Herpes & Childbirth - Interventions for Reducing Neonatal Herpes

C-sections & Herpes Suppressive Therapy During Pregancy

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Part II: Introduction

It's all well and good to assess a woman's risk of transmitting herpes to her infant. However, what about the interventions that are designed to reduce the likelihood of neonatal herpes? Is there good evidence that they work?

There's definitely evidence. However, not everyone finds it convincing.

Return to Herpes and Childbirth Part I - Overview

How effective is suppressive therapy for herpes during pregnancy?

A 2003 systematic review analyzed the results of five studies on the use of acyclovir during the last month of pregnancy.

It found that suppressive therapy was highly effective. It substantially reduced outbreak frequency. It also reduced the likelihood of detecting any HSV at the time of delivery and the frequency of asymptomatic viral shedding. No patients in the acyclovir group tested positive for herpes via viral culture, compared to five percent of untreated women.

Right now the Academy of Obstetricians and Gynecologists strongly recommends that pregnant women at risk for recurrent genital HSV outbreaks consider suppressive therapy at or after 36 weeks. This is based on consensus and expert opinion.

Do c-sections reduce neonatal herpes transmission? Enough to make them worthwhile?

At any given hospital the number of neonatal herpes infections is relatively low. Therefore, there have not been a huge number of studies performed which have actually assessed how effective c-sections are at preventing neonatal herpes.

Furthermore, those studies that do exist were not highly powered. However, those studies which have examined the question do suggest a solid relationship between c-sections and a reduction in neonatal herpes. Interestingly, the largest study examining the question of c-section efficacy found that symptomatic women were less likely to have infants with neonatal herpes.

It didn't matter that women with genital lesions were presumably more likely to be shedding virus. They were almost always given c-sections.

That said, c-sections alone will not completely prevent neonatal herpes transmission. Several smaller studies have seen cases where neonatal herpes occurred after a c-section. That may be more likely if a woman's water breaks a long time before she gives birth. Furthermore, c-sections can have significant physical and psychological consequences. That may encourage some women to seek out other options.

Current ACOG guidelines state that c-sections are indicated for women with active herpes infections or prodromal symptoms at the time of delivery. However, they are not recommended for women who have a history of herpes but are not in the middle of an outbreak.

Conclusion: Can Women with Genital Herpes Give Birth Vaginally?

Herpes and childbirth are two highly emotionally charged issues. That is why women should get all the information they can about their options and discuss them in detail with their doctors.

Evidence suggests that women with long-established, asymptomatic genital herpes infections have a very low risk of neonatal herpes. They don't need to let their childbirth choices be dictated by the virus.

The case is more complex for women who became infected with herpes late during their pregnancy, or who experience regular outbreaks. In both circumstances, women have two options they can use to reduce their infant's risk of neonatal herpes - suppressive therapy and c-sections.

There is research to support both choices. However, results are clearer for women with recurrent infections than those with primary infections. That's true despite the differences in their absolute risk. This is, at least in part, because there are substantially fewer women who are diagnosed with a primary herpes infection during pregnancy.

That makes interventions difficult to research.

In the end, evidence suggests that vaginal birth can be a reasonable and informed choice for women who have genital herpes. However,, it is certainly not the choice for everyone. Circumstances will vary. Women should not hesitate to discuss the pros and cons of all available options with their doctors during their prenatal care.


American College of Obstetricians and Gynecologists (ACOG). Management of herpes in pregnancy. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2007 Jun. 10 p. (ACOG practice bulletin; no. 82)

Brown ZA et al. Genital herpes complicating pregnancy. Obstet Gynecol. 2005 Oct;106(4):845-56. R

Brown ZA et al. Effect of serologic status and cesarean delivery on transmission rates of herpes simplex virus from mother to infant. JAMA. 2003 Jan 8;289(2):203-9.

Garland SM et al. Do antepartum herpes simplex virus cultures predict intrapartum shedding for pregnant women with recurrent disease? Infect Dis Obstet Gynecol. 1999;7(5):230-6.

Rouse DJ, Stringer JS. Cesarean delivery and risk of herpes simplex virus infection. JAMA. 2003 May 7;289(17):2208; author reply 2208-9.

Sheffield JS et al. Acyclovir prophylaxis to prevent herpes simplex virus recurrence at delivery: a systematic review. Obstet Gynecol. 2003 Dec;102(6):1396-403.

Tronstein E et al. Genital shedding of herpes simplex virus among symptomatic and asymptomatic persons with HSV-2 infection. JAMA. 2011 Apr 13;305(14):1441-9.

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