How to treat primary HSV infection in laboring mother

[fw5tape6kq]

I'm currently reading over ACOG guidelines for this and am confused about what to do with a laboring mothering who comes in with a new, primary genital HSV infection discovered on PE and PCR testing while she is in labor. Obviously, she gets a C-section because she has active genital lesions. But does she get any form of antiviral therapy in the meantime? Is it basically seen as too late to be of any clinical use, or does she get acyclovir any way because it can't be of any harm? I haven't been able to find a definitive answer to this, and I need to for purposes of a test.

There's also this in the bulletin....
"Data regarding interventions to reduce vertical transmission in the specific setting of primary herpes are limited. One randomized trial of acyclovir versus placebo given from 36 weeks of gestation until delivery to women with their first episode of genital herpes infection during pregnancy found a significant reduction in clinical recurrences at delivery (35). The number of cesarean deliveries for clinical herpes recurrences was reduced; however, the total number of cesarean deliveries in the treatment and placebo groups was similar. The number of deliveries was insufficient to evaluate efficacy of antiviral treatment to prevent neonatal herpes. Evidence of the effectiveness of cesarean delivery before labor for the prevention of vertical transmission is lacking."

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[anonperson]

I'm currently reading over ACOG guidelines for this and am confused about what to do with a laboring mothering who comes in with a new, primary genital HSV infection discovered on PE and PCR testing while she is in labor. Obviously, she gets a C-section because she has active genital lesions. But does she get any form of antiviral therapy in the meantime? Is it basically seen as too late to be of any clinical use, or does she get acyclovir any way because it can't be of any harm? I haven't been able to find a definitive answer to this, and I need to for purposes of a test.

There's also this in the bulletin....
"Data regarding interventions to reduce vertical transmission in the specific setting of primary herpes are limited. One randomized trial of acyclovir versus placebo given from 36 weeks of gestation until delivery to women with their first episode of genital herpes infection during pregnancy found a significant reduction in clinical recurrences at delivery (35). The number of cesarean deliveries for clinical herpes recurrences was reduced; however, the total number of cesarean deliveries in the treatment and placebo groups was similar. The number of deliveries was insufficient to evaluate efficacy of antiviral treatment to prevent neonatal herpes. Evidence of the effectiveness of cesarean delivery before labor for the prevention of vertical transmission is lacking."

How long are you waiting to do the section?
If the decision has been made to perform the section, typically this can be accomplished in 30-60 minutes (I am assuming in house anesthesia, staff etc).

I haven't read anything specifically in terms of giving these patients acyclovir while waiting for the section to happen. I don't think it's unreasonable to give acyclovir to the patient in the setting but I am unsure how fast pharmacy can get either IV or PO acyclovir to L and D to be honest. Also, I am unsure if this would reduce risk of transmission to the fetus. I would expect the patient to be ready to go by the time the medication even gets ready.

Regarding the last statement, I think the meta analysis it is based on is this:
Third trimester antiviral prophylaxis for preventing maternal genital herpes simplex virus (HSV) recurrences and neonatal infection. - PubMed - NCBI

Main limitation is that neither the placebo or experimental group kids developed neonatal herpes but the data is clear that suppression therapy reduces viral shedding, active HSV outbreaks, which in turn leads to decreased C-Sections for that specific indication. At this point, suppression therapy is fairly standard and I don't think there will be a lot of research comparing women on placebo vs acyclovir. I think ethically it wouldn't pass muster at this point and the numbers needed to properly power a study of this type would be pretty high and no one is really interested in paying for that.