Those with severe or disseminated HSV are given IV acyclovir, 5 to 10 mg/kg every 8 hours for 2 to 7 days until clinically improved. This is followed by oral antiviral drugs to complete at least 10 days of total therapy (W orkowski, 2015). For intense discomfort, oral analgesics and topical anesthetics may provide some relief, and comorbid urinary retention is treated with an indwelling bladder catheter.
For recurrent HSV infections during pregnancy, antiviral treatment is provided mainly for symptom relief (see Table 65-4) . Although uncommon, acyclovir resistance has been reported, predominantly with HSV-2 and in immunocompromised patients (Andrei,r2013).
During pregnancy, amniocentesis, percutaneous cord blood sampling, or transabdominal chorionic villus sampling may be performed even with active genital lesions. With active lesions, however, internal electronic monitoring during labor is not recommended. T ranscervical procedures may best be delayed until lesions have resolved (American College of Obstetricians and Gynecologists, 20 16b).
To diminish vertical transmission risks, cesarean delivery is indicated for women with active genital lesions or prodromal symptoms (American College of Obstetricians and Gynecologists, 20 16b). Several studies have shown that acyclovir or valacyclovir suppression initiated at 36 weeks' gestation for gravidas with recurrences during pregnancy lowers the number of HSV outbreaks at term. The goal is to decrease the need for cesarean delivery (Hollier, 2008). his suppressive therapy will also decrease viral shedding (Scott, 2002; Sheield, 2006; Watts, 2003). One systematic review evaluated acyclovir prophylaxis given from 36 weeks to delivery to women with HSV recurrence during pregnancy. Sheield and colleagues (2003) found that suppressive therapy was associated with signiicantly lower rates of clinical HSV recurrence, cesarean deliveries for HSV recurrences, total HSV detection, and asymptomatic shedding. Subsequent studies using valacyclovir suppression have shown similar results (Andrews, 2006; Sheield, 2006). Because of these studies, the
TABLE 65-4. Oral Antiviral Medications for Herpesvirus Infection in Pregnancya
Acyclovir, 400 mg three times daily for 7-10 d
Valacyclovir, 1 9 twice daily for 7-1r0 days
Acyclovir, 400 mg three times daily for 5 days
Acyclovir, 800 mg twice daily for 5 days
Acyclovir, 800 mg three times daily for 2 d
Valacyclovir, 500 mg twice daily for 3 days
Valacyclovir, 1 9 once daily for 5 days
Acyclovir,r400 mg three times daily from 36 weeks until delivery
Valacyclovir, 500 mg twice daily from 36 weeks until delivery
Famciclovir not preferred during pregnancy due to fewer safety data.
Data from Workowski, 2015.
American College of Obstetricians and Gynecologists (2016b) recommends viral therapy at or beyond 36 weeks for women who had primary genital herpes infection or active recurrent genital herpes during pregnancy. It is unclear whether suppression is needed for women with outbreaks before but not during pregnancy. Notably, despite maternal antiviral suppression, several cases of atypical neonatal herpes infection have been reported (Pinninti, 2012).