Acyclovir prophylaxis to prevent herpes simplex virus recurrence at delivery: a systematic review.

OBJECTIVE Genital herpes simplex virus (HSV) infection is one of the most common viral sexually transmitted diseases in the United States. Perinatal transmission of the virus to the fetus or neonate is a major concern in affected pregnancies. Our objective was to systematically review published data to estimate the effect of prophylactic acyclovir provided to pregnant women near term on the rate of recurrent genital herpes at delivery; the number of cesarean deliveries performed for clinical HSV recurrences or prodromal symptoms; and the prevalence of HSV virologic detection at delivery. DATA SOURCES Our search included MEDLINE (1966-March 2003), LILACS, EMBASE, conference proceedings, abstracts from scientific forums and bibliographies of published articles with the following medical headings: acyclovir, pregnancy, Herpes viridae, and Herpesviridae. METHODS OF STUDY SELECTION Prospectively designed criteria included randomized, clinical trials detailing the use of acyclovir in pregnancy for women with HSV published in either abstract or article form. Five trials with a total enrollment of 799 patients were included in the analysis. TABULATION, INTEGRATION, AND RESULTS The studies were reviewed independently by three of the authors. With RevMan software, a fixed-effects model was used to calculate a summary odds ratio (OR) comparing the effect of treatment with placebo. Acyclovir prophylaxis beginning at 36 weeks' gestation was effective in reducing clinical HSV recurrences at the time of delivery (OR 0.25; 95% confidence interval [95% CI] 0.15, 0.40), cesarean deliveries for clinical recurrence genital herpes (OR 0.30; 95% CI 0.13, 0.67), total HSV detection at delivery (OR 0.11; 95% CI 0.04, 0.31), and asymptomatic HSV shedding at delivery (OR 0.09; 95% CI 0.02, 0.39). CONCLUSION The results of this meta-analysis indicate that prophylactic acyclovir beginning at 36 weeks' gestation reduces the risk of clinical HSV recurrence at delivery, cesarean delivery for recurrent genital herpes, and the risk of HSV viral shedding at delivery.