HPV

1. Herpes simplex virus is caused by members of the hervesviridae family of DNA viruses. There are two major serotypes. (i) HSV-1 which causes conjunctivitis,stomatitis, and gingivitis as well as 20% of genital infections and (ii) HSV-2 which accounts for 80% of genital infections. It is the most common viral pathogen in the United States with over 45 million people infected and more than 500.000 new cases annually. 2. Risk factors include multiple sexual partners, unprotected intercourse ,multiparity,other sexually transmitted infections, a history of recent exposure to HSV or intercourse with an HSV-positive partner, and history of prior HSV infection. 3. Maternal complications include localized erythema, swelling, and pain. Serious complications such as hepatitis,encephalitis, and death are rare. 4. There are 1500-2000 cases of neonatal HSV infection in the United States annually, and most are due to HSV-2. First-episode primary infection leads to a viremia and an increased risk of vertical transmission; however, in utero HSV infections is rare. Most neonatal infections result from contact with infected secretions at the time of vaginal delivery. Indeed, neonatal disease occurs in 30-60% of infants exposed to HSV at vaginal delivery. Recurrent HSV is not associated with viremia ; as such, the fetus is not at risk if the fetal membranes remain intact and there is no labor. If the fetus is infected inutero, complications may include preterm birth, intrauterine fetal demise or neonatal mortality ( 15-60% ), localized infection (skin, eye, mouth, CNS), or disseminated HSV. 5. Symptoms depend on the stage of the disease First-episode primary infections refers to the first clinical presentation in the absence of circulating anti-HSV IgG. Typical symtoms include painful vesicles on the vulva, vagina and/or servixthat develop 2-14 days after exposure along with tender adenopathy and systemic symptoms (low-grade fever,malaise) in two-thirds of cases. The lesions resolve spontaneously in 3-4 weeks without treatment. Firts-episode nonprimary infections refers to the first clinical presentations but in the presence of anti-HSV IgG, suggesting evidence of prior infections. Recurrent infections refers to reactivations of dormant virus, and symptoms are generally less severe with no systemic features. 6. Prevention of HSV includes avoiding contact with infected persons persons and the routine use of barrier contraception. There is no vaccine or immune globulin

available. Of noten anti- HSV-1 IgG does not prevent primary infection with HSV-2, vice versa.

7. Antiviral chemoprophylaxis starting at 35-36 weeks gestationis recommendedfor women at risk of viral shedding at delivery to decrease the likelihood of a lesion in labor requiring cesarean delivery. Whether this decreases the rate of neonatal

infection is not known. 8. Maternal HSV infection can be confirmed by viral isolation from vesicular fluid or infected tissues, but problems with specimen sampling and transportation limit the sensitivity to 60-70% .Serologic testing is often performed, but is of limited utility. Such testing does not easily distinguish between anti HSV-1 and anti HSV-2

antibodies,and in excess of 30% of all pregnant women have anti-HSV-2 IgG. 9. The management of maternal HSV infection is primarily supportive. Antiviral treatment of primary HSV can decrease the severity and duration of symptoms in the mother, but does not prevent fetal infection. Acyclovir is the treatment of choice; alternatives include valacyclovir and famciclovir. Topical is less effective than oral treatment and is therefore not recomended. Dissemenated disease should be treated with iv acyclovir in an ICU setting. It is unclear whether antivital treatment decreases the severity or duration of symptomsin reccurrent HSV infections, although it may abort an outbreak if given during the clinical prodrome or whithin 1 day of the onset of lesions. 10. Fetal infection can be confirmed by detection of viral particles or DNA in fetal serum, amniotic fluid or flacental tissues; however, invasive, prenatal testing is not routinely recommended. 11. Differential diagnosis includes other herpesvirus infections, such as varicella zoster. 12. To prevent vertical transmission, cesarean delivery should be recommended for all women with an active genital lesion or clinical prodrome in labor. Duo to the low yield of viral cultures and poor corellation between culture and asymptomatic viral shedding in labor, screening for viral shedding in labor is not recommended.

REFERENCE 1. Obstetric clinical alogarithms : management and evidence: By E.R. Norwitz M. Blefort, G. R. Saade and H. Miller Published 2010 Blackwell Publishing.