This is the current release of the guideline.

This guideline updates a previous version: American College of Obstetricians and Gynecologists (ACOG). Management of herpes in pregnancy. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 1999 Oct. 10 p. (ACOG practice bulletin; no. 8).

Genital herpes simplex virus (HSV) infection in pregnancy

Pregnant women with genital herpes simplex virus infection

The MEDLINE database, the Cochrane Library, and American College of Obstetricians and Gynecologists' (ACOG's) own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1985 and October 2006. The search was restricted to articles published in the English language. Priority was given to the articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document.

Guidelines published by organizations or institutions such as the National Institutes of Health and the American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles.

Not stated

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force.

I Evidence obtained from at least one properly designed randomized controlled trial.

II-1 Evidence obtained from well-designed controlled trials without randomization.

II-2 Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.

II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Not stated

Analysis of available evidence was given priority in formulating recommendations. When reliable research was not available, expert opinions from obstetrician-gynecologists were used. See also the "Rating Scheme for the Strength of Recommendations" field regarding Grade C recommendations.

Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A - Recommendations are based on good and consistent scientific evidence.

Level B - Recommendations are based on limited or inconsistent scientific evidence.

Level C - Recommendations are based primarily on consensus and expert opinion.

Several analyses have evaluated the cost effectiveness of various screening protocols for pregnant patients to reduce the incidence of neonatal herpes simplex virus (HSV) infection. The results from these analyses are highly variable—estimates of the cost to prevent one case of neonatal herpes range from $200,000 to $4,000,000. A number of factors influence these cost estimates, including the costs of testing and counseling, effectiveness of antiviral therapy, the probability of lesions or shedding at delivery in asymptomatic women in whom HSV has been diagnosed only by the screening test, and the likelihood of neonatal herpes with vaginal delivery. Currently, there is no evidence of cost-effectiveness of screening strategies from clinical trials or well-designed cohort studies in pregnancy.

Practice Bulletins are validated by two internal clinical review panels composed of practicing obstetrician-gynecologists generalists and sub-specialists. The final guidelines are also reviewed and approved by the American College of Obstetricians and Gynecologists (ACOG) Executive Board.

The grades of evidence (I-III) and levels of recommendations (A-C) are defined at the end of "Major Recommendations" field.

The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B):

• Women with active recurrent genital herpes should be offered suppressive viral therapy at or beyond 36 weeks of gestation.
• Cesarean delivery is indicated in women with active genital lesions or prodromal symptoms, such as vulvar pain or burning at delivery, because these symptoms may indicate an impending outbreak.

The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):

• In women with premature rupture of membranes, there is no consensus on the gestational age at which the risks of prematurity outweigh the risks of herpes simplex virus (HSV).
• Cesarean delivery is not recommended for women with a history of HSV infection but no active genital disease during labor.
• Routine antepartum genital HSV cultures in asymptomatic patients with recurrent disease are not recommended.
• Routine HSV screening of pregnant women is not recommended.

Definitions:

Grades of Evidence

I Evidence obtained from at least one properly designed randomized controlled trial.

II-1 Evidence obtained from well-designed controlled trials without randomization.

II-2 Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.

II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments could also be regarded as this type of evidence.

III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Levels of Recommendations

Level A - Recommendations are based on good and consistent scientific evidence.

Level B - Recommendations are based on limited or inconsistent scientific evidence.

Level C - Recommendations are based primarily on consensus and expert opinion.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Although neutropenia is a recognized, transient complication of acyclovir treatment of neonatal herpes simplex virus infection, it has not been reported following maternal suppressive therapy. The acyclovir concentrations at which neutropenia occurred were approximately 5 to 30 times higher than were observed in umbilical vein plasma in a pharmacokinetic study of valacyclovir in pregnancy

If a woman with herpes simplex virus has an obvious lesion on the breast, breastfeeding is contraindicated.

These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

An implementation strategy was not provided.

Not applicable: The guideline was not adapted from another source.

American College of Obstetricians and Gynecologists (ACOG)

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins - Obstetrics

Not stated

Not stated

This is the current release of the guideline.

This guideline updates a previous version: American College of Obstetricians and Gynecologists (ACOG). Management of herpes in pregnancy. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 1999 Oct. 10 p. (ACOG practice bulletin; no. 8).

Electronic copies: Not available at this time.

Print copies: Available for purchase from the American College of Obstetricians and Gynecologists (ACOG) Distribution Center, PO Box 933104, Atlanta, GA 31193-3104; telephone, 800-762-2264, ext. 192; e-mail: sales@acog.org. The ACOG Bookstore is available online at the ACOG Web site .

Proposed performance measures are included in the original guideline document.

The following is available:

• Genital herpes. Atlanta (GA): American College of Obstetricians and Gynecologists (ACOG); 2008. Available from the American College of Obstetricians and Gynecologists (ACOG) Web site . Copies are also available in Spanish.

Print copies: Available for purchase from the American College of Obstetricians and Gynecologists (ACOG) Distribution Center, PO Box 933104, Atlanta, GA 31193-3104; telephone, 800-762-2264, ext. 192; e-mail: sales@acog.org. The ACOG Bookstore is available online at the ACOG Web site .

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

This NGC summary was completed by ECRI on January 14, 2005. This summary was updated by ECRI Institute on July 21, 2008. The updated information was verified by the guideline developer on August 11, 2008.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.