When genital herpes complicates pregnancy

It was three o’clock in the morning when Olga* woke me up. When an expectant mother calls, especially in the middle of the night, sleep has a way of hightailing out of the room. I sat up, my mind already imagining the myriad of complications that could have happened.

Olga was 33 weeks pregnant with twins resulting from in-vitro fertilisation (IVF). The couple had tried to conceive for nine years, with four failed IVF trials before the stars finally aligned. They were weeks away from welcoming their twin bundles of joy and we were all anxiously counting the days.

I picked up the call to find Donald*, her husband, on the phone. Olga was in distressing pain. She was seated in the bathtub, filled with cold water in the dead of the night. Olga came on the phone and explained that she had developed some vulval irritation two days prior and she assumed it was a case of yeast infection.

Having been treated for the yeast infection in the past, she self-medicated with an antifungal cream previously prescribed, awaiting her next clinic visit for review. This gave her some temporary relief and she was able to get through the day.

However, towards evening, the itch worsened and while reapplying the cream, she noted a rash around the vulva.

She opted to wait out the night and report to clinic in the morning but this was not to be. The itch became a searing pain that could not allow her to sleep. She could not find relief from anything and her last option was to soak in the cold water in an attempt to put out the fire between her legs! Donald had to bundle Olga out of the tub and straight to the emergency department for pain management. By the time I saw her, she was blissfully relieved of the maddening pain and able to give a coherent history and tolerate a physical examination and lab tests.

The test results confirmed what we suspected, that Olga had Herpes simplex infection in pregnancy. This was definitely a major hurdle at this stage of the pregnancy. Whereas herpes simplex outside of pregnancy is regarded as less threatening, pregnancy throws a real big spanner in the works.

Herpes simplex viruses occur in two types. Type 1 occurs predominantly in the oral region, including the lips, nose and mouth. Type 2 occurs more commonly in the genital region. However, both types may cross over, especially due to oral sex. Most patients will clear the infection from the system even without treatment and may seek treatment in severe disease with intolerable system.

Herpes simplex infection has the capacity to stay quietly in the body without causing symptoms for literally a lifetime after the initial infection. This is because the body produces lasting antibodies that keep the infection in check.

However, every so often, especially when the immune system is weakened, the infection reactivates with new onset of the symptoms. It is therefore more likely to cause severe illness in those with immunosuppression such as patients with HIV who are not on treatment, those on immunosuppressive treatments such as transplant patients, and those born with immunosuppressive conditions.

Pregnancy presents a unique condition, involving two separate patients, both at risk. Pregnancy suppresses immunity in the woman.

This is a physiologic response to protect the baby from being rejected by the mother’s immune system. They are therefore more likely to get severe herpes simplex.

The baby remains at risk of contracting the infection from the mother. In the baby’s case, their naïve immunity puts them at such high risk that the mortality rate is over 80 per cent. For those mothers having a reactivation of the infection, they already have antibodies, which they pass onto baby and therefore the risk of passing it on to the baby while in the womb is as low as three per cent.

However, for those who get the infection for the first time in pregnancy, this risk rises to over 50 per cent. The highest risk to the baby remains at delivery. If the mother has active genital infection at delivery, baby has over 85% risk of getting the infection!

With these challenges in mind, we ascertained that Olga was suffering from reactivated herpes. We were able to start her in antiviral medication in the ward and later discharged her to remain on it at home until birth. Her babies were delivered by caesarian section and they both tested negative for the infection. It was a long journey but she could eventually exhale!

Dr Bosire is an obstetrician/gynaecologist