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H:\Infections In Pregnancy 2008 Cert Day 1[1]
 

H:\Infections In Pregnancy 2008 Cert Day 1[1]

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    H:\Infections In Pregnancy 2008 Cert Day 1[1] H:\Infections In Pregnancy 2008 Cert Day 1[1] Presentation Transcript

    • Infections in Pregnancy Chris Rust, RNC- OB, MSN Sandy Warner RNC-OB, MSN
    • Acquired Immune Deficiency Syndrome
      • Organisms
      • - HTLV III– Human T- Cell Lymphotrophic
      • Virus
      • - HIV – Human Immune Deficiency Virus
      • Classes
      • I - Primary HIV
      • II - Asymptomatic /Latent HIV – months to yrs
      • III - Clinical Illness – life expectancy – 5 yrs.
      • IV - AIDS
    • AIDS
      • Selectively targets and
      • destroys T-cells,
      • macrophages and
      • monocytes thereby
      • decreasing and
      • eventually eliminating
      • cellular immunity.
    • Mode of Transmission
      • Direct contact with body fluid
      • Direct transmission to infant through vagina
      • Transplacentally
      • Breast milk
      • Rates
      • - 20 % HIV transmission in utero
      • - 80 % during L & D
    • Risk Factors
      • Multiple sex partners
      • Infected with another STI
      • Illicit IV drug use
      • Emigrant from an HIV-endemic area such as Haiti or Africa
      • Prostitution
      • Received a blood transfusion between 1977 and 1985
      • Gilbert,E.S. (2007). Manual of high risk pregnancy & delivery . St. Louis: Mosby-Elsevier, p. 568.
    • Detection
      • Two types of testing
      • - Rapid HIV tests
      • ▪ OraQuick Advance HIV-1 Antibody Test
      • ▪ Uni-Gold Recombigen HIV Test
      • ▪ Reveal Rapid HIV-1 Antibody Test
      • - Confirmatory tests
      • ▪ Western blot – most specific test
      • ▪ IFA – (immunoflourescence Assay)
    • Maternal Effects
      • Initial symptoms -mono-like initial symptoms – fever, pharyngitis, lymphadenopathy, arthralgia, n&v, fatigue, weight loss
      • Erythematous maculopapular rash
      • Diffuse urticaria
      • Alopacia
      • Multiple infections
      • Disseminated Kaposi sarcoma
      • PTL, IUGR, PROM, postpartum endometritis
      • Susceptible to opportunistic infections
    • Newborn Effects
      • All newborns will have + antibodies for HIV
      • 20-30% will remain positive by 15-18 months and will develop AIDS (300 per year in the US)
      • Increased risk of stillbirth, neonatal mortality
      • With treatment transmission risk < 2 %
    • Treatment
      • Antepartum – ( > 28 wks) - ZDV 200 mg. po. TID or 300 mg. BID.
      • Intrapartum – IV ZDV and a single dose of NVA (nevirapine) or 3TC (lamivudine) at onset of labor.
      • - If the patient has a viral load of < 1000 copies/
      • ml c-section may not be required
      • Postpartum – ZDV po and protease inhibitors
      • Neonatal – ZDV syrup 2 mg/kg po Q 6 hrs from 12 hours of birth through 6 weeks of life (Term infants)
      • Gilbert,E.S. (2007). Manual of high risk pregnancy & delivery . St. Louis: Mosby-Elsevier, p.569.
    • Other Factors
      • Total isolation
      • No scalp electrodes
      • Double glove
      • Vaginal delivery
      • No breastfeeding
      • If scheduled C/S drug administration 3 hours prior to surgery is optimal
    • Other Factors for Infant
      • Mechanical suction of newborn
      • Minimize infant exposure to maternal fluids
      • Give infant a bath as soon as possible
      • No injections or eye ointment until bath is given
      • HIV DNA PCR blood test along with CBC as part of their admission lab work
      • (Infants become anemic when taking ZDV)
    • Hepatitis
      • Hepatitis A - 40%
      • Hepatitis B - 45%
      • Hepatitis C - 5-10%
      • Hepatitis D - 5-10%
      • Hepatitis E - 5-10%
      • 136,000 new cases/yr.
