Genital Herpes With Special Reference To Pregnancy

Genital herpes is a sexually transmitted disease (STD) caused by herpes simplex viruses type 1 (HSV-1) and type 2 (HSV-2). The anxiety for a pregnant woman is that she may transfer the virus to her baby during pregnancy and childbirth with potentially severe consequences. In this article measures to avoid such disaster are discussed.

Herpes simplex virus type 1 and type 2 are common infections worldwide. Herpes simplex virus type 2 is the cause of most genital herpes and is almost always sexually transmitted whereas the type 1 virus is more commonly associated with sores around the mouth. There is no exclusivity with some ulcers around the mouth being caused by the type 2 virus and some genital infections being related to the type 1 virus. These are probably related to oral sex.

Herpes simplex infections can be diagnosed by visual inspection by a doctor. Swabs from the affected area can be taken and the virus cultured in the laboratory. When a person contracts infection, the immune system produces antibodies that can be measured in the serum (blood with its cells removed).

In the USA one adult in five has antibodies to type 2 herpes. The number of people who have been diagnosed with the condition rose from 10% to 14% between 1988 and 1999. Seroprevalence of HSV-1 decreased from 62.0% in 1988-1994 to 57.7% in 1999-2004, a relative decrease of 6.9%.

Herpes infections may be primary, secondary, recurrent or asymptomatic with viral shedding. In a primary infection, the infection is apparent but there are as yet no antibodies to either HSV-1 or HSV-2 at the time of the outbreak indicating no prior exposure. Typically, lesions appear 2-14 days after contact. Without antiviral therapy, the lesions last for 20 days. Viral shedding lasts 12 days, with the highest rates of shedding occurring before symptoms develop and during the first half of the outbreak. Viral shedding ceases before complete resolution of the lesion. Antibody response occurs 3-4 weeks after the primary infection and is life-long. However, unlike protective antibodies to other viruses, antibodies to HSV do not prevent local recurrences. The symptoms associated with local recurrences tend to be milder than those occurring with primary disease.

The lesions of a primary infection begin as tender vesicles (blisters), which may burst to become ulcers. The vagina is commonly inflamed and the cervix is involved in 80% of patients. Pre-existing HSV-1 antibodies can alleviate clinical manifestations of subsequently acquired HSV-2. More than 75% of patients with primary genital HSV infection are asymptomatic. Asymptomatic primary HSV infections in pregnant women at term are responsible for most neonatal (newborn) HSV infections.

Symptoms associated with primary infections may be local and constitutional. Local symptoms include intense pain, dysuria (pain passing urine), itching, vaginal discharge, and lymphadenopathy (swelling of the lymph glands). Constitutional symptoms include fever, headache, nausea, malaise, and myalgia (aching muscles).

A non-primary first episode infection is a first genital HSV outbreak in a woman who has HSV type 1 antibodies. Because of the partial protection of the pre-existing antibodies, these women tend to have fewer and shorter systemic symptoms. The duration of lesions is shorter, averaging 15 days, and viral shedding lasts for approximately 7 days.

A recurrent infection is defined as a genital HSV outbreak in a woman with type 2 antibodies. Recurrent HSV outbreaks may be symptomatic or asymptomatic. Lesions typically last for 9 days, and viral shedding lasts for approximately 4 days. The viral load tends to be lower in recurrent outbreaks than with primary lesions, and shedding tends to occur during the prodrome (pre-symptomatic phase) and early stage of the clinical outbreak.

Primary infections in pregnancy are over diagnosed. Correct classification of gestational genital herpes infections can only be accomplished when clinical evaluation is combined with viral isolation and serologic testing using a type-specific assay. Most severe first clinical episodes of genital herpes infections among women in the second and third trimesters of pregnancy are not primary infections and are not commonly associated with perinatal morbidity.

Most herpes affected babies acquire the virus at the time of delivery. Just 5% of all cases of neonatal (newborn) HSV infection result from transplacental transmission during pregnancy. In this regard, it is one of the TORCH (toxoplasmosis, rubella, cytomegalovirus, and herpes simplex) infections, which are associated with microcephaly (small head), microphthalmia (small eyes), intracranial (within the brain) calcifications, and chorioretinitis (inflammation in the eyes). The acquisition of genital herpes during pregnancy has been associated with spontaneous miscarriage, prematurity and congenital and neonatal herpes.

