HSV in pregnancy an update on guidelines Joint BASHH and FSRH Meeting 15/01/16 Emily Clarke ST4 GUM, Solent NHS Trust, Portsmouth DIT rep to the BASHH Herpes Advisory Panel

Aims • BASHH 2014 herpes guidelines – Herpes proctitis – Transmission: Key points to cover with patients

• BASHH/RCOG 2014 herpes in pregnancy guidelines – – – – –

Recurrent HSV / acquisition in 1st & 2nd trimesters Primary acquisition in 3rd trimester Primary lesions in labour HSV in PPROM Preventing maternal HSV acquisition

Herpes proctitis in MSM • USA: HSV 16% (3% had HSV + ≥1 other STI)1 • Australia: 32% had visible external gential ulceration2 HIV positive

HIV negative

HSV-1

14.2%

6.5%

HSV-2

22.0%

12.3%

Total

36.2%

18.8%

1. Klausner et al. Clin Infect Dis 2004;38(2):300-2 2. Bissessor et al. Sex Transm Dis 2013;38:300-2

The case of David Golding

Assumption that best practice had occurred despite lack of documentation • “The available medical notes were not specific as to advice provided to the appellant. According to [medical expert], he would have expected a full discussion to have taken place … at the Genitourinary Clinic following the guideline of the British Association for Sexual Health and HIV. This refers to condom use when lesions are present, the possibility of infectivity even when a person is asymptomatic, and disclosure of the condition to a partner.”

Transmission: Key points • Abstinence during lesion recurrences / prodromes • Transmission may occur due to asymptomatic shedding • Male condoms may reduce the risk of transmission, but do not completely prevent it – 50% ↓ in transmission if using condoms 25-60% of the time – Protective effect greater for women1 Martin et al. Arch Intern Med 2009;169:1233-40

Suppressive antiviral therapy reduces the rate of acquisition of symptomatic HSV • Asymptomatic shedding – Reduced by ~80-90% by all antivirals – Valaciclovir better than famciclovir , aciclovir at least as good as valaciclovir

• Valaciclovir 500mg OD – Reduces the rate of acquistion of HSV-2 & clincially symptomatic HSV in serodiscordant couples – Monogomous HIV-negative non-pregnant heterosexual couples

Transmission: Key points • Disclosure is advised in all relationships – Difficult issue for patients – More likely to happen in ongoing relationship – Associated with lower transmission risks & may be a protection against legal action

• Document discussions around disclosure & transmission

Aetiology

unknown 8% HSV-1 41% HSV-2 51%

• ~50:50 HSV-1: HSV-2 • Most acquired by contact with maternal secretions, 25% possibly postnatal • Risks highest: – Prior to development of maternal antibodies – New infection (especially within 6/52 of delivery) as viral shedding may persist

Disseminated herpes • Infant – More common in premature infants – Due to primary infection in mother

• Mother – Encephalitis / hepatitis / disseminated skin lesions – Rare, but more common in pregnancy (especially if immunocompromised) – High maternal mortality

UK incidence • Rare in UK in comparison with Europe & USA • Active surveillance by BPSU • 1986-911 – 76 cases in 5½ years – Annual incidence of 1.65/100,000 live births (i.e. 1 in 60,606)

• 2004-62 – 86 cases in 3 years – Approximate doubling of incidence (provisional)

• No further data published 1. Tookey et al, Paediatr Perinat Epidemiol 1996;10:432-42 2. BPSU 21st Annual Report 2006-7

Recurrent HSV & primary acquisition in 1st & 2nd trimesters managed similarly Recurrent genital HSV

Primary acquisition of genital herpes in 1st or 2nd trimester

Treat primary episode / recurrences (if necessary) with standard doses of aciclovir

Consider aciclovir 400mg tds from 36/40 gestation (32/40 if HIV positive)

Recurrent HSV & primary acquisition in 1st & 2nd trimesters managed similarly Offer vaginal delivery No genital HSV lesions at delivery

Normal postnatal care

Genital HSV lesions at delivery Normal postnatal care Discharge home at 24h if baby well Advise patients RE later management if concerns

Your patient asks… • Will I have a miscarriage? • What is the risk of neonatal HSV? • Should I have a Caesarean section or a vaginal delivery? • Is short course aciclovir safe in early pregnancy? • I am taking aciclovir suppression. Should I stop before trying to get pregnant? • When should I seek medical help for my baby?

Your patient asks… • Will I have a miscarriage? – No evidence of an increased risk of spontaneous miscarriage with primary HSV in 1st trimester

• What is the risk of neonatal HSV? – Risk of neonatal HSV is low even if lesions are present at delivery (0-3% for vaginal delivery)

Should I have a Caesarean section or a vaginal delivery? • Offer vaginal delivery but final decision by woman • Risk of neonatal HSV transmission versus risks of Caesarean section to mother & future pregnancies • With small risk of transmission, invasive procedures can be used if required

Is short course aciclovir safe in early pregnancy? • Not licensed in pregnancy • Well tolerated in pregnancy • Considered safe – – – – –

Pregnancy register Standard animal studies Mechanism of action of the drug Used to treat acquisitions in early pregnancy Category B classification by FDA

• Transient neonatal neutropenia reported

I am taking aciclovir suppression. Should I stop before trying to get pregnant? • No advice included in BASHH/RCOG guidelines • Tolerable symptoms: advise stop • Reduce transmission risk to male partner: consider artificial insemination • Severe symptoms: encourage immediate stop on pregnancy • If insists on continuing – Warn patient – Give the lowest effective dose – Do not use aciclovir 400mg tds (as used from 36/40)

When should I seek medical help for my baby? • Any concerns but especially: – Skin / eye / mucous membrane lesions – Lethargy / irritability – Poor feeding – Fever

• Avoid postnatal transmission – Hand hygiene – Cold sores

Primary acquisition of genital HSV in 3rd trimester Treat primary episode with standard doses of aciclovir Consider aciclovir 400mg tds until delivery Recommend planned Caesarean section (especially if within 6/52 of delivery Inform neonatologist Normal postnatal care Discharge home if baby well at 24 hours Advise patients regarding later management if any concerns

A woman has primary genital lesions at onset of labour. She asks… • I really want to have a vaginal delivery. What is the risk? • Is there any way to reduce that risk? • What will happen to my baby after delivery?

I really want to have a vaginal delivery. What is the risk? • 41% risk of neonatal HSV • Disease localised to skin/eye/mouth (30%) – Neuro/ocular morbidity