To conclude the main points:
First and foremost, what is herpes and what are the risks of becoming infected? Genital herpes comes from the sexually transmitted herpes simplex virus largely as either HSV-1 or HSV-2. HSV-1 is typically seen as an oral infection, but can be transferred and cause a genital infection. HSV-2 is typically seen in the genitalia. HSV, when active can cause one or more sores that blister and break taking sometimes over a week to heal. Most people remain asymptomatic or mistake symptoms for another skin condition like acne. Even when no active lesions are present, the person still sheds the virus 10% of the time in consistently asymptomatic people, and 20% of the time in symptomatic people. According to the CDC 11.9% of people are known to be infected with the virus, but 87.4% of people who have the virus never receive a clinical diagnosis(CDC Herpes Facts, 2019). This is largely because the CDC no longer recommends proactively screening for herpes in a standard STD screen. They found that someone diagnosed when not having active symptoms will on average not change their sexual behavior such as wearing a condom or remaining abstinent (CDC Screening, 2019).
It is near impossible to measure the viral load at any given time as it can fluctuate up to 10-fold over hours, so statistical modeling is used more frequently than actual in-situ modeling. Researches at NIH discovered there is no specific minimum threshold in which transmission between an infected partner and uninfected partner will not occur, but did find that more transmissions occurred when the viral load exceeded 104 HSV DNA copies. This included partners on antiviral medication. Their ultimate conclusion was that transmission would be significantly reduced if interventions were able to keep viral loads below this level. However, the study did not account for the differences in the type of sexual activity besides coitus nor the regional anatomical shedding. They also did not account for gender differences, but posited that since women have more mucosa which the HSV can easily breach versus men who contain anucleate cells that are not easily breached; uninfected women are more likely to contract HSV from an infected partner than vice versa. They also have a lower threshold viral load for transmission than their male counterparts. This is supported in that women make up the majority of the HSV infected populous. (Schiffer, 2014)
Couples are counseled to use condoms, infected partner take antivirals, and abstain from intercourse when lesions are present. Although condom use has been shown to decrease the transmission of HSV-2, it isn’t guaranteed. In one older study, the specifically only looked at the criteria of HSV-2 transmission and condom use. They found of their 1843 participants, 6.4% (118) became infected. (Wald, 2005). 80% of active shedding occurs whilst the person is asymptomatic. Lesions are not a good indicator of a high or low viral load that could lead towards transmission. High viral loads often occur before lesions are visible, and the virus may actually be absent when lesions are present due to the nature of healing tissue compared to viral clearances. The majority of transmission occurs during asymptomatic shedding.
The biggest question is: will partners definitely contract herpes from one another? This unfortunately is almost impossible to answer given the high variable viral load, intervention usage, and susceptibility of her own body to the virus. In the Schiffer et. Al study, the participants of the trail were counseled to prevent transmission, knew the status of their partner, and many were on antivirals. The couples who did not transmit the virus were dubbed by the researches as “survivors” when they had been together for a mean of 2 years. A larger hurdle for one trying to conceive, is they may ultimately need to forgo condom use and thus increase their chance of contracting the virus. Additionally, it has been shown that HSVs exist in semen and can infect their partners. It has been recommended that sperm banks screen not only men, but the semen itself for the herpesviruses due to the quickly fluctuating viral loads. (Kaspersen, 2013) Even if a couple decided not to have unprotected intercourse and use other means to become pregnant, the virus could still be in the semen being used.
In healthy adults with no interest in reproduction, herpes was originally thought to be mostly a nuisance. However, we are continually learning more about its implications in neurological health in adults. Just last year HSV-1 was linked to be a major factor in Alzheimer’s (Itzhaki, 2018). It also has shown to increase susceptibility to HIV infections (Schiffer, 2014).
As a midwife however, my ultimate concern is how it will effect the dyad of pregnant person and neonate. If the baby contracts HSV there is a wide range of issues that vary from only lesions to central nervous system damage to even death. Lesions that effect the skin, eyes, mouth with no CNS involvement account for roughly 45% of cases. Systemic treatment using antivirals (specifically acyclovir) results in positive outcomes and contain the virus from spreading. The baby may still have outbreaks as they move through their childhood. 30% of cases include infections to the central nervous system and result in poor feeding due to lethargy, seizures, and possible cutaneous lesions. Testing of the cerebrospinal fluid can confirm CNS involvement. Other outcomes may include epilepsy, blindness, and cognitive disabilities. Morbidity is higher in infants from an HSV-2 infection than HSV-1. Disseminated infections account for 25% of HSV infections and involve multiple organs such as the brain, liver, and lungs. Morbidity is a high 30% with disseminated infections, even with antiviral treatments. Symptoms manifest like sepsis and usually exclude a rash or lesions, thus subsequent testing for HSV DNA should be done. (Lawrence Corey, 2009).
