The Committee on Practice Bulletins of the American College of Obstetricians and Gynecologists (ACOG) has developed a practice bulletin on the management of herpes in pregnancy. The guidelines were designed to help physicians make decisions about appropriate obstetric and gynecologic care. The complete practice bulletin appears in the October 1999 issue of Obstetrics and Gynecology.

The guidelines cover the following aspects of the management of herpes simplex virus (HSV) infection in pregnancy: etiology and incidence; presentation of infection, including primary infection, nonprimary first episode, recurrent infection and neonatal herpes infection; various paths of transmission, including sexual and direct contact, transmission from mother to fetus and transmission during pregnancy; and clinical considerations and recommendations.

The ACOG committee makes the following recommendations based on limited or inconsistent scientific evidence:

• Women with primary HSV infection during pregnancy should be treated with antiviral therapy.

• Cesarean delivery should be performed in women with first-episode HSV infection who have active genital lesions at the time of delivery.

• For women at or beyond 36 weeks of gestation with a first episode of HSV infection occurring during the current pregnancy, antiviral therapy should be considered.

The ACOG committee also makes the following recommendations based mainly on consensus and expert opinion:

• Cesarean delivery should be performed on women with recurrent HSV infection who have active genital lesions or prodromal symptoms at delivery.

• Expectant management of patients with preterm labor or preterm premature rupture of membranes and active HSV infection may be warranted.

• For women at or beyond 36 weeks of gestation who are at risk for recurrent HSV infection, antiviral therapy also may be considered, although such therapy may not reduce the likelihood of cesarean delivery.

• In women with no active lesions or prodromal symptoms during labor, cesarean delivery should not be performed on the basis of a history of recurrent disease.

Clinical Considerations and Recommendations

Medical Management of Pregnant Women with Primary HSV Infection. Antiviral therapy is recommended for women with primary HSV infection during pregnancy to reduce viral shedding and help in the healing of lesions. Primary HSV infection cannot be distinguished from non-primary first-episode disease without serology. Primary infection poses a higher risk of vertical transmission than does recurrent infection.

Medical Management of Pregnant Women with Recurrent HSV Infection. A randomized trial of acyclovir given after 36 weeks of gestation in women with recurrent genital herpes infection showed a significant decrease in clinical recurrences. There was also a reduction in the number of cesarean deliveries performed for active infection, although this finding was not statistically significant.

Drug Treatment of HSV Infection During Pregnancy. Many antiviral compounds are available for the treatment of HSV infection (see Table); however, none has received approval from the U.S. Food and Drug Administration (FDA) for use in pregnancy. Oral acyclovir reduces viral shedding, reduces pain and heals lesions faster when compared with placebo. The drug is safe and has minimal side effects, but only 20 percent of each oral dose is absorbed.

Valacyclovir and famciclovir have been approved by the FDA for the treatment of primary genital herpes, recurrent disease and suppression of recurrent outbreaks.

Role of Universal Screening for HSV During Pregnancy or Delivery. Universal screening for HSV is not recommended for pregnant women with current or past HSV infection because viral cultures are expensive and imprecise.

Role of Cesarean Delivery in Women with HSV Infection. Women with active genital lesions or symptoms of vulvar pain or burning should deliver by cesarean. While the incidence of infection in infants whose mothers have recurrent infections is low, cesarean delivery is recommended because of the potentially serious nature of the disease. Cesarean delivery is not necessary in women with a history of HSV but no active genital disease during labor.

Cesarean delivery is not recommended in women who have recurrent HSV infection and nongenital lesions because the risk of transmission is notably low. Nongenital lesions should be covered with an occlusive dressing before vaginal delivery.

The ACOG guidelines also discuss the following: how the diagnosis of HSV infection can be confirmed; when vaginal delivery is appropriate in patients with active HSV infection and ruptured membranes; how to manage women with active HSV infection and preterm rupture of membranes; which invasive procedures are contraindicated in women with HSV infection; and whether women with active HSV infection should breastfeed.