History

Fact Explanation
Pain in the vulval region The genital lesions are painful and there is inflammation of the vulval region - vulvitis.[1]
Pruritus The presence of genital lesions and their secretions lead to pruritus in the vulval region.[1]
Dysuria Due to inflammation of the distal urinary tract and genital area.
Vaginal discharge Due inflammation of the lower vagina. Vaginal discharge is a rare symptom seen particularly in recurrent infection.[2]
Urinary retention The severe pain associated with the peri-urethral skin lesions can lead to urinary retention.[2]
Systemic prodromal symptoms - fever, malaise and myalgia Seen one to two days prior to the appearance of the rash. Due to a systemic inflammatory reaction.[2]
The patient may be asymptomatic. Viral shedding can occur in asymptomatic individuals particularly with recent primary infection, near the time of clinical recurrences and in immune-compromised persons. [1],[3]
The presentation can be either the first episode or a recurrence. Primary infection tends to be more severe than the recurrences. The symptoms of secondary episodes are usually less severe with few systemic symptoms.[4]
Neonatal Herpes simplex infection Acquisition of the infection during the intra partum period through exposure of the fetus to infected secretions of the the maternal genital tract.[1] Diagnosis of a herpes simplex infection in an infant requires a high index of suspicion since the presentation is with non-specific symptoms such as fever, poor feeding or seizures. Presentation with a vesicular rash within the first 8 weeks should arouse suspicion. [4]
Congenital HSV infection. Occurs due to transplacental acquisition of the infection.[1]
References
  1. Guidelines for the Management of Herpes Simplex Virus in Pregnancy. The Society of Obstetricians and Gynaecologists of Canada, June 2008 [ Viewed 21 March 2014]. Available from : http://sogc.org/guidelines/guidelines-for-the-management-of-herpes-simplex-virus-in-pregnancy-replaces-2-aug-1992/
  2. SEN P, BARTON SE. Genital herpes and its management BMJ [online] 2007 May 19, 334(7602):1048-1052 [viewed 11 September 2014] Available from: doi:10.1136/bmj.39189.504306.55
  3. WALD A, Zeh J, Selke S, Ashley RL, Corey L. Virologic characteristics of subclinical and symptomatic genital herpes infections. N Engl J Med,1995, 333, 770–5.
  4. CAROLINE M. RUDNICK, GRANT S. HOEKZEMA. Neonatal Herpes Simplex Virus Infections. Am Fam Physician, 2002 Mar 15, 65(6), 1138-1142.

Examination

Fact Explanation
Tender inguinal lymphadenopathy. Lymphatic drainage of the genital skin is to the superficial inguinal nodes. Involvement of the genital skin with the herpes virus infection leads to enlarged painful lymph nodes.[1]
Characteristic rash in the genital skin and adjacent areas. The rash consists of vesicular lesions, with an erythematous base.[2] They often evolve into pustules, then ulcerations, and finally into crusted lesions. The rash is located in the area of the sacral dermatomes,usually S2, S3 segments.
Minor erythema of the vulval region An atypical presentation of the characteristic rash.[2]
Fissures in the genital skin An atypical presentation of the characteristic rash.[2]
Recurrent episodes of genital herpes are associated with fewer lesions and are unilateral on the genitals. Secondary episodes genital herpes tend to be less severe when compared to primary infections.[2]
Neonatal Herpes simplex infection Three types of presentation have being identified: skin, eye, and mouth infection; central nervous system disease with encephalitis, with or without skin, eye, and mouth infection; finally disseminated disease that can affect the central nervous system, lung, liver, adrenals, skin, eye or mouth. [3]
Congenital HSV infection Presentations include microcephaly, hydrocephalus, chorioretinitis and vesicular skin lesions. [4]
References
  1. BEAUMAN JG. Genital herpes: a review. Am Fam Physician [online] 2005 Oct 15, 72(8):1527-34 [viewed 11 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16273819
  2. Guidelines for the Management of Herpes Simplex Virus in Pregnancy. The Society of Obstetricians and Gynaecologists of Canada, June 2008 [ Viewed 21 March 2014]. Available from : http://sogc.org/guidelines/guidelines-for-the-management-of-herpes-simplex-virus-in-pregnancy-replaces-2-aug-1992/
  3. CAROLINE M. RUDNICK, GRANT S. HOEKZEMA. Neonatal Herpes Simplex Virus Infections. Am Fam Physician, 2002 Mar 15, 65(6), 1138-1142.
  4. JONES CL. Herpes simplex virus infection in the neonate: clinical presentation and management. Neonatal Network, 1996 December, 15(8), 11–5.

