Managing varicella zoster infection in pregnancy.

Varicella zoster virus (VZV) infection can be serious for pregnant women and their babies, although it is rare. The implications of primary VZV infection vary with the gestational age at infection. For the mother, the risk of severe illness is greatest after mid-pregnancy, when she is relatively immunocompromised. For the fetus, the risk of congenital infection is greatest when maternal infection occurs in the first or second trimester. Maternal infection is preventable by preconception vaccination.

Managing genital herpes infections in pregnancy.

Genital herpes is common and is becoming more so, with a seroprevalence of 25% in middle class primary care settings. Primary genital herpes in pregnancy most often is subclinical, but it also can cause severe illness. Further, active genital herpes at the time of vaginal delivery poses significant risk of neonatal infection, especially if the mother acquired the infection in the third trimester. It is important to prevent genital herpes acquisition in pregnancy and to diagnose recurrent genital herpes to prevent neonatal herpes.

Diabetic nephropathy in pregnancy: suboptimal hypertensive control associated with preterm delivery.

BACKGROUND: Nephropathy complicates 5% to 10% of pregnancies in women with diabetes and is associated with adverse outcomes. Given the importance of blood pressure (BP) control in reducing cardiovascular and renal complications outside of pregnancy, we hypothesized that poorly controlled hypertension in early pregnancy among women with diabetic nephropathy would be associated with adverse outcomes. METHODS: To examine the impact of hypertensive control in early pregnancy on perinatal outcomes, we performed a retrospective cohort study of pregnancies complicated by diabetic nephropathy with "Above Target" mean arterial pressure (> or = 100 mm Hg; N = 21) and "Below Target" mean arterial pressure (< 100 mm Hg; N = 22), which approximates the American Diabetes Association and the Seventh Report of the Joint National Committee recommended target of 130/80 mm Hg, measured at < 20 weeks' gestation. RESULTS: There were no differences in maternal age (mean +/- SEM: 27.2 +/- 1.2 v 29.5 +/- 1.0 years), duration of diabetes (median, range: 17.5, 13 to 24 v 16, 1 to 25 years), or glucose control (glycosylated hemoglobin [HbA1c] 8.0% +/- 0.3% v 8.1% +/- 0.4%) between the Above and Below Target groups. The Above Target group had more proteinuria (4.69 +/- 1.08 v 1.65 +/- 0.43 g/24 h; P = .007) and higher serum creatinine levels (1.23 +/- 0.17 v 0.85 +/- 0.06 mg/dL; P = .02). The Above Target group was more likely to deliver at < 32 weeks' gestation (38.1% v 4.6%; P = .007). The increased risk of preterm delivery remained significant after adjusting for duration of diabetes and glucose control. CONCLUSIONS: Suboptimal control of hypertension in early pregnancy in women with diabetic nephropathy is associated with a significant risk of preterm delivery. Improved preconceptional control of hypertension may reduce adverse perinatal outcomes in women with diabetic nephropathy.

Genital herpes complicating pregnancy.

Approximately 22% of pregnant women are infected with herpes simplex virus (HSV)-2, and 2% of women will acquire HSV during pregnancy. Remarkably, up to 90% of these women are undiagnosed because they are asymptomatic or have subtle symptoms attributed to other vulvovaginal disorders. Diagnosis of genital herpes relies on laboratory confirmation with culture or polymerase chain reaction assay of genital lesions and type-specific glycoprotein G-based serologic testing. Neonatal herpes is the most severe complication of genital HSV infection and is caused by contact with infected genital secretions at the time of labor. Maternal acquisition of HSV in the third trimester of pregnancy carries the highest risk of neonatal transmission. Despite advances in the diagnosis and treatment of neonatal herpes, little change in the incidence or serious sequelae from this infection has occurred. As such, prevention of the initial neonatal infection is critically important. Obstetricians are in a unique position to prevent vertical HSV transmission by identifying women with genital lesions at the time of labor for cesarean delivery, prescribing antiviral suppressive therapy as appropriate, and avoiding unnecessary invasive intrapartum procedures in women with genital herpes. Enhanced prevention strategies include identification of women at risk for HSV acquisition during pregnancy by testing women and possibly their partners for HSV antibodies and providing counseling to prevent transmission to women in late pregnancy.