Neonatal herpes is a severe systemic (involving all the body) viral infection with a high morbidity (illness) and mortality. Neonatal herpes can cause skin, eye or mouth infections, damage to the central nervous system and other internal organs and mental retardation. It is relatively uncommon in the UK with an incidence of 1.65 per 100 000 live births annually, which compares to 11 per 100, 000 deliveries in the USA.

Neonatal herpes may be caused by herpes simplex type 1 (HSV-1) or herpes simplex type 2 (HSV-2), as either viral type can cause genital herpes. The risks are greatest when a woman acquires a primary infection during late pregnancy, so that the baby is delivered before the development of protective maternal antibodies. All women should be asked at their first antenatal visit if they or their partner have ever had genital herpes. Female partners of men with genital herpes, who themselves give no history of genital herpes, should be advised about reducing their risk of acquiring this infection.

Women who report a history of genital herpes can be reassured that, in the event of an HSV recurrence during pregnancy, the risk of transmission to the neonate is extremely small, even if genital lesions are present at delivery. Women with no history of genital herpes may reduce their risk of acquiring herpes during pregnancy by avoiding sexual intercourse at times when their partner has an HSV recurrence. The impact of this intervention is limited because sexual transmission of HSV commonly results from sexual contact during periods of asymptomatic viral shedding.

Aciclovir is well tolerated in late pregnancy and there is no clinical or laboratory evidence of maternal or fetal toxicity. Aciclovir has been used extensively in pregnancy and it appears to be safe. The use of intravenous aciclovir may reduce the risk of neonatal herpes by minimising maternal viraemia and reducing exposure of the fetus to HSV for women who develop first episode genital herpes within six weeks of delivery. A randomised controlled trial for women with recurrent herpes was unable to demonstrate that acyclovir in late pregnancy significantly reduces the number of caesarean sections. The conclusion was that there is little evidence to suggest that acyclovir should be used for the suppression of recurrent genital herpes infection during pregnancy.

Where first-episode genital herpes lesions are present at the time of delivery and the baby is delivered vaginally, the risk of neonatal herpes is about 40%. The risk of transmission is associated with duration of rupture of the membranes, the risk increasing considerably after the membranes had been ruptured for more than four hours.

Caesarean section is recommended for all women presenting with first-episode genital herpes lesions at the time of delivery, but is not indicated for women who develop first episode genital herpes lesions earlier in the pregnancy. If the first episode of genital herpes lesions within six weeks of the expected date of delivery or onset of preterm labour, elective caesarean section may be considered at term, or as indicated, and the paediatricians should be informed.

In the 1980s, it was common practice to take swabs for viral cultures weekly from women with a history of genital herpes during the last six weeks of pregnancy and if the results were positive delivery would be by elective caesarean section. This practice is no longer recommended as it has been demonstrated that antenatal swabbing did not predict the shedding of virus at the onset of labour.

For women presenting with recurrent genital herpes lesions at the onset of labour, the risks to the baby of neonatal herpes are negligible with two major studies showing no transmission to the baby. In one study, one baby in 34 with active recurrent herpes was affected. The practice of caesarean delivery for women with a history of genital herpes lesions that recur at delivery would result in more than 1580 excess caesarean deliveries being performed for every poor neonatal outcome prevented at a cost per neonatal herpes case averted of $2.5 million at 1993 rates. Furthermore, there could well be more maternal deaths by this practice than newborn babies saved. In Holland, caesarean sections have not been routinely performed for this indication since 1987 and there has been no increase in the reported incidence of neonatal herpes.
by: David Viniker

Genital Herpes

Genital herpes is a sexually transmitted disease (STD) caused by the herpes simplex viruses type 1 (HSV-1) or type 2 (HSV-2). Most genital herpes is caused by HSV-2. Most individuals have no or only minimal signs or symptoms from HSV-1 or HSV-2 infection. When signs do occur, they typically appear as one or more blisters on or around the genitals or rectum. The blisters break, leaving tender ulcers (sores) that may take two to four weeks to heal the first time they occur. Typically, another outbreak can appear weeks or months after the first, but it almost always is less severe and shorter than the first outbreak. Although the infection can stay in the body indefinitely, the number of outbreaks tends to decrease over a period of years.