Differential Diagnoses

Fact Explanation
Syphilis Caused by the spirochete Treponema pallidum, primary syphilis presents with painless ulcers involving the vulva, vagina and cervix.[1] The characteristic lesions (chancres) consist of a central ulcer with raised edges and are usually solitary.[2] Two lesions may develop on opposing labial surfaces known as kissing lesions.
Chancroid This is a sexually transmitted infection caused by Haemophilus ducreyi.[1] The patient presents with painful shallow ulcers which involve the vulva, vagina & cervix. The initial lesions develop as papules which progress to pustules and then to ulcers. Painful inguinal lymphadenopathy is frequently seen.
Donovanosis Donovanosis is a chronic bacterial infection with Klebsiella granulomatosis.[1] The presentation is with painless nodules which progress to painless suppurative ulcers. The ulcer morphology includes a red colored base with rolled up edges. The ulcers tend to expand overtime. The lesions tend to bleed frequently.
Genital warts Consists of warty lesions on the vulva, vagina and cervix. The lesions are painless and are usually multiple.[2] Involvement of non-genital sites can also be seen - mouth,lips etc. The causative organism is the human papilloma virus.
Lymphogranuloma venereum A venereal disease caused by Chlamydia trachomatis.[2] The disease is described in 3 stages. The primary stage consists of painless ulcers on the vaginal wall, cervix and vulva which develop from papules. Healing without scarring occurs. The patient may be asymptomatic during this period. The second stage consists of painful regional lymphadenopathy while the third stage involves the lower gastrointestinal tract presenting with tenesmus, rectal pain etc.
References
  1. MONGA Ash, DOBBS Stephen. Gynaecology by Ten Teachers. 19 ed. London : Hodder Arnold, 2011.
  2. European STD guidelines. International union against sexually transmitted infections. October 2001 [viewed 22 March 2014]. Available from : http://www.iusti.org/sti-information/pdf/guidelines.pdf

Investigations - for Diagnosis

Fact Explanation
A combination of clinical findings and laboratory investigations are used. The presence of the characteristic rash with a compatible history should point towards a clinical diagnosis which needs to be confirmed by laboratory investigations.[1]
Viral culture Swabs of vesicular fluid. Reporting of results can take up to 2 to 3 days. The sensitivity of the test is 75% for the first episode and 50% for recurrences. The sensitivity is also dependent on the time of specimen collection.[2]
Polymerase chain reaction (PCR) for detection of viral DNA. A more accurate test than viral culture with a sensitivity of 59%. [3]
Direct immunofluorescent staining to detect the virus. The sensitivity of this test is 80 to 90 percent compared with viral culture.[4]
HSV antibody testing A pregnant mother presenting in the 3rd trimester with a first episode of genital herpes needs to be differentiated between a primary infection or a recurrence. A positive antibody test will indicate a recurrence. This information helps in deciding the mode of delivery.[5]
Diagnosis of an HSV infection in an infant Cultures obtained from vesicular fluid, blood, fluid obtained from the eyes, nose and mucous membranes should be studied.[6]
References
  1. SEN P, BARTON SE. Genital herpes and its management BMJ [online] 2007 May 19, 334(7602):1048-1052 [viewed 11 September 2014] Available from: doi:10.1136/bmj.39189.504306.55
  2. AMEETA SINGH, JUTTA PREIKSAITIS, ALEX FERENCZY, BARBARA ROMANOWSKI. The laboratory diagnosis of herpes simplex virus infections. Canadian journal of Infectious diseases & medical microbiology, 2005 Mar-Apr, 16(2), 92–98.
  3. SLOMKA MJ, EMERY L, MUNDAY PE, MOULSDALE M, BROWN DW. A comparison of PCR with virus isolation and direct antigen detection for diagnosis and typing of genital herpes. Journal of Medical Virology, 1998 Jun, 55(2), 177-83.
  4. CAROLINE M. RUDNICK, GRANT S. HOEKZEMA. Neonatal Herpes Simplex Virus Infections. American Family Physician, 2002 Mar 15, 65(6), 1138-1142.
  5. Management of genital herpes in pregnancy. Royal College of Obstetricians and Gynaecologists, September 2007 [ Viewed 20 March 2014]. Available from: http://www.rcog.org.uk/womens-health/clinical-guidance/management-genital-herpes-pregnancy-green-top-30
  6. KIMBERLIN D. W.. Neonatal Herpes Simplex Infection. Clinical Microbiology Reviews [online] December, 17(1):1-13 [viewed 11 September 2014] Available from: doi:10.1128/CMR.17.1.1-13.2004

Investigations - Screening/Staging

Fact Explanation
Sexually transmitted infection(STI) screen Genital herpes is a sexually transmitted infection. Hence in the presence of one STI, screening should be done to exclude other STIs.[1] Due to fetal implications it is important to exclude other sexually transmitted infections in high risk patients.[2]
Antenatal screening of pregnant women Identification of women who are susceptible to genital herpes in pregnancy by screening for HSV antibodies is not currently indicated.[1]
References
  1. Management of genital herpes in pregnancy (Green-top Guideline No. 30). Royal College of Obstetricians and Gynaecologists, September 2007 [ Viewed 20 March 2014]. Available from: http://www.rcog.org.uk/womens-health/clinical-guidance/management-genital-herpes-pregnancy-green-top-30
  2. MEYERS D,GREGORY K,NELSON H,PETITTI D. USPSTF Recommendations for STI Screening. American family physician, 2008 Mar, 77(6), 819-824.