The risk of neonatal herpes infection from a pregnant person with established genital herpes is 1 in 5500 births. Bloodwork should be drawn around 15-20 weeks to identify if the pregnant partner is seropositive, which will have implications to the care received in labor. Some precautions include avoiding AROM, scalp electrodes, and recommending a cesarean if lesions are present on the cervix or vagina at time of birth. (Warren, 2014) One piece that seems to effect neonatal outcomes the most is when herpes is contracted. If the pregnant person already has HSV before pregnancy, or contracts it early on in pregnancy, the risk of infecting the baby is less than 1% from HSV-2 shedding at term (Johnson, 2018). However, if the person contracts herpes in the third trimester, the risk of infecting the baby jumps to 30-50%. This is due to the inability to build up and pass antibodies onto the baby in the short amount of time before birth. This the recommendation is strongly to not to have intercourse during the third trimester. Antiviral therapy and condoms again, do not provide 100% coverage against transmission.
It is possible to have a healthy vaginal birth with seropositive HSV. Parameters might include no active lesions from a non-initial outbreak, only external lesions covered with surgical adhesive film or spray on bandage. (Davis, 2012) Some providers recommend antivirals during the last 4 weeks of pregnancy to reduce the risk of active lesions; this only reduces active lesions, it does not reduce the risk of neonatal HSV infection.
What does this all mean for people in this situation? Should they have babies? Should they use a donor? Should the birthing person schedule a cesarean and generally remove all worries? I can’t answer those questions for another person. Contracting herpes isn’t the end of the world. There are better and more effective antiviral treatments out all the time. Even is the pregnant person does end up contracting the virus while attempting to conceive a baby, she can choose to have a cesarean. There is such negative stigma associated with choosing a c-section these days, but if that is what helps her mitigate risk, then this is when it is truly a blessing to have this option. There are even beautiful ways to have a family centered cesarean, prepare for a supported recovery period, and opt for a VBAC next time when the risks are lower. The possibilities are endless, but love of partner and baby is what is most important through all of this.
Suggested Main Reading – The Updated Herpes Handbook by Terrie Warren, R.N. M.S. M.Ed Nurse Practitioner. 2014. Available for free online.
- Maternal and Neonatal Herpes Simplex Virus Infections by Lawrence Corey and Anna Wald. 2009. Available for free with registration in the New England Journal of Medicine.
References CDC. (2019, 29 1). Retrieved from STD - Herpes Facts: https://www.cdc.gov/std/herpes/stdfact-herpes-detailed.htm
CDC. (2019, 1 29). Retrieved from STD Screening: https://www.cdc.gov/std/herpes/screening.htm
Davis, E. (2012). Heart and HAnds. A Midwife's Guide to Pregnancy and Birth, p. 18.
HSV-2 Transmission probablity. (2019, 1 29). Retrieved from NCBI: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4006256/
Itzhaki, R. (2018, October 19). Cooroboration of a major role for HSV-1 in Alzheimer's. Retrieved 1 30, 2019, from Frontiers in Aging: https://www.frontiersin.org/articles/10.3389/fnagi.2018.00324/full
Johnson, T. C. (2018, September 9). Pregnancy and Genital Herpes . Retrieved from WebMD: https://www.webmd.com/genital-herpes/guide/genital-herpes-pregnant
Kaspersen, M. (2013, July 8). Seminal Shedding of Human Herpesviruses. Retrieved 1 30, 2019, from NCBI - NIH: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3717016/#B66
Lawrence Corey, A. W. (2009, October 1). Maternal and NEonatal Herpes Simplex Virus Infections. Retrieved from New England Journal of Medicine: https://www.nejm.org/doi/full/10.1056/NEJMra0807633
Moore, D. E. (1989, June 16). Transmission of Genetial Herpes by Donor Insemination. Retrieved from JAMA: https://jamanetwork.com/journals/jama/article-abstract/377694
Schiffer, J. (2014, June 6). HSV-2 Transmission Probability based on quantity of viral shedding. Retrieved 1 29, 2019, from NCBI - NIH: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4006256/#RSIF20140160C20
Wald, e. A. (2005, 11 15). Relationship Between Condom use and HSV Aquisition. Retrieved 1 29, 2019, from NCBI - NIH: https://www.ncbi.nlm.nih.gov/pubmed/16287791
Warren, T. (2014). The Updated Herpes Handbok. Retrieved from Westover Heights: https://westoverheights.com/wp-content/uploads/2014/08/Updated-Herpes-Book.pdf
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