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It is currently standard practice in the United States to perform cesarean delivery on pregnant women with recurrent herpes to reduce the risk of transmission of the virus to newborns. Still, 20 to 30 percent of all infants born with herpes simplex virus (HSV) are delivered via cesarean, according to the UCSF analysis, which raises questions about the effectiveness of this practice.
"There is currently insufficient evidence to support the practice of performing cesareans on mothers who show visible signs of HSV in an attempt to reduce transmission rates to their newborns," says senior author A. Eugene Washington, MD, MPH, MSc, professor and chair of the UCSF Department of Obstetrics, Gynecology and Reproductive Sciences.
"A promising intervention strategy is to suppress HSV outbreaks during the time of delivery by having women take the drug acyclovir," Washington says. Acyclovir is prescribed to treat HSV, and is commonly taken by pregnant women with HSV.
UCSF researchers reviewed and assessed published medical literature regarding the effectiveness and cost of different strategies to prevent vertical herpes transmission from pregnant women with a history of symptomatic genital herpes. Their analysis was then applied to a hypothetical population of 10,000 pregnant women with HSV.
They found that acyclovir in late pregnancy prevents outbreaks of genital herpes in women with recurrent infection and would prevent more neonatal HSV infections and save money over the current strategy of no acyclovir and cesarean delivery when genital lesions are present.
The four strategies UCSF researchers assessed were: A) cesarean delivery if genital HSV lesions were present; B) the antiviral drug acyclovir prophylaxis in late pregnancy with cesarean delivery if genital HSV lesions were present; C) acyclovir in late pregnancy with vaginal delivery if genital HSV lesions were present with screening and follow-up of exposed infants; and, D) no intervention.
The UCSF researchers found that the current practice of performing a cesarean prevents 2.8 cases of neonatal herpes and leads to 1,082 cesareans for herpes for every 10,000 women with genital herpes lesions at delivery. The costs for this strategy are more than $4 million.
Strategy B prevents 5.5 cases of neonatal HSV for every 10,000 women, with 216 women undergoing cesarean because of genital lesions despite the antiviral drug, at costs of more than $3 million.
In strategy C, UCSF researchers found that five cases of neonatal HSV are prevented with 10,000 mothers taking acyclovir and no cesarean deliveries for herpes, at costs of more than $2.3 million.
"Both acyclovir strategies prevent 1,360 maternal outbreaks of genital herpes at delivery," Washington says.
In strategy D, in which no intervention was applied, zero cases of neonatal infection are prevented, and 6.2 newborns are born with HSV (one in 1,604 women), at total treatment costs of more than $350,000.
More than 40 percent of newborns infected with HSV will die or suffer neurologic impairment, according to the UCSF analysis. "Because most neonatal herpes is transmitted by mothers with no symptoms of infection, women with recurrent genital herpes who have protective antibodies may opt for no intervention," Washington says.
Ten to 40 percent of women in the United States have antibodies to genital herpes, revealing an infection in their past. The rate of herpes transmission from these women to their newborns is less than one percent because of protective maternal antibodies, according to the study. In contrast, antibody-negative women with primary infections have transmission rates approaching 50 percent.
"Our analysis suggests that the current standard of practice of cesarean delivery for lesions is comparatively less effective and more costly than acyclovir," Washington says. "However, policy needs to incorporate patient preferences before it is changed."
Despite their low risk of herpes transmission, mothers with recurrent genital herpes may prefer to take acyclovir to decrease the discomfort and anxiety associated with outbreaks around the time of delivery, according to the UCSF analysis.
Co-authors of the study are Adrienne G. Randolph, MD, former UCSF research fellow, and Rachel M. Harshorn, BS, a UCSF medical student.
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CONTACT: UCSF News Services Rebecca Higbee (415) 476-2557
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