    • Hepatitis
      • Inflammation of the liver caused by a viral infection
      • Acute or chronic
      • Degeneration and necrosis of the liver
      • Inflammation and swelling blocks bile duct secretion
      • Incubation period 1-6 months
      • Affects 1 in 500-1,000 pregnancies
      • Bile backs up leading to jaundice
      •  ALT, Alk Phos,  Bilirubin
    • Hepatitis B -Transmission
      • Sexual contact
      • Shared needles
      • Transplacental
      • Direct contact with secretions (blood, stool, semen, saliva, amniotic fluid, breast milk)
      • Shared personal items (toothbrush, razor, washcloth)
      • HBV can survive up to one week in dried blood or body secretions
    • Detection
      • Hepatitis B virus is a double-stranded DNA virus consisting of:
      • - HBcAG – [core antigen] acute infection
      • only found in liver
      • - HBsAG –[surface antigen]- acute/chronic
      • first to appear
      • - HBeAG – [e antigen] HBV is active in serum and patient is highly infective
    • Acute HBV infection:
      • HBsAg is elevated
      • HBeAg is elevated
      • Immunoglobulin M (IgM) anti-HBc is elevated
      • Gilbert,E.S. (2007). Manual of high risk pregnancy & delivery . St. Louis: Mosby-Elsevier, p.561.
    • Chronic HBV Infection (Carrier state)
      • HBsAg remains elevated
      • IgG anti-HBc remains elevated
      • IgM anti-HBc is absent
      • If HBsAg is positive but HBeAg is negative this indicates a carrier state without active liver disease.
      • If HBsAg & HBeAg are both positive it indicates a carrier state with active liver disease.
      • Gilbert,,E.S. (2007). Manual of high risk pregnancy & delivery . St. Louis: Mosby-Elsevier , p.561.
    • Maternal Effects
      • Pregnant patient with acute HBV :
      • - Chronic low grade fever
      • - Nausea and vomiting
      • - Anorexia
      • - Fatigue
      • - Skin rashes
      • - Arthralgia
      • Gilbert,E.S. (2007). Manual of high risk pregnancy & delivery . St. Louis: Mosby-Elsevier,p.561.
    • Fetal /Newborn Effects
      • 70% chance of fetus being infected if acute onset is in 3 rd trimester
      • 70-90 % chance of being infected if mother is chronic carrier
      • Rarely develops symptoms
      • 90% chance of becoming chronic carrier
      • 25% chance of developing cirrhosis and/or liver cancer by age 50.
      • Also at risk if other family members are chronic carriers
    • Treatment
      • Mother – If exposed during pregnancy and HBsAg (–) give HBIG, repeat HBIG in 1 month, followed by Hepatitis vaccine series.
      • If the Mother contracts HBV during pregnancy – can only treat symptoms (bedrest, diet high in protein, low in fat)
      • Infant –
      • If Mom is HBsAg (+) give HBV vaccine and
      • HBIG within 12 hrs. of delivery and at 1 & 6
      • months.
    • High Risk Categories
      • Pregnant women from:
      • 1) China
      • 2) Southeast Asia
      • 3) Central Africa
      • 4) Middle Eastern
      • 5) Pacific Island
      • 6) Alaska
      • IV drug users
      • Prostitutes
      • Other STIs’ and/ or multiple partners
      • Recipients of multiple transfusions
      • Health care workers with blood and needlestick exposure
    • Hepatitis A
      • Formerly known as infectious hepatitis
      • 1:1,000 pregnancies
      • Found in southeast Asia, Africa, Central America, Mexico, Middle East
      • Spread through fecal-oral route, person to person contact or ingestion of contaminated food or water – Not spread by blood
      • Incubation period 28 days
      • Transmission common in Day Cares
      • Acute Infection – IgM Anti-HAV
      • Not a chronic carrier
      • Immunization available
    • Hepatitis C
      • Major cause of acute and chronic hepatitis
      • Asymptomatic in most people
      • Breastfeeding does not increase transmission rate
      • Transmission same as Hepatitis B but not as easy to spread through sexual intercourse
      • High rate of chronic disease
    • Hepatitis C
      • C/S has not proved beneficial in lowering vertical transmission rates
      • Diagnosis – detecting the antibody to Hepatitis C through Enzyme Immune Assay (EIA). If positive the confirmative test is RIBA.
