistical improbability, not because of our management. Thus, although we have shown that the adoption of ACOG guidelines for herpes management is not unsafe, we do not believe that we have proven its safety.
References 1. Whitley mortality
R, Arvin A, Prober in neonates with
C, et al. Predictors of morbidity herpes simplex virus infections.
and The
National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group. N Engl J Med 1991;324:450-4. 2. Committee on Fetus and Newborn, Committee on Infectious Diseases. Perinatal 1980;66:147-9.
herpes
simplex
virus
infections.
Pediatrics
3. Grossman JH 3d, Wallen WC, Sever JL. Management of genital herpes simplex virus infection during pregnancy. Obstet Gynecol 1981;58:1-4. 4. Harger JH, Pazin GJ, Armstrong JA, Breinig MC, Ho M. Characteristics and management of pregnancy in women with genital herpes simplex virus infection. Am J Obstet Gynecol1983;145:78491. 5. Vontver
LA,
Hickok
DE,
Brown
Z, Reid
L, Corey
L. Recurrent
genital herpes simplex virus infection in pregnancy: Infant outcome and frequency of asymptomatic recurrences. Am J Obstet Gynecol 1982;143:75-84. 6. Whitley RJ, Nahmias AJ, Visintine AM, Fleming CL, Alford CA. The natural history newborn. Pediatrics
of herpes simplex 1980;66:489 -94.
virus
infection
of mother
and
7. Yeager AS, Arvin AM. Reasons for the absence of a history of recurrent genital infections in mothers of neonates with herpes simplex virus. Pediatrics 1984;73:188-93. 8. Binkin NJ, Kaplan JP, Cates W. Preventing neonatal herpes. The
Roberts
et al
Genital
Herpes
and
Cesarean
263
value of weekly viral cultures in pregnant women with recurrent genital herpes. JAMA 1984;251:2816-21. 9. Arvin AM, Hensleigh PA, Prober CG, et al. Failure of antepartum maternal cultures to predict the infant’s risk of exposure to herpes simplex virus at delivery. N Engl J Med 1986;315:796-800. 10. Prober CG, Hensleigh PA, Boucher FD, Yasukawa LL, Au DS, Arvin AM. Use of routine viral cultures at delivery to identify neonates exposed to herpes simplex virus. N Engl J Med 1988;318: 887-91. 11. Gibbs RS, Amstey MS, Sweet RL, Mead PB, Sever JL. Management of genital herpes infection in pregnancy. Obstet Gynecol 1988;71:
779-80. 12. Hankins
GDV, Cunningham FG, Luby II’, Butler SL, Stroud J, Roark M. Asymptomatic genital excretion of herpes simplex virus during early labor. Am J Obstet Gynecol 1984;150:100-1. 13. American College of Obstetricians and Gynecologists. Perinatal herpes simplex virus infections. ACOG technical bulletin no. 122, Washington, DC American College of Obstetricians and Gynecologists.
Address reprint requests to: Scoff W. Roberts, MD University of Kansas School of Medicine-Wichita Department of Obstetrics and Gynecology Division of Maternal-Fetal Medicine 3243 East Murdock, Suite 201 Wichita, KA 67208
Received May 10, 1994. Received in revised form August 29, 1994. Accepted September 21,1994.
Copyright 0 1995 by The Gynecologists.
American
College
of Obstetricians
and
FOURTH ANNUAL COMPREHENSIVE WORKSHOP FOR RESIDENTS,FELLOWS, AND O.R. PERSONNEL March H-22,1995 The American Association of Gynecologic Laparoscopists is sponsoring a workshop, to be held at The Doubletree at Lincoln Centre in Dallas, Texas. This course has been approved for 11 cognate hours (Formal Learning) by The American College of Obstetricians and Gynecologists. For further information, contact the Registration Desk, The American Association of Gynecologic Laparoscopists, 13021 East Florence Avenue, Sante Fe Springs, CA 90670-4505; 0300) 554-2245.
264 Roberts
et al
Genital Herpes and Cesarean
Obstetrics b Gynecology