Preventing neonatal herpes?

In the United Kingdom no national management policies exist for women with genital herpes during pregnancy. Some women are subjected to frequent genital examinations and multiple viral cultures, some have unnecessary caesarean sections, and others receive no additional monitoring. The number of cases of herpes simplex infection seen in genitourinary clinics in England and Wales more than doubled between 1978 and 1988.' A recently established voluntary notification system within the United Kingdom shows an incidence of neonatal herpes of less than 3 per 100,000 live births.2 Insufficient data exist to establish a trend but this incidence is probably an underestimate because notification is voluntary; many mothers are both asymptomatic at the time of delivery and have no history of genital herpes;3 the condition may develop after infants have left hospital, making diagnosis less likely; and classical lesions may never develop. Early treatment of neonates with anti-virals has not been shown to eliminate the considerable risk of death or serious sequelae of this condition4 so the reasons for the failure of current policies must be examined and rational alternatives proposed. Whilst most infants with neonatal herpes are thought to be infected during labour, transplacental infection does rarely occur. Infection from non-genital maternal sources, for example, the breast,5 has been documented, as has infection from relatives and medical or paramedical personnel.3 The role of invasive monitoring techniques such as scalp electrodes in facilitating transmission is unknown. Clear advice to hospital personnel and pregnant women about the risks to neonates from herpetic lesions might prevent some such cases. Primary maternal genital herpes during pregnancy has been shown to pose a high risk of transmission to the neonate as large amounts of virus are present, the cervix is frequently affected, lesions are larger and present for longer and maternal antibody levels may be lower than in recurrent disease.6 Recurrent genital herpes presents a lower risk to the neonate but factors which probably affect transmission including duration of labour, duration of membrane rupture, site of herpes lesions, amount of virus present, maternal antibody levels and fetal instrumentation during labour have rarely been considered in studies of women with recurrent disease. Recent prospective studies have described seven women with primary herpes simplex during the third trimester or at term. Of the seven babies, three had neonatal herpes infection and two others had serious perinatal morbidity with no known cause.78 Four prospective studies identified women with recurrent …