      • (Anti-HCV). Specimen obtained by liver biopsy
      • No cure
    • Hepatitis D (Delta)
      • Occurs with Hepatitis B
      • Incubation 2-8 weeks
      • More common in the Mediterranean Sea
      • Identify antibody to Hepatitis D Anti-HDV or liver biopsy
      • Highly infectious
      • Obtained from multiple transfusions, IV drug abuse, hemophilia
      • Covered by Hepatitis B vaccine
      • Diminished liver function, increased jaundice, altered mental status
    • Hepatitis E (HEV)
      • Obtained through sewage contaminated food or water
      • Increased during times of floods, hurricanes or rainy season
      • Similar to Hepatitis A
      • Found in India, Southeast Asia, Africa, South America
      • Usually affects people of childbearing age (15-40 years old)
      • Does not exist as a chronic carrier
      • IgG anti-HEV shows immunity
    • Hepatitis E (HEV)
      • Characterized by mild illness – high mortality rate if infection is acute in third trimester due to liver failure
      • Neonates die from HEV infection more than from any other type of viral hepatitis
      • Vertical transmission has been reported
      • Acute infection diagnosed by a positive serum test for IgM anti-HEV antibody. This test is not available in most labs.
    • Gonorrhea
      • Agent - Neisseria Gonorrhea (gram negative)
      • Mode of Transmission – Oral, rectal, genital.vertical transmission to fetus
      • Incubation – 10 days – Does not cross the placenta
      • 0.5 to 7 % in pregnancy
      • Screen for chlamydia and trich
      • PID in 40% if untreated
      • Symptoms – Chills, fever, vaginal discharge/ bleeding
    • Gonorrhea
      • Detection
      • - Endocervical /Urethral /rectal/ throat culture
      • - ELISA Immunoassays
      • - If asymptomatic do DNA culture
      • Treatment
      • - Fetus – Erythromycin eye ointment
      • - Mother – Ceftriaxone 125 mg IM
      • and Cefixime 400 mg PO
      • - Treat all sexual partners
    • Maternal Effects
      • 70-80% asymptomatic
      • Endocervicitis causes weakening of the fetal membranes and leads to PROM /PTL
      • Associated with septic abortions
      • GU infections with dysuria, pyuria
      • Often seen with chlamydia
      • Postpartum endometritis, decreased fertility
      • Yellow purulent discharge
      • Tenderness of Skein/ Bartholin glands
      • May cause sever disseminated infection – arthritis, perciarditis, meningitis, dematitis
    • Maternal Effects
      • Postpartum endometritis, decreased fertility
      • Yellow purulent discharge
      • Tenderness of Skein/ Bartholin glands
      • May cause sever disseminated infection – arthritis, pericarditis, meningitis, dematitis
    • Fetal Effects
      • PROM
      • Chorioamnionitis
      • Purulent conjunctivitis
      • Sepsis/meningitis
      • May breastfeed after antibiotic treatment – frequent handwashing extremely important
    • Syphilis
      • Agent – Spirochete - Treponema Pallidium
      • Incubation – 10 - 90 days (average 21 days)
      • Mode of transmission – Sexual, oral, anal, vaginal, direct contact with lesion, placental transmission, through vagina during birth
    • Congenital Syphilis
    • Syphilis
      • Detection
      • - RPR (Rapid Plasma Reagin)
      • VDRL ( Venereal Disease Research Laboratory) > 1:32 = reactive
      • FTA-ABS – Flourescent treponeum
      • antibody absorption – Confirmatory test
      • Must have 2 positive tests for confirmation
      • Will have positive test within 4 wks of exposure
    • Maternal Effects
      • Primary chancre – painless ulcer on lips, genitalia, oral cavity
      • Secondary- flu-like symptoms, red macules on soles and palms, generalized lymphadenopathy, patchy hair loss, neuromuscular and cardiovascular symptoms
      • Latent – can lay dormant for many years
      • Tertiary-involves heart, blood vessels, nervous system, muscle movement, dementia
    • Fetal Effects
      • Varies depending on gestation
      • IUGR, anomalies, IUFD, PTL,stillborn
      • Absent nasal bridge, pneumonia, hepatitis, jaundice, skin lesions, hydrops, seizures
      • Placenta large and pale with club-like, thick villi
      • 25% die in utero, 30 % die post delivery, 40% develop tertiary syphllis
    • Treatment
      • Prevention
      • Primary, secondary and early latent – PCN G 2.4 mil units IM x 1 dose
      • Latent & tertiary - PCN G 2.4 mil units IM q weekly x 3 weeks
      • < 1 yr old - PCN G 2.4 million units IM x 1 dose
    • Group Beta Strep
      • Agent
      • - Beta Hemolytic Streptococcus (Gram +
      • cocci) – contains 5 subtypes
      • Mode of transmission – 10 - 30 % maternal carriage (Colonizes in rectum, vagina, cervix & urethra
      • - Ascending infection - 50%
