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Herpes simplex virus (HSV) prodromal symptoms: Prior to the outbreak of the classic vesicles, the patient may complain of burning, itching, or tingling.

Neonatal herpes infection: HSV can cause disseminated infection with major organ involvement; be confined to encephalitis, eyes, skin or mucosa; or be asymptomatic.

Clinical Approach

Herpes cultures are not useful in the acute management of pregnant women who present in labor or with rupture of membranes. They are helpful in making the diagnosis during the prenatal course, when the patient may develop lesions and the diagnosis is in question. Once a woman has been diagnosed with HSV, the practitioner uses his or her best clinical judgment to assess for the presence of HSV in the genital tract during the time of labor. A meticulous inspection of the external genitalia, vagina, cervix (by speculum examination), and perianal area should be undertaken for the typical herpetic lesions, such as vesicles or ulcers (Figure 23-1). Additionally, the patient

Figure 23-1. First episode of primary genital herpes simplex virus infection.

(Reproduced with permission from Wendel GD, Cunningham FG. Sexually transmitted diseases in pregnancy. In: Williams obstetrics, 18th ed. (Suppi. 13). Norwalk, CT: Appleton & Lange, August/September 1991.)

Figure 23-1. First episode of primary genital herpes simplex virus infection.

(Reproduced with permission from Wendel GD, Cunningham FG. Sexually transmitted diseases in pregnancy. In: Williams obstetrics, 18th ed. (Suppi. 13). Norwalk, CT: Appleton & Lange, August/September 1991.)

should be queried thoroughly about the presence of prodromal symptoms. When there are no lesions or prodromal symptoms, the patient should be counseled that she is at low risk for viral shedding and has an unknown risk of neonatal herpes infection. Almost always, the patient will opt for vaginal delivery under these circumstances. In contrast, the presence of prodromal symptoms or genital lesions suspicious for HSV is sufficient to warrant a cesarean delivery to prevent neonatal infection.

Acyclovir has activity against both HSV-1 and HSV-2. In a primary herpes outbreak, oral acyclovir reduces viral shedding, pain symptoms, and is associated with faster healing of the lesions. Newer medications, such as valacy-clovir and famciclovir, require less frequent dosing because of their increased bioavailability. Suppressive acyclovir therapy usually is reserved for frequent outbreaks. Some practitioners advocate the use of oral suppressive acyclovir when the woman has her first episode of HSV infection during pregnancy. This therapy may decrease the symptoms during the time of labor and decrease the need for cesarean delivery.

Comprehension Questions

[23.11 Which of the following is an indication for cesarean section due to maternal herpes simplex virus?

A. Vesicular lesions noted on the cervix

B. History of lesions noted on the vagina I month previously, now not visible

C. Lesions noted on the posterior thigh

D. Tingling of the chest wall with lesions consistent with herpes zoster

[23.2] In pregnant women with rupture of membranes, cesarean section is abandoned when the duration since rupture of membranes exceeds which of the following?

E. No limit

[23.3] A 30-year-old woman arrives completely dilated to the hospital and delivers a term neonate vaginally. Shortly after the delivery, the woman is discovered to have several blisters of the vulva that are suspicious for herpes simplex virus. She states that she has a history of herpes. Which of the following is the best management of the baby?

A. Acyclovir to the neonate

B. Blood culture of the neonate for herpes simplex virus

C. Herpes culture of the lesions and isolation of the baby until the culture result returns

D. Vaccination of the neonate with herpes vaccine

[23.4] Which of the following is the most common cause of an infectious vulvar ulcer disease in the United States?

A. Syphilis

B. Herpes simplex virus

C. Chancroid

D. Lymphogranuloma venereum

E. Bartholin gland abscess

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