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Physicians Continue to Disagree About Vaginal Delivery and Herpes

Family Practice News, February 15, 1995, page 29

Vaginal Delivery During Recurrent Herpes: Experts Agree to Disagree

SAN FRANCISCO -- Try as they might, physicians attending a workshop at the annual meeting of the International Herpes Management Forum could not agree to recommend vaginal delivery in pregnant women with a lesion from recurrent genital herpes.

Some European members clearly were disappointed that they could not persuade their American colleagues to drop an emphasis on cesarean section delivery in these cases.

Instead, the workshop group agreed that The potential risks of both modes of delivery should be discussed with the mother to be (preferably well before delivery) and informed consent obtained for the chosen method. If vaginal delivery is selected, avoid the use of instruments such as forceps or fetal scalp monitors whenever possible.

About 1 in 10 women with recurrent herpes will have a lesion at delivery.

"I'm very disappointed," said Dr. Willem van der Meijden, a gynecologist in the department of dermatology and venereology at University Hospital, Rotterdam, The Netherlands.

"The rate of cesarean sections has gone down dramatically in the Netherlands, and there is not a single extra case of neonatal herpes. That was reached primarily by telling obstetricians not to operate on women with a history of genital herpes:' he said.

Dr. Babill Stray-Pedersen, professor of obstetrics and gynecology at the University of Oslo, said that only 8% of babies in the Netherlands are delivered by cesarean section, compared with 13% in Norway and 22% in the United States. In the United States, maternal mortality is three to four limes higher with cesarean section than with vaginal delivery, and cesarean section generates 20 times as much morbidity.

Primary herpes simplex virus type 2 infection in the mother carries a 50% chance of infecting the baby, but with recurrent herpes the rate of neonatal infection is 1-3%. "As far as we know now, whether you have a lesion or not, the transmission rate is the same" in recurrent herpes, she said.

Dr. Stray-Pedersen cited one study that calculated one maternal death for every 1.75 cases of neonatal herpes prevented under a policy of cesarean sections when recurrent lesions are present. Approximately 1,580 "excess" cesarean sections would be needed to prevent one case of neonatal herpes (JAMA 270:77- 82,1993).

An Israeli physician complained that much of the medical world follows the lead of the United States. "To change the practice in my country, we must try to change the practice in the U.S.," he said.

Dr. Larry Corley, head of the virology division at the University of Washington School of Medicine, Seattle, said cesarean sections in the presence of recurrent lesions are a sore subject for some U.S. physicians as well.

"You can't manage it rationally in the United States" because of the threat of lawsuits, he said. "That C-section may not be warranted [in these cases] is probably correct," he added, but he still recommends avoiding vaginal delivery in these women.

The only way to change the practice in this country may be to give suppressive antiviral therapy to women with a history of herpes simplex virus disease in order to prevent lesions at delivery and avoid a cesarean section. "You may treat hundreds who don't need it, but it still may be cheaper than a C-section:' he suggested.

The lack of data on the protective effects of cesarean section vs. vaginal delivery left most of the group reluctant to recommend either one. Dr. van dei Meijden suggested establishing "Mode of Delivery Registry" for women with recurrent genital herpes during labor, so that institutions with different approaches could compare outcomes.

Until there are substantive data, he said, "it is clear that much is not clear"

All agreed that vaginal delivery is appropriate in women with recurrent herpes but no lesion at the time of delivery. They suggested culturing to detect the presence or absence of asymptomatic viral shedding, mainly in the hopes that a negative result will relieve some of the worry for parents sent home with instructions to be alert for herpes symptoms in their child.

The group also recommended marking the mother's and baby's charts--in code, if it's a sensitive subject--to indicate the presence of maternal herpes. Women should be examined at the time of birth and asked to point to any affected area if they think they are having a recurrence. Cultures should be taken from a woman with symptoms irrespective of the presence or absence of a lesion.

[CDC- Primary herpes infection in the mother has a 50% chance of infecting the baby.]