      • - Vaginal tract infection– 25%
      • - Other – 25%
      • Detection
      • - Urine culture
      • - Anogenital culture
    • GBS
      • Most common cause of neonatal sepsis
      • - Early – within 24 hours – 80%
      • - Late – within a week
      • Greatest risk to preterm infants
      • Screen all patients at 35-37 weeks, earlier if past hx PTL
      • Risk of GBS transmission:
      • - Not treated -1:200
      • - Treated – 1:4000
      • All women who have been GBS + in the past should receive treatment
    • Maternal Effects
      • Asymptomatic
      • UTIs’
      • Labor or postpartum infection with fever, tachycardia and abdominal distention
      • Duration of carrier unpredictable
      • Current research on vaccine to tx GBS
    • Fetal Effects
      • Treatment at term eliminates 85 % of early onset GBS
      • PPROM
      • Infant with sepsis at delivery and GBS in CSF and /or blood
      • Symptoms – lethargy, jaundice, poor feeding , temperature instability, abdominal distention, pallor, tachycardia
      • 5-20% mortality rate – get sick quick
    • Late Onset GBS
      • Usually meningitis
      • 15-30% will have permanent neurological damage, deafness, blindness, learning disabilities
      • Very rate – Only 25 % of these babies have moms that are GBS +
    • Treatment
      • Maternal treatment
      • - In labor- PCN 5 million units initial dose and
      • then 2.5 mil. units q 4 hrs, or Ampicillin
      • 2 gm IVPB then 1 gm q 4 hrs – prefer at least two doses prior to delivery and the last dose to be at least 4 hours prior to delivery
      • - PPROM – Ampicillin 1 gm IVPB q 6 hrs
      • for 24 hrs then po when a prenatal patient
      • (Clindaycin if pt. allergic to PCN)
      • Ampicillin and Gentamycin for the infant after delivery
    • Who should be treated?
      • Positive GBS in urine culture during pregnancy
      • Previous infant with GBS
      • Birth before 3 7 weeks(10-15 fold increase)
      • Rupture of membranes > 18 hrs.
      • Temperature > 100.4
    • Chlamydia
      • Agent – Chlamydia Trachomatis (Gram negative)
      • Mode of transmission – Genital
      • Most common bacterial STI – especially high in teens
      • 5-30% carriage by pregnant women
      • Commonly seen with GC and Trich
      • Pregnant mother colonizes infant
    • Chlamydia
      • May be asymptomatic (75%)
      • Detection –
      • - Endocervical / urethral / tissue culture
      • - ELISA (Enzyme-linked immunosorbent assay)-
      • rapid detection test
      • - Direct smear using flourescent antibody
      • Treatment
      • - Mother – Erythromycin 500 mg po qid x 7 days
      • in pregnancy or Amoxicilliin 500 mg po tid x 7
      • days
      • - Infant – Erythromycin opthalmic ointment at
      • birth
    • Maternal Effects
      • If not treated – PID, infertility, tubal pregnancy, chronic pelvic pain
      • Dysuria, yellow purulent discharge, cervicitis, bleeding, postpartum endometritis up to 2 weeks after delivery
      • Associated with other STIs’
      • Treat sexual partner
    • Fetal Effects
      • PTL/PROM
      • IUGR
      • Chorioamnionitis
      • 10% infants develop pneumonia
      • 50% develop conjunctivitis,10% develop pneumonia– usually 5-12 days after deliver
      • 2/3 of infants born vaginally to mothers with Chlamydial infection become infected during delivery
      • May breastfeed after treatment
    • Bacterial Vaginosis
      • Agent - Non-specific vaginitis - Hemopilus, Gardnerella vaginalis or Candidiasis
      • Anerobic gram negative rods or fungal organism
      • Mode of transmission – Sexual transmission or tissue trauma
    • Bacterial Vaginosis
      • Due to sexual intercourse, hormonal changes, antibiotics, spermicidal products, pregnancy, douching– very contagious vaginosis
      • Cause – Overgrowth of one or more types of normal bacteria present in 15-25% of pregnancies
    • BV
      • Detection – positive diagnosis if 3 of 4 characteristics below are present:
      • - Clue cells (wet prep)
      • - pH > 4.5
      • - Fishy odor when discharge
      • mixed with KOH
      • - Thin, grayish-white discharge
      • or white curdy, cottage cheese discharge
    • Maternal /Fetal Effects
      • Risk increased by douching, using intrauterine devices (IUDs), and smoking
      • Associated with ectopic pregnancies, spontaneous abortions, PID, PROM, PTL, postpartum endometritis
      • May cause neonatal septicemia
    • Treatment
      • First trimester - Clindamycin vaginal cream 5 gm hs x 7 days or Flagyl gel 0.75%
      • (5 gm) vaginal cream twice daily x 5 days
      • Second trimester – Flagyl 250 mg po tid x 7 days or Clindamycin 300 mg po tid x 7 days
      • If breastfeeding – Flagyl 2 gm po x 1 and discard milk for 24 hrs.
