Question:

A 22-year-old woman, gravida 1 para 0, at 36 weeks gestation comes to the office for a routine prenatal visit. The patient has had no contractions, vaginal bleeding, or leakage of fluid. Fetal movement is normal. The patient has a history of genital herpes simplex virus but has not had an outbreak in several years. She has had no vulvar pain or pruritus and has not noticed any vulvar lesions. Her pregnancy has otherwise been uncomplicated, and her only medication is a daily prenatal vitamin. Vital signs are normal. Fetal heart rate is 145/min. Fundal height is 36 cm. On pelvic examination, no lesions are noted on the vulva, vagina, or cervix. The remainder of the physical examination is unremarkable. Which of the following is the best next step in management of this patient?

Administer acyclovir suppressive therapy until delivery

Continue routine prenatal care only

Initiate acyclovir therapy only if lesions develop

Schedule cesarean delivery at 39 weeks gestation

Schedule induction of labor at 37 weeks gestation

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Explanation:

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This patient has a history of genital herpes simplex virus (HSV) infection with no recent outbreaks. During most of pregnancy, patients with a history of HSV infection typically require no additional management compared with uninfected patients. However, beginning at 36 weeks gestation until delivery, pregnant women with a history of genital HSV receive antiviral prophylaxis (eg, acyclovir, valacyclovir) regardless of symptoms (Choices B and C).

This management is recommended because active HSV at delivery increases the risk of vertical transmission due to direct neonatal contact with viral particles shed from the infected vulva, vagina, cervix, or buttock. Vertical transmission of HSV at delivery can cause neonatal meningoencephalitis or sepsis, which often results in long-term sequelae (eg, blindness, neurocognitive disability, persistent seizures).

HSV prophylaxis reduces asymptomatic viral shedding and outbreak recurrences; patients with no prodromal symptoms or active lesions (indicating low viral shedding) have a decreased risk of vertical transmission. In asymptomatic patients on antiviral prophylaxis, vaginal delivery is safe and recommended. In contrast, patients with prodromal symptoms or active lesions at delivery are at risk of neonatal transmission and require a cesarean delivery (Choice D).

(Choice E) Induction of labor is indicated in patients with an obstetric indication for delivery (eg, hypertension, gestational diabetes mellitus). Induction of labor does not reduce the risk of neonatal HSV and is therefore not indicated.

Educational objective:
Women with herpes simplex virus receive antiviral prophylaxis from 36 weeks gestation until delivery to decrease the risk of active lesions at delivery. Patients with active lesions during delivery require cesarean delivery to help prevent vertical transmission and neonatal infection; in contrast, those with no lesions can undergo vaginal delivery.