Primarily by Linda Wallen, MD Edited May, 2005 Herpes Simplex Virus Primarily by Linda Wallen, MD Edited May, 2005

Epidemiology of Herpes Simplex 5 % patients have a history of HSV > 20% have serologic evidence of HSV Primary infection = Patient has NO antibodies to HSV Nonprimary= prior exposure to either HSV-1 or HSV-2 Recurrent infection = + antibodies to reactivating virus type Shedding at delivery not predicted from past cultures > 2/3 of babies with HSV infection are born to mothers with NO previous history of HSV Risk neonatal infection with recurrence= 2-5% Risk neonatal infection with primary inf.= 35%

Pathway of Infection for Neonatal HSV < 5% with intrauterine acquired infection Primary infection may be associated with a higher risk of spontaneous abortion, preterm delivery, and neonatal infection Higher viral load, longer excretion (14-21 days) No transplacental antibody 85% cases are acquired at the time of delivery Risk increased with PROM (> 6 hour), application of fetal scalp electrodes and other invasive tests 10% acquired postnatally

Presentation of Neonatal HSV Infection > 90% present between 5-19 days of age > 20% NEVER have skin lesions Initial symptoms vague in 30% Lethargy Poor feeding Fever Irritability Intrauterine acquisition: skin lesions, scars, chorioretinitis, evidence of CNS involvement (hydranencephaly or microcephaly)

Onset of Neonatal HSV Infection 5 10 15 20 25 Onset of symptoms (day) * SEM CNS HSV type 1 HSV type 2 Disseminated Acta Paediatr 84:256, 1995

Signs & Symptoms of Neonatal HSV Before Treatment Pediatrics 108 (2): 226, 2001

Diagnosis of Neonatal HSV Infection Gold standard = Positive culture of: lesion, nasopharynx, conjunctiva, rectum, or CSF Rapid diagnostic methods Polymerase chain reaction on CSF and blood Fluorescent antibody stain on vesicle scraping

Treatment of Neonatal HSV Acyclovir 60 mg/kg/day IV given q8h Suspect infection - 2 d of negative cultures Definite infection - 14 d for SEM, 21 d CNS Topical ocular ointment for eye lesions

Mortality & Morbidity after 1 Year of Age: 1981-1997 Severe Disability Pediatrics 108 (2): 227, 2001

Peripartum Management of Pregnant Women with History of HSV If no active lesions, normal vaginal delivery No current recommendation to culture for mother or infant for HSV Options with active lesions at onset of labor: If term and ROM <4-6 (?24) hours, C-section If preterm and ROM, may manage expectantly with or without acyclovir, betamethasone treatment, etc. OR may offer C-section C-section does NOT eliminate risk of neonatal HSV

Peripartum Management of Pregnant Women with Possible Primary HSV Viral culture of active lesions Serological classification if accurate testing available Value of acyclovir is not known If 3rd trimester, consider weekly cultures primary infection associated with prolonged viral shedding If preterm and ROM, may manage expectantly +/- acyclovir, betamethasone treatment, etc. OR may offer C-section

Management of the Asymptomatic Neonate Exposed to HSV at Delivery For recurrent maternal HSV: Separate from other newborns, may stay with mom in private room Instruct parents re: subtle signs infection, skin lesions Obtain cultures at 24-48 hours from vesicles, nasopharynx, conjunctiva, and rectum (do not pool rectal cultures with other cultures) If cultures are positive then treat with acyclovir Delay circumcision for > 1 month

Management of the Asymptomatic Neonate Exposed to HSV at Delivery For first episode genital infection: Manage with contact precautions (gown, glove), isolation Obtain cultures from vesicles, nasopharynx, conjunctiva, and rectum (do not pool rectal cultures with other cultures) Lumbar puncture for HSV PCR and culture Treat with acyclovir Delay circumcision for > 1 month