      • Hydrogen peroxide douche
      • Condoms to prevent re-infection
    • Human Papilloma Virus (HPV)
      • Agent – Condylomata Human Papilloma virus – > 200 types of HPV
      • Appears as genital warts
      • Incubation period –
      • 3-9 months prior to
      • appearance of warts
      • Most prevalent STI
    • Human Papilloma Virus (HPV)
      • Mode of transmission –
      • 1) Sexual contact
      • 2) Pass on to the fetus during labor and
      • delivery
      • 3) If burned off they vaporize in the air and
      • begin to grow on human surfaces that they
      • land on.
      • Several strains of HPV cause cancer – (16, 18, 45, 56)
      • Strains 6 & 11 are found in newborn laryngeal papillomatosis
    • Detection
      • 1) Visually – Dry, wart-like clusters that
      • resemble cauliflower. May be small or large.
      • Most often found on vagina, labia, cervix and
      • perineal area
      • 2) Microscopic pathology (cytology culture –
      • Hybrid II capture tubes containing anti-
      • RNA/DNA hybrid antibody – Light spectrum
      • is measured to determine one of 70 strains)
      • Important to have annual pap smears
    • Maternal/Fetal Effects
      • Maternal – Warts, pruritis, bleeding, dysparunea, cervical dysplasia ( May enlarge in pregnancy)
      • Fetal/Newborn – Vaginal delivery unless lesions obstruct passage(.04% risk of exposure). C/S may decrease exposure risk
      • - Observe for laryngeal pappilomatosis – stridor, hoarseness, cough, abnormal cry, respiratory distress as late as 2-3 months
    • Treatment
      • During pregnancy -Trichloracetic acid applications weekly
      • Post delivery -Laser, cryotherapy, Interferon injections (anti-neoplastic drug used in women over 18 who have not responded to other treatments)
      • Newborn treatment depends on size of warts
      • Treat partners
      • Use condoms
      • May breastfeed
    • Trichimoniasis
      • Agent- Trichomoniasis Vaginalis
      • Mode of transmission – Multiple sexual contacts. It is not transmitted across the placenta
      • Lives for a varying amount of time I fresh water, semen, urine toilet tissue, toilet seats, damp wash cloths,
      • 50 % of women also have GC
      • PTL and LBW when associated with other STIs’.
