Protocols

Subject: Genital Herpes

Screening/Diagnosis:

Primary Infection: Patient not previously documented as having herpes.

A. Suspicious Genital Lesion:

1. Obtain cultures from fresh filled vesicles

2. Unroof vesicles with a small needle such as that found on a TB syringe (this may be painful)

3. Dip sterile swab in transport media and then scrape vigorously over the suspicious lesions or vesicles. Simply collecting fluid on the lesion is unsatisfactory.

4. If lesion is crusted over, virus yield can be improved by applying a saline soaked sponge over the lesions for 10-15 minutes prior to obtaining the culture.

Infection in Pregnancy: Patients documented by culture or pap smear in the past

or during the current pregnancy as having herpes.

1. Educate re: symptoms and clearly document "h/o herpes" on OB record.

Offer acyclovir prophylaxis at 36 weeks until delivery.

2. Advise that if herpes lesions or prodrome are present in the lower genital tract or on the vulva at the time of labor, a cesarean section will be necessary.

3. If a patient with a history of herpes presents with signs or symptoms of early labor or rupture of membranes, refer for immediate evaluation to Duke University.

4. In patients with active lesions after 32 weeks please refer to high risk clinic for evaluation and management discussion

Recommendations

1. Avoid sexual contact as long as lesions or pain persists. When sexual activity is resumed, a condom should be used.

2. Analgesics such as Tylenol with codeine may be prescribed to decrease the amount of pain.

3. Acyclovir and other thymidine kinase inhibitors can be prescribed for outbreaks as well as prophylaxis in pregnancy. Consult with health care provider regarding use for outbreaks during pregnancy and for prophylaxis either after an outbreak or around the time of delivery.

4. If a patient is on prophylactic therapy it can be continued in pregnancy.

5. Acyclovir and other thymidine kinase inhibitors can be used if breast feeding.

Prepared in conjunction with the

Division of Maternal-Fetal Medicine

Duke University Medical Center

Director

Date

1/16/07

References

Genital Herpes

1. ACOG Practice Bulletin No. 8, Oct 1999. Management of Herpes in Pregnancy.

2. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines 2006. MMWR 2006:55(No. RR-20)

The Clinical Care Guidelines Development Committee of the Perinatal Improvement Board of Duke University Health System has developed a series of multi-disciplinary protocols to offer guidance to health care providers who are caring for pregnant women with high risk conditions.

These protocols are designed to assist health care providers in the management of a variety of problems that occur in pregnancy and the time of delivery. They should not be interpreted as standard of care, but instead represent only general guidelines for the care of pregnant women with high risk conditions. We recognize that services offered by individual providers depend not only on their training, experience and institutional resources, but on the medical facts and circumstances of the specific care situation.

The protocols remain the intellectual property of the Duke University Health System. They cannot be reproduced in whole or part without the expressed permission of the Health System.

These protocols are reviewed by the Department of Obstetrics and Gynecology Division of Maternal-Fetal Medicine, the Department of Pediatrics Division of Neonatology and the Department of Anesthesiology Division of Women’s Anesthesia. Please contact Andra H. James (andra.james@duke.edu), Chair, Clinical Care Guidelines Development Committee of the Perinatal Improvement Board with ideas for additional protocols.

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Protocols