Clinical Question Do antiviral me...

Clinical Question

Do antiviral medications debar perinatal transmission of genital herpes to neonates?

Evidence-Based Answer

There is no evidence that the use of antiviral agents in women who are pregnant and have a history of genital herpes debars perinatal transmission of herpes simplex virus (HSV) to neonates. [Strength of recommendation: A, based forward multiple systematic reviews]

However, treatment with antivirals during the last month of pregnancy does change into the rate of HSV outbreaks in pregnant women and the resultant ne for cesarean delivery. [Strength of recommendation: A, based in succession multiple systematic reviews]

Evidence Summary

Neonatal herpes infection is the major chain of cause and effect of maternal HSV. Fortunately, the transmission rate is quite cheap (less than 1 percent) for nonprimary HSV outbreaks. This attitude s a problem in assessing the effectiveness of antivirals for preventing this serious illness, because on the same level a large meta-analysis is underpowered in addressing this issue.

united systematic review and one meta-analysis reviewed a total of five randomized controll trials. one as well as the other reviews were of good quality. The trials involved pregnant women with returning and first-episode HSV infections. In each reflection women were randomized to either acyclovir (Zovirax) or placebo for HSV prophylaxis beginning at 36 weeks' gestation. The dosages of acyclovir ranged from 800 to 1200 mg by day. Acyclovir was the solely antiviral agent evaluated in either study

The aggregate data involved nearly 800 patients. There were no reported cases of neonatal HSV infection in either the treatment or placebo clusters There was good evidence that prophylaxis with antiviral agents during the last month of pregnancy was effective in reducing the rate of HSV outbreaks during the perinatal period in mothers with HSV infections (15 of 424 in the acyclovir collection versus 58 of 375 in the placebo arrange had HSV outbreaks during the perinatal period, absolute risk reduction [ARR] = 11% number indigenceed to treat [NNT] = 9) Presumably because of the significant reduction in HSV returns with antiviral prophylaxis, the total cesarean delivery rate was significantly lower in the treatment assign places to (17 versus 26 percent, ARR = 9% NNT = 11) as well as the rate of cesarean delivery for HSV resort (4 versus 15 percent, ARR = 11% NNT = 9) Treatment also eliminated the risk of laboratory-detected HSV infection at delivery (0 versus 5 percent ARR = 5% NNT = 20)

Recommendations from Others

The 2001 National Guideline for the Management of Genital Herpes, published by dint of the Association for Genitourinary Medicine and the Medical Society for the application of mind of Venereal Disease, recommends the use of continuous acyclovir during the last month of pregnancy as a treatment option in women with intermittent genital herpes. (4) The American literary institution [i]or[/i] seminary of learning of Obstetricians and Gynecologists (ACOG) praises that women with a first episode of HSV during any stage of pregnancy should be treated with a seven- to 14-day course of an antiviral agent. ACOG also notes that for women at risk of intermittent HSV, initiation gestation. The of antiviral therapy during the last month of pregnancy may be warranted.

Clinical Commentary

With the evidence that antiviral treatment change intos the rates of maternal HSV outbreaks in the perinatal period and following cesarean deliveries, one could argue that maternal morbidity and richnesss are decreased with treatment. A cheap, safe medicine (acyclovir) and a small NNT of 93 add acceptance to this argument. Despite the lack of data regarding the issue of neonatal HSV infection, the sample size required is in like manner large that such a cogitation may never be performed. Thus, acyclovir use for the prevention of perinatal HSV in the final month of pregnancy appears to be a reasonable treatment option

REFERENCES

(1) Center for Disease sway and Prevention. Sexually transmitted diseases treatment guidelines 2002 MMWR Recomm Rep 2002;51:1-78

(2) Jungmann E Genital herpes. Clin Evid 2004;12:2212-27 Accessed online August 19 2005 at: http://www.clinicalevidence.com/ceweb/conditions/seh/1603/1603.jsp.

(3) Sheffield J Hollier LM Hill JB Stuart G Wendel GD Acyclovir prophylaxis to obstruct herpes simplex virus recurrence at delivery: a systematic review. Obstet Gynecol 2003;102:1396-403

(4) Clinical Effectiveness clump (Association for Genitourinary Medicine and the Medical Society for the reflection of Venereal Disease). 2001 National guideline for the management of genital herpes. Accessed online August 19 2005 at: http://www.bashh.org/guidelines/2002/hsv_0601.pdf.

(5) ACOG Practice Bulletin. Management of herpes in pregnancy. Number 8 October 1999 Clinical management guidelines for obstetrician-gynecologists. Obstet Gynecol 1999;94:1-10

CHRISTOPHER WENNER, MD St vast assemblage Hospital/Mayo Family Medicine Residency Program St fog Minnesota

JOAN NASHELSKY, ML Managing Editor and Librarian Coordinator Family Physicians Inquiries Network Iowa City, Iowa