How common is genital herpes?

Results of a nationally representative study show that genital herpes infection is common in the United States. Nationwide, at least 45 million people ages 12 and older, or one out of five adolescents and adults, have had genital HSV infection. Over the past decade, the percent of Americans with genital herpes infection in the U.S. has decreased.

Genital HSV-2 infection is more common in women (approximately one out of four women) than in men (almost one out of eight). This may be due to male-to-female transmission being more likely than female-to-male transmission.

How do people get genital herpes?

HSV-1 and HSV-2 can be found in and released from the sores that the viruses cause, but they also are released between outbreaks from skin that does not appear to have a sore. Generally, a person can only get HSV-2 infection during sexual contact with someone who has a genital HSV-2 infection. Transmission can occur from an infected partner who does not have a visible sore and may not know that he or she is infected.

HSV-1 can cause genital herpes, but it more commonly causes infections of the mouth and lips, so-called “fever blisters.” HSV-1 infection of the genitals can be caused by oral-genital or genital-genital contact with a person who has HSV-1 infection. Genital HSV-1 outbreaks recur less regularly than genital HSV-2 outbreaks.

What are the signs and symptoms of genital herpes?

Most people infected with HSV-2 are not aware of their infection. However, if signs and symptoms occur during the first outbreak, they can be quite pronounced. The first outbreak usually occurs within two weeks after the virus is transmitted, and the sores typically heal within two to four weeks. Other signs and symptoms during the primary episode may include a second crop of sores, and flu-like symptoms, including fever and swollen glands. However, most individuals with HSV-2 infection never have sores, or they have very mild signs that they do not even notice or that they mistake for insect bites or another skin condition.

People diagnosed with a first episode of genital herpes can expect to have several (typically four or five) outbreaks (symptomatic recurrences) within a year. Over time these recurrences usually decrease in frequency. It is possible that a person becomes aware of the “first episode” years after the infection is acquired.

What are the complications of genital herpes?

Genital herpes can cause recurrent painful genital sores in many adults, and herpes infection can be severe in people with suppressed immune systems. Regardless of severity of symptoms, genital herpes frequently causes psychological distress in people who know they are infected.

In addition, genital HSV can lead to potentially fatal infections in babies. It is important that women avoid contracting herpes during pregnancy because a newly acquired infection during late pregnancy poses a greater risk of transmission to the baby. If a woman has active genital herpes at delivery, a cesarean delivery is usually performed. Fortunately, infection of a baby from a woman with herpes infection is rare.

Herpes may play a role in the spread of HIV, the virus that causes AIDS. Herpes can make people more susceptible to HIV infection, and it can make HIV-infected individuals more infectious.

How is genital herpes diagnosed?

The signs and symptoms associated with HSV-2 can vary greatly. Health care providers can diagnose genital herpes by visual inspection if the outbreak is typical, and by taking a sample from the sore(s) and testing it in a laboratory. HSV infections can be diagnosed between outbreaks by the use of a blood test. Blood tests, which detect antibodies to HSV-1 or HSV-2 infection, can be helpful, although the results are not always clear-cut.

Is there a treatment for herpes?

There is no treatment that can cure herpes, but antiviral medications can shorten and prevent outbreaks during the period of time the person takes the medication. In addition, daily suppressive therapy for symptomatic herpes can reduce transmission to partners.

How can herpes be prevented?

