Maternal antiviral suppressive therapy may not be as effective as thought

By Piriya Mahendra

Maternal antiviral suppressive therapy does not necessarily prevent the development of neonatal herpes simplex virus (HSV) disease, warn researchers in The Journal of Pediatrics.

Although various studies have proved the efficacy of antiviral therapy to suppress clinical reactivations of genital herpes in women, such maternal suppressive therapy does not completely prevent subclinical virus shedding and transmission, report Robert Tolan (The Children's Hospital at St Peter's University Hospital, New Jersey, USA) and team.

Therefore, physicians who care for neonates must have a "high index of suspicion" for HSV infection in an unwell infant and should consider evaluation of those born to mothers receiving antenatal antiviral suppression therapy, they write.

Eight mother-neonate dyads were identified between 2005 and 2009. Of the six mothers who were screened prenatally for group B Strep, all tested positive for the bacterium.

Of the remaining two mothers, one had not been tested, and the other had bacterial vaginosis and genital human papillomavirus infection.

Six mothers had no history of genital HSV infection prior to falling pregnant. Two mothers with a history of clinical genital HSV had no clinically recognized outbreak during the pregnancy.

Perinatal transmission of HSV occurred in seven infants whose mothers took suppressive therapy, which was continued until the day of birth in five cases.

Seven infants were diagnosed with HSV by 8 days of age. One infant was diagnosed at 27 days of age after coming to medical attention with central nervous system (CNS) disease. This is an unusually late presentation for neonatal HSV and it is possible that it was a first reactivation or progression of infection or delayed presentation with milder disease due to maternal antenatal antiviral therapy, say the authors.

Specifically, five infants had disease limited to the skin, eye, and mucous membranes or mouth, two had CNS disease (one with and one without disseminated disease), and one had intrauterine/disseminated disease.

The American College of Obstetricians and Gynecologists' recommendation that suppressive antiviral therapy be offered to women with a history of recurrent genital HSV is based on limited or inconsistent evidence, and until now, no study has investigated the impact of this therapy on neonatal HSV disease, say Tolan et al.

"The effect of suppressive therapy on the natural history and clinical presentation of neonatal HSV remains to be defined," they conclude.

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