    • Detection
      • Symptoms – frothy, thin, odorless, yellow-green discharge in copious amounts, pruritis, dysuria, strawberry cervix, painful intercourse, postpartum endometritis
      • Test – wet prep (saline solution) Look under microscope for white cells and erythrocytes
      • Ph> 4.5
    • Treatment
      • Clotrimaxole vaginal cream @hs x 7 days for first trimester
      • Flagyl 2 gm po x 1 dose (Avoid alcohol)
      • May breastfeed
      • Use condoms and treat sexual partners
    • Toxoplasmosis
      • Agent – Toxoplasmosis gondii (protozoan)
      • Mode of transmission –eating raw or undercooked meat, vegetables, fruit, drinking unpasteurized milk, ingesting cysts found in cat feces, transplacentally
      • Detection
      • - IFAT (Indirect Flourescent Antibody Test)-
      • from maternal tissue or serum for IgM or IgG
      • - ELISA
    • Maternal/Fetal Effects
      • Fetal – congenital toxoplasmosis, IUGR, enlarged liver and spleen, anemia, jaundice, neurologic damage, microcephaly, hydrops, deafness, low IQ
      • * 10-24 wks highest risk period
      • Maternal – 90% asymptomatic, mono-like symptoms, lymph swelling , PTL, miscarriage, 15-30 % of pregnant women will have + antibodies from previous exposure
    • Treatment
      • Spiramycin 1 gm q 8 hrs, Pyrimethamine 25 mg po qd, with sulfadiazine 1 gm po qid. Must be given with Folinic acid 6 mg IM or po 3 x per week
      • May reduce neonatal incidence by 50%
      • Watch maternal platelets
      • At birth infant is tx with Pyrimethamine and Sulfadiazine
      • May breastfeed
      • Isolate
    • Prevention
      • Cook meats thoroughly
      • Wash kitchen utensils
      • Wash hands
      • Wash fruits and vegetables
      • Avoid contact with cat liter boxes, sand boxes, garden soil
    • Rubella
      • RNA virus. Member of Togaviridae family
      • Incubation period – 10-14 days
      • Mode of transmission – Respiratory secretions, airborne, transplacentally
      • If infected in 1 st trimester 50 -90% of infants will have severe congenital anomalies or death
      • 2 nd or 3 rd trimester – subtle to no effects
    • Rubella
      • Detection – HAA antibody test. If < 1:8 patient will be non-immune
      • 20 % of the population is not immune to rubella
      • Prevent pregnancy at lease 28 days post vaccination
      • ISG (immune serum globulin ) may be given to decrease fetal effects
      • Viral culture on infant
      • Strict isolation – no caretakers who are pregnant
    • Maternal/Fetal Effects
      • Maternal – Maculopapular rash starting on the face and migrating downward. Rash lasts 3- 5 days, fever, malaise, post-auricular and occipital adenopathy
      • Viral shedding for 15 days
      • Spontaneous abortion, hydrops
      • Watch for sinusoidal FHR pattern
      • May breastfeed after viral shedding period
    • Rubella
    • Herpes Simplex Virus (HSV)
      • Type I (Oral) and Type II (Genital)
      • Transmitted by direct contact with lesion
      • – primary lesion occurs in 2-20 days
      • - vesicles rupture within 1-7 days and form ulcers that take an average of 12 days to heal
      • Routes of transmission - vaginal birth, ascending infection especially with ROM, transplacentally if primary infection
    • HSV
      • Pregnant women infected with the virus for the first time can shed the virus for 8-100 days or for recurrent infection 6-40 days
      • 15-35 % women of childbearing age are HSV II +
      • Period of remission and occurrence
      • Oral sex can mix lesions
    • Detection
      • Tissue (Viral) culture of open lesion for giant body cells (Znack prep)
      • ELISA
      • Positive PAP smear
      • Western blot
    • Maternal Effects
      • Maternal – Painful papules that change to fluid filled vesicles/ulcers in clusters that crust over and heal. Located on vulva, vagina, cervix, labia, perineum
      • Severe pain, burning, itching, low grade fever malaise, numbness, tingling, enlarged lymph nodes or may be asymtomatic, predisposition to cervical cancer
      • Deliver within 4 hrs of ROM if active lesion – must do C/S
    • Fetal Effects
      • Miscarriage if transplacental transmission,
      • Neonatal mortality 50-60 % if primary infection during pregnancy
      • Neurologic & opthalmic sequela
      • Microcephaly, bulging fontanels
      • Systemic infection in 70%
      • RDS, pneumonia
      • Intracranial calcifications, skin lesions,
      • Seizures, tremors, lethargy,
    • Herpes Disease Progression
      • 500,000 people are infected with genital herpes each year and another 10 million have recurrent lesions
      • One in five pregnant women have had an HSV infection
      • Herpes can become dormant- once it gets into the dorsal root ganglia antiviral drugs are useless
      • Recurrent outbreaks are triggered by stress, illness, exposure to ultraviolet light, tissue damage or suppression of the immune system
    • HSV
    • Neonatal HSV
    • Treatment
      • Mother – Acyclovir 800 mg bid x 5 days
      • or Valtrex 500 mg for 14 days in 3rd trimester
      • Infant – Acyclovir 30-60 mg / kg day for 10-21 days for neonates
      • Treat sexual partners
      • No AROM
      • NO FSE, vacuum extractor
      • May breastfeed as long as lesion is not on the breast. Must use excellent hand washing