Management - General Measures

Fact Explanation
Use of saline baths For relief from discomfort and pruritus.[1] A Sitz bath is a warm water bath used for cleansing purposes & relief of pain,itching etc. A plastic tub filled with water resting on the toilet can be used as a Sitz bath. Sitting in the warm water for 15 to 20 minutes can provide relief from the discomforting symptoms of genital herpes.
Analgesia and local anesthetic gel Pain relief.[1] Oral analgesics such as acetaminophen, ibuprofen, or aspirin in appropriate dosage can be used for relief of pain. Local anesthetic agents such as lidocaine 5% can also be applied to the genital lesions.
Care for genital lesions Wash the genital lesions gently with soap and water daily and allow to dry.Advise to use loose fitting under clothing. The wounds should be observed for secondary bacterial infection and if infection is detected should be treated with appropriate antibiotic agents.[2]
Patient counseling and education An important aspect of the management where the clinician should counsel the patient regarding the diagnosis. The patient should be educated on the natural history of the disease, mode of transmission,fetal risks and prevention of disease transmission.[1] Contact tracing should be done to identify the source of the infection and treat the affected. The sexual partners should be examined and treated if necessary.
References
  1. Management of genital herpes in pregnancy (Green-top Guideline No. 30). Royal College of Obstetricians and Gynaecologists, September 2007 [ Viewed 20 March 2014]. Available from: http://www.rcog.org.uk/womens-health/clinical-guidance/management-genital-herpes-pregnancy-green-top-30
  2. SEN P, BARTON SE. Genital herpes and its management BMJ [online] 2007 May 19, 334(7602):1048-1052 [viewed 11 September 2014] Available from: doi:10.1136/bmj.39189.504306.55

Management - Specific Treatments

Fact Explanation
Referral to a genitourinary physician A pregnant woman with a suspected first-episode of genital herpes should be referred to a genitourinary physician.Referral to a genitourinary physician allows planning of the management according the patient's status.[1]
Aciclovir Oral or intravenous Aciclovir is used since it has been shown to reduce the duration and severity of symptoms. Drug regimes used include oral Aciclovir 200 mg five times daily or 400mg three times daily for 5 days. Disseminated HSV infection needs intravenous aciclovir. Aciclovir is well tolerated in pregnancy and is not teratogenic. However caution is advised with usage prior to 20 weeks of gestation.The use of daily suppressive Aciclovir from 36 weeks gestation onwards to reduce the likelihood of genital lesions at term is not recommended.[2]
Management of primary genital herpes at the time of delivery. Caesarean section should be recommended to all pregnant women presenting with a primary episode of genital herpes at the time of delivery, or within 6 weeks of the expected date of delivery. Pregnant women who develop primary genital herpes lesions within 6 weeks of delivery and opt for a vaginal birth, artificial rupture of membranes should be avoided and invasive procedures should not be used; in order to prevent contamination. Intravenous Aciclovir is given intrapartum to the mother and subsequently to the neonate.[1]
Management of recurrent episodes of genital herpes Patients who have an symptomatic first infection and who have a severe infection have an increased risk of recurrence.[3] Antiviral therapy for recurrent episodes is rarely indicated since spontaneous recovery in 7-10 days is expected. Vaginal delivery is not contraindicated if it is a recurrent episode during the antenatal period. Routine viral cultures to detect viral shedding close to term is not currently recommended.
Management of a recurrent episode of genital herpes at delivery Caesarean section is not routinely recommended, the decision on the mode of delivery should be done according to the wishes of the patient.In the presence of ruptured membranes measures to expedite the vaginal delivery should be taken. Avoid invasive procedures during labor.The risk of neonatal infection is minimal.[2]
Prevention of genital herpes in pregnancy. Women who have partners with genital herpes should be advised to practice measures on reducing their risk of acquiring the infection.[4] Usage of barrier contraception, treating the partner’s infection etc. should be practiced.
References
  1. Management of genital herpes in pregnancy (Green-top Guideline No. 30). Royal College of Obstetricians and Gynaecologists, September 2007 [ Viewed 20 March 2014]. Available from: http://www.rcog.org.uk/womens-health/clinical-guidance/management-genital-herpes-pregnancy-green-top-30
  2. Guidelines for the Management of Herpes Simplex Virus in Pregnancy. The Society of Obstetricians and Gynaecologists of Canada, June 2008 [ Viewed 21 March 2014]. Available from : http://sogc.org/guidelines/guidelines-for-the-management-of-herpes-simplex-virus-in-pregnancy-replaces-2-aug-1992/
  3. BENEDETTI J, COREY L, ASHLEY R. Recurrence rates in genital herpes after symptomatic first-episode infection. Ann Intern Med [online] 1994 Dec 1, 121(11):847-54 [viewed 11 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/7978697
  4. BROWN ZA, GARDELLA C, WALD A, MORROW RA, COREY L. Genital herpes complicating pregnancy. Obstet Gynecol [online] 2005 Oct, 106(4):845-56 [viewed 11 September 2014] Available from: doi:10.1097/01.AOG.0000180779.35572.3a