The surest way to avoid transmission of sexually transmitted diseases, including genital herpes, is to abstain from sexual contact, or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

Genital ulcer diseases can occur in both male and female genital areas that are covered or protected by a latex condom, as well as in areas that are not covered. Correct and consistent use of latex condoms can reduce the risk of genital herpes.
Persons with herpes should abstain from sexual activity with uninfected partners when lesions or other symptoms of herpes are present. It is important to know that even if a person does not have any symptoms he or she can still infect sex partners. Sex partners of infected persons should be advised that they may become infected and they should use condoms to reduce the risk. Sex partners can seek testing to determine if they are infected with HSV. A positive HSV-2 blood test most likely indicates a genital herpes infection
Where can I get more information?
CDC-INFO Contact Center
1-800-CDC-INFO (1-800-232-4636)
Email: cdcinfo@cdc.gov

National Herpes Hotline Please see disclaimer at bottom of this page.
(919) 361-8488

Solving Herpes

Herpes is a viral disease that "hides" mostly in fatty tissue that surrounds nerve cells and pathways. There are three classified types of herpes, although the first two below are the same virus found in different places.
Herpes Simplex 1: This is...

the most common, and it usually occurs on or around the lips, but it can occur anywhere on the body. It is often transmitted to other persons via kissing.

Herpes Simplex 2: This is actually the same virus as #1 above, but is found generally on the genital regions, and is usually transmitted by sexual contact.

Herpes Zoster: Also known as "Shingles", this can be the most painful of all. It is thought to be a "left-over" from chicken pox that lies dormant (or can) for many years and suddenly appears.

All of these forms are generated to a large extent by stress as a major factor. However, there are several other factors involved. It's important to understand these to prevent outbreaks.

The first two forms of Herpes Simplex require a certain balance of two amino acids to reproduce. These are Argenine and Lysine. If, and when, the Argenine level gets high, and the Lysine level gets low, Herpes comes out to play (reproduce).

That's when you first notice an itch that becomes a small reddened area with one or more very small pimples. Don't kiss anyone or have sex without a condom (depending on the area of the Herpes outbreak) during this time. Herpes is spread by contact, and is very infectious.

There is no cure for herpoid viruses to date. Herpes is estimated to affect 80 million people in America, and about 20% of the US population has genital Herpes

So, while we cannot cure it, we do have some control of outbreaks. If we keep the level of Lysine high, the conditions for reproduction are limited. (Another benefit of high Lysine levels is that it seems to help keep the heart healthy). It should be noted that this is not always that simple. Our diet is important. Sugar, chocolate, and nuts are high in Argenine, and many athletes use Argenine as strength building. Herpes is known as the Holiday disease, particularly at Halloween, Thanksgiving and Christmas seasons.

I've had genital Herpes for 60 years, and have never infected another person to my knowledge. I found out what I'm writing here, and have been careful about sex without a condom whenever I "itch".

In later years, I've found that I require more Lysine than I did 40 years ago, when I discovered the Lysine/Argenine balance. I now take 1 pill (1000 mg) of Lysine per day, and still very occasionally get an outbreak.

Dealing with an outbreak

In spite of "best intentions", we humans fail. We overeat those foods that are high in Argenine, and we have stress almost constantly, so we will get outbreaks. There are different remedies available, some prescription, and some over-the-counter (OTC).

First take care of the affected skin area. Keep the area dry and clean during outbreaks to help healing. Avoid physical contact with the area from the time of first noticing symptoms (typically tingling, itching, burning) until all sores are completely healed, not just scabbed-over. Until that time, you and your "discards" are highly infectious. The scabs and any other residue that is on your clothes is dangerous, and it's possible to re-infect yourself and others.

Next, treat the outbreak carefully. Valtrex and similar ointments do help to dry up the infection quickly, but I found a simpler and cheaper way years ago. I simply wet an edge of a bar of ordinary soap, (or a drop of liquid soap) and rub it all over and around the affected area, coating it with a layer of soap. I also scratch the area, and break the small pimples before and while doing this. I wash my hands thoroughly after doing this, then let the soapy area dry before putting on clothes. Within a week or so, the tiny scabs are gone and the skin is "normal".

There are some that will disagree with this, but it's been very effective for me, and many others I've advised. It's cheap and avoids doctors and drugs. Some further advice - Latex condoms reduce your risk of spreading or getting herpes. Wash your hands with soap and water if you touch a sore.

If you understand and follow these simple instructions, then Herpes Simplex isn't that much of a problem.
by: Dr. Phil Bate