Poor correlation between genital lesions and detection of herpes simplex virus in women in labor.

OBJECTIVE: To estimate the accuracy of clinical diagnosis of genital herpes for herpes simplex virus (HSV) detection among women in labor. METHODS: Viral detection by culture and HSV DNA polymerase chain reaction (PCR) among women who underwent cesarean delivery for genital herpes was compared with women without HSV symptoms in labor who had genital swabs collected for HSV culture and to a subset of these women who had genital specimens available for PCR analysis, regardless of culture results. RESULTS: From 1989 to 1999, 126 of 19,568 (0.6%) women underwent cesarean delivery for HSV. Twenty-six percent of 110 of these women had HSV detected by culture from at least 1 genital specimen and 46% of 70 of these women had HSV detected by PCR. During the same period, 61 of 12,623 (0.5%) asymptomatic women had HSV detected by culture. Between 1995 and 1996, 57 of 2,109 (2.7%) asymptomatic women had HSV detected by PCR. Thus, the presence of genital lesions had a sensitivity for HSV detection of 37% by culture and 41% by PCR. The amount of HSV present in asymptomatic women with HSV detected in genital secretions by PCR was often as high as those with genital lesions, although the median amount of HSV DNA detected was greater in women with lesions. CONCLUSION: Clinical diagnosis of genital herpes at the time of labor correlates relatively poorly with HSV detection from genital sites or lesions by culture or PCR and fails to identify asymptomatic women who have HSV in their genital secretions at the time of labor.

Neonatal herpes should be a reportable disease.

Neonatal herpes is a devastating disease, the most serious complication of genital herpes, one of the most common serious congenital or perinatal infections, and the most frequent complication of sexually transmitted infections among children. Nevertheless, neonatal herpes is not reportable to health authorities in most states. The potential for prevention has been enhanced by recent diagnostic and therapeutic advances, and the disease meets widely accepted criteria for reporting, including incidence rates that exceed those of comparable conditions, epidemiologic instability, disease severity, direct and indirect socioeconomic costs, concern by persons at risk, the potential for prevention by public health interventions, and the prospect that the resulting data would influence public health policy. The absence of national surveillance contributes to beliefs by healthcare providers and the public health community that genital and neonatal herpes are uncommon conditions that affect small segments of society, beliefs that directly interfere with prevention. Neonatal herpes should be a reportable condition.

Common use of inaccurate antibody assays to identify infection status with herpes simplex virus type 2.

In recent proficiency testing of herpes simplex virus type-specific serologic evidence by the College of American Pathologists, commercially available herpes simplex virus antibody assays that were not glycoprotein-G based demonstrated high false-positive rates (14%-88%) for herpes simplex virus type-2 antibodies in sera that were positive for herpes simplex virus type-1 antibodies but negative for herpes simplex virus type-2 antibodies. Herpes simplex virus serologic testing should be performed with only glycoprotein-G-based tests.

A double-blind, randomized, placebo-controlled trial of acyclovir in late pregnancy for the reduction of herpes simplex virus shedding and cesarean delivery.

OBJECTIVE: The purpose of this study was to assess the efficacy of acyclovir in the reduction of herpes simplex virus culture and polymerase chain reaction positivity and cesarean delivery. STUDY DESIGN: Women with recurrent genital herpes simplex virus were randomized to acyclovir 400 mg three times daily or placebo from 36 weeks of gestation until delivery. A subset of daily specimens for herpes simplex virus culture and DNA polymerase chain reaction was self-collected. Analyses used chi(2), Fisher exact, and Mann-Whitney U tests. RESULTS: Lesions occurred at delivery among 11 of 78 women (14%) who received placebo and 4 of 84 women (5%) who received acyclovir (P =.08). Herpes simplex virus culture and polymerase chain reaction positivity near delivery occurred in 7% and 34% women in the placebo group and 0 and 2% in the acyclovir group (P =.03 and <.01, respectively). Cesarean delivery for herpes simplex virus occurred in 8 of the women (10%) in the placebo group and in 3 of the women (4%) in the acyclovir group (P =.17). Despite reductions in herpes simplex virus detection, 6% of the women who received acyclovir had herpes simplex virus detected by polymerase chain reaction on >20% of days. Neonatal outcomes were similar between groups. CONCLUSION: Acyclovir significantly reduced, but did not eliminate, herpes simplex virus lesions and detection in late pregnancy.

