4.4 Viral infections

For clinical signs and diagnosis, refer to the Clinical guidelines, MSF.

4.4.1 Genital herpes

If the mother has visible herpetic lesions at time of childbirth:

• Limit vaginal exams; no artificial rupture of membranes.
• Discuss caesarean section on a case-by-case basis.
• For the mother:
  • Pain management: paracetamol PO (Appendix 7).
  • Antiviral treatment: aciclovir PO, 400 mg 3 times daily for 7 days
  • In immunocompromised patients, continue the treatment until symptoms resolve.
  • Prophylactic treatment (aciclovir PO: 400 mg 4 times daily as of 36 weeks LMP and until delivery) can be proposed to reduce the risk of recurrent herpes at delivery.
• For the neonate, see Chapter 10, Section 10.4.3.

4.4.2 Varicella (chickenpox)

There is a risk of severe maternal varicella pneumonia and severe neonatal varicella.
Administration of aciclovir PO (800 mg 5 times daily for 7 days) as soon as possible after the onset of rash may reduce these risks [1] Citation 1. Clinical practice guideline of the Society of Obstetricians and Gynaecologists of Canada. Management of Varicella Infection (Chickenpox) in Pregnancy, No. 274, March 2012.
http://sogc.org/wp-content/uploads/2013/01/gui274CPG1203E.pdf?1668a1 .

4.4.3 Hepatitis

Hepatitis B

Without intervention, mother-to-child transmission of the hepatitis B virus (HBV) is high (up to 90%).

• For the mother: no special obstetric measures.
• For the neonate: routine hepatitis vaccination as soon as possible within 24 hours after birth has been demonstrated to prevent 70 to 95% of infections [2] Citation 2. Hepatitis B. Epidemiology and Prevention of Vaccine-Preventable Diseases. The Pink Book.
  http://www.cdc.gov/vaccines/pubs/pinkbook/hepb.html#hepA (Chapter 10, Section 10.1). 

Hepatitis E

Hepatitis E carries a very high mortality rate for pregnant women (20% during the third trimester). It can cause spontaneous abortion, preterm delivery, and intrauterine foetal death.

The virus is acquired by fecal-oral route (primarily by drinking contaminated water). The virus can cause outbreaks, especially in situations where large numbers of people are gathered (refugees, displaced persons), when hygiene and sanitation are poor.

Treatment is symptomatic (good hydration, avoidance of hepatotoxic medications). Prevention (water, hygiene, sanitation) is the only protection against the disease.

4.4.4 HIV infection

Mother-to-child HIV transmission may occur at any time during pregnancy, labour, delivery and the breastfeeding period. With no intervention, the risk of transmission is approximately 15 to 25% and 20 to 45% if the child is breastfed [3] Citation 3. World Health Organization, UNFPA. HIV transmission through breastfeeding. A review of available evidence. Geneva, 2004.
http://www.unfpa.org/webdav/site/global/shared/documents/publications/2004/hiv_transmission.pdf . This risk may be reduced to less than 2%.

Offer HIV testing to all pregnant women with unknown HIV status when they come for ante- or postnatal consultations or delivery. 
HIV negative women should also be re-tested at their first antenatal consultation, during the third trimester and during the breastfeeding period.

For antiretroviral therapy protocols in mothers and children, refer to specialised prevention of mother-to-child transmission (PMTCT) guides. 

Ante-natal care

HIV-infected pregnant women need antiretroviral therapy regardless of their CD4 count and clinical stage. The treatment should start as soon as possible, regardless of gestational age and should be taken for life.

Intra-partum care

• Continue (or start) antiretroviral therapy.
• Observe standard precautions to avoid contact with blood and body fluids.
• Avoid:
  • prolonged labour;
  • prolonged rupture of membranes;
  • early artificial rupture of membranes;
  • invasive procedures such as episiotomy or instrumental delivery. However, they must be performed if they are necessary.
•  The criteria for induction of labour are the same as for non HIV-infected women.
• Delay cord clamping for 1-3 minutes.
• Administer antiretroviral prophylaxis to the neonate immediately after birth.
• Prevention and treatment of postpartum haemorrhage: as for non HIV-infected women. 

A planned caesarean section can be beneficial if the viral load is detectable. However, given the risks associated with the intervention (surgical, anaesthetic and infectious) and the risk of uterine rupture during subsequent pregnancies, caesarean section is not recommended routinely.

Postpartum care

• For the mother: continue (or start) antiretroviral therapy.
• For the neonate: systematic antiretroviral prophylaxis and early diagnosis of infection.