Invasive Obstetric Procedures and Cesarean Sections in Women With Known Herpes Simplex Virus Status During Pregnancy

Abstract

Background: Neonatal herpes is a potentially devastating infection that results from acquisition of herpes simplex virus (HSV) type 1 or 2 from the maternal genital tract at the time of vaginal delivery. Current guidelines recommend (1) cesarean delivery if maternal genital HSV lesions are present at the time of labor and (2) antiviral suppressive therapy for women with known genital herpes to decrease HSV shedding from the genital tract at the time of vaginal delivery. However, most neonatal infections occur in infants born to women without a history of genital HSV, making current prevention efforts ineffective for this group. Although routine serologic HSV testing of women during pregnancy could identify women at higher risk of intrapartum viral shedding, it is uncertain how this knowledge might impact intrapartum management, and a potential concern is a higher rate of cesarean sections among women known to be HSV-2 seropositive.

Methods: To assess the effects of prenatal HSV-2 antibody testing, history of genital herpes, and use of suppressive antiviral medication on the intrapartum management of women, we investigated the frequency of invasive obstetric procedures and cesarean deliveries. We conducted a retrospective cohort study of pregnant women delivering at the University of Washington Medical center in Seattle, Washington. We defined the exposure of interest as HSV-2 antibody positivity or known history of genital herpes noted in prenatal records. The primary outcome was intrapartum procedures including fetal scalp electrode, artificial rupture of membranes, intrauterine pressure catheter, or operative vaginal delivery (vacuum or forceps). The secondary outcome was incidence of cesarean birth. Univariate and multivariable logistic regressions were performed.

Results: From a total of 449 women included in the analysis, 97 (21.6%) were HSV-2 seropositive or had a history of genital herpes (HSV-2/GH). Herpes simplex virus-2/GH women not using suppressive antiviral therapy were less likely to undergo intrapartum procedures than women without HSV-2/GH (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.25-0.95; P = .036), but this relationship was attenuated after adjustment for potential confounders (adjusted OR, 0.69; 95% CI, 0.34-1.41; P = .31). There was no difference in intrapartum procedures for women on suppressive therapy versus women without HSV-2/GH (OR, 1.17; 95% CI, 0.66-2.07; P = .60). Similar proportions of cesarean sections were performed within each group of women: 25% without history of HSV-2/GH, 30% on suppressive treatment, and 28.1% without suppressive treatment (global, P = .73).

Conclusions: In this single-site study, provider awareness of genital herpes infection either by HSV serotesting or history was associated with fewer invasive obstetric procedures shown to be associated with neonatal herpes, but it was not associated with an increased rate of cesarean birth.

Keywords: cesarean section; genital herpes; herpes simplex virus-2; pregnancy; suppressive therapy.

Figure 1.

(A) shows a flow diagram of study participant selection. Charts were reviewed from 750 women with consecutive deliveries at University of Washington Medical Center in 2006, 606 of which had exposure data. After excluding women with active genital lesions, nonvertex fetal presentation, and scheduled cesarean births, 449 women were included in the analysis. Of these, 97 (21.6%) had herpes simplex virus-2 antibody positive or with a history of genital herpes (HSV-2/GH). (B) shows the distribution of HSV-2 antibody positivity and clinical history of genital herpes in the 97 women with HSV-2/GH. Women with a clinical history are further divided into those who were HSV-2 antibody positive and those positive for antibodies to HSV-1 only. The distribution of the 57 women (58.8%) on suppressive anti-HSV therapy is also shown. ^aHSV-1 antibodies detected in 39 (65%); ^bHSV-1 antibodies detected in 14 (51.9%). C-section, cesarean section.

Figure 2.

Proportions of women undergoing intrapartum procedures and cesarean delivery, by risk group, are shown. Risk groups include asymptomatic women with and without herpes simplex virus (HSV)-2 antibody positivity or a clinical history of genital herpes (HSV-2/GH). Women with HSV-2/GH are further stratified by whether or not they were receiving suppressive antiviral therapy at delivery. Global P values for differences between groups are shown. C-section, cesarean section.