Effect of serologic status and cesarean delivery on transmission rates of herpes simplex virus from mother to infant.

CONTEXT: Neonatal herpes most commonly results from fetal exposure to infected maternal genital secretions at the time of delivery. The risk of transmission from mother to infant as it relates to maternal herpes simplex virus (HSV) serologic status and exposure to HSV in the maternal genital tract at the time of labor has not been quantified. Furthermore, no data exist on whether cesarean delivery, the standard of care for women with genital herpes lesions at the time of delivery, reduces HSV transmission. OBJECTIVE: To determine the effects of viral shedding, maternal HSV serologic status, and delivery route on the risk of transmission of HSV from mother to infant. DESIGN: Prospective cohort of pregnant women enrolled between January 1982 and December 1999. SETTINGS: A university medical center, a US Army medical center, and 5 community hospitals in Washington State. PATIENTS: A total of 58 362 pregnant women, of whom 40 023 had HSV cultures obtained from the cervix and external genitalia and 31 663 had serum samples tested for HSV. MAIN OUTCOME MEASURE: Rates of neonatal HSV infection. RESULTS: Among the 202 women from whom HSV was isolated at the time of labor, 10 (5%) had neonates with HSV infection (odds ratio [OR], 346; 95% confidence interval [CI], 125-956 for neonatal herpes when HSV was isolated vs not isolated). Cesarean delivery significantly reduced the HSV transmission rate among women from whom HSV was isolated (1 [1.2%] of 85 cesarean vs 9 [7.7%] of 117 vaginal; OR, 0.14; 95% CI, 0.02-1.08; P =.047). Other risk factors for neonatal HSV included first-episode infection (OR, 33.1; 95% CI, 6.5-168), HSV isolation from the cervix (OR, 32.6; 95% CI, 4.1-260), HSV-1 vs HSV-2 isolation at the time of labor (OR, 16.5; 95% CI, 4.1-65), invasive monitoring (OR, 6.8; 95% CI, 1.4-32), delivery before 38 weeks (OR, 4.4; 95% CI, 1.2-16), and maternal age less than 21 years (OR, 4.1; 95% CI, 1.1-15). Neonatal HSV infection rates per 100 000 live births were 54 (95% CI, 19.8-118) among HSV-seronegative women, 26 (95% CI, 9.3-56) among women who were HSV-1-seropositive only, and 22 (95% CI, 4.4-64) among all HSV-2-seropositive women. CONCLUSION: Neonatal HSV infection rates can be reduced by preventing maternal acquisition of genital HSV-1 and HSV-2 infection near term. It can also be reduced by cesarean delivery and limiting the use of invasive monitors among women shedding HSV at the time of labor.

Case study: type-specific HSV serology and the correct diagnosis of first-episode genital herpes during pregnancy.

It is now known that the physical presentation of genital herpes simplex (HSV) infection can be misleading in making the diagnosis of genital herpes. An incorrect diagnosis can be particularly damaging in pregnancy where it may result in extended exposure of the fetus to antiviral agents, an inappropriate route and timing of delivery and a significant increase in fetal exposure to HSV during labour and delivery. Case 1 describes a 32-year-old woman at 30 weeks in her first pregnancy who had the appearance and clinical course typically ascribed to primary genital HSV infection. In contrast, Case 2, a 24-year-old woman at 34 weeks' gestation, had the physical appearance of a recurrent episode. Type-specific serological testing revealed that what Case 1 was actually experiencing was the first symptomatic reactivation of genital herpes, whereas Case 2 had a true primary genital HSV-2 infection that was accompanied by minimal symptoms. Had serology testing not been available, Case 1 would probably have delivered unnecessarily by Caesarean section, and Case 2 would have been managed as a recurrent infection and allowed to deliver vaginally with potentially disastrous results. These cases illustrate the usefulness of a type-specific serology in diagnosing genital herpes in pregnant women.