Few aspects of herpes provoke the degree of concern as the threat the disease poses to the health and welfare of the newborn. Because of the newborn’s incomplete natural defense mechanisms, HSV is much more threatening to it than to an adult or even a young child.
As we learned in Chapter One, our immune system strikes quickly and acts to check the advance of the virus in a battle for control of the body. Thanks to our natural body defenses, cell and tissue destruction is localized and held to a minimum. The virus then retreats to the trigeminal ganglia in the case of facial herpes and to the sacral ganglia in genital herpes. In only two weeks or so, all clinical evidence of the infection is gone.
The process is much different in the fragile body of a newborn. A child comes into the world with only a minimal level of protective circulating antibodies. These are transferred from the mother to the fetus during development. The degree of protection these antibodies afford the newborn early in life depends on their number and quality. U.S. infants contracting herpes during delivery range between 300 to 1500 individuals per 3.5 million live births per year. If a mother has a positive herpesvirus culture at the time of delivery, there is a 50% to 60% chance that the baby will become infected at birth. About half the infants who contract the disease will develop a generalized infection. In such cases, serious brain damage or death is the expected result.
With proper care and monitoring it is possible to prevent many such tragedies. If herpes is present at the time of delivery, a Caesarean section should be performed to insure the safety of the infant. This does not mean automatic Caesarean delivery for every woman who has herpesvirus. As long as herpes is not present in its active form at delivery, a normal delivery through the birth canal will probably be indicated.
NEONATAL HSV INFECTION
Symptoms of herpes disease in the newborn may occur anytime during the first month of life. The average age of onset of the general disease is 16 days. Since approximately one-third of affected infants will have no visible symptoms, a delay in diagnosing the disease may result. According to the journal of the American Medical Association, (JAMA), “neonatal herpes occurs at a rate of approximately one in 7000 to 10,000 births and has a mortality rate of 70%.
In some cases the infants do not exhibit lesions. It is important to make an early diagnosis of the disease so that it can be treated before it does irreparable harm. The lack of lesions makes this more difficult. You should be aware of the other signs indicating the baby may have contracted herpes.
Other signs of infection include many findings, such as temperature instability, respiratory difficulty, convulsions, and hepatitis. These findings may be present singly or in combination.
Neonatal HSV infection is broken into three categories. First, newborns are considered to have “disseminated disease” when they have involvement in many vital organs such as the spleen or liver. Enlargement is also possible. The second category is one in which the newborn has encephalitis, which affects the brain, including thought processes. There is no organ enlargement and usually no skin lesions. Encephalitis is manifested by neurologic findings and changes in certain cells. Encephalitis is the most common of the three manifestations of neonatal HSV. Infants with the disseminated disease have a low survival rate, while those with encephalitis have a higher survival rate but many have brain damage.
In the third form, the newborn develops skin lesions. These lesions look much like adult lesions and can be found almost anywhere on the skin, mouth or eyes.
There is a treatment for neonatal herpes, although the two drugs used are both considered to be test treatments. The newborns are treated with either adenine arabinoside (Ara- A) or acyclovir (ACV).
It might be helpful to know that chances are better of having no active lesions at birth than of having an active case. If the patient will believe this, and work with this idea, she will stand a much better chance of going into the delivery room without a recurrent episode. It all gets back to the healthy attitude concept. A mother who spends needless energy agonizing about the possibility of having active lesions at birth is actually more apt to have a recurrence than the mother who accepts the disease as dormant and remains confident that it will remain so through childbirth.
TRANSMISSION FROM MOTHER TO BABY
Transmission of herpesvirus to newborn babies can happen in one of two ways. The newborn can contract the virus during birth, or the infant can contract the virus after birth by contact with someone who has active facial herpes. If the mother has an active episode of genital herpes at or near the time of birth, any herpesvirus present in a sore in or near the vagina may enter the baby as he passes through the infected birth canal. A mother may also infect her child by passing virus from an active facial lesion. In fact, any well-meaning relative or friend can effect this type of transmission. It is best to observe such people before they handle the newborn.
This can be done with a minimum of embarrassment since active facial lesions are normally easy to detect. This might be an appropriate time to again mention Herpetic Whitlow. This is herpes, generally on the fingers, that may be contracted by dentists, dental personnel, nurses, and other health personnel. If you notice any suspicious sores on your friends who may be in one of these fields, it may be best to let them admire the child from across the room or wear gloves when handling the infant. I feel it is better to be overcautious for the first six months than to be sorry.
I might also mention here that oral sex near the time of delivery can pass virus to the expectant mother’s genitals. There is presently no evidence that infants infected with HSV-1 carry a lesser risk than infection with HSV-2.
The July 1980 issue of Pediatrics magazine recommends that in cases where “the partner has documented genital infection, avoidance of sexual contact in the last several months of pregnancy is recommended.” It goes on to explain that Pap smears of the cervix obtained in most clinical facilities will identify HSV-infected women in only 75% of the cases that the virus is proven to exist. The authors consider a woman to be free of infection and a candidate for vaginal delivery if tests are negative on two successive examinations, the last of which must be obtained within one week of delivery. She must, of course, be free of lesions at delivery also.
It has been observed, although not frequently, that infants delivered by Caesarean section to mothers with genital herpes and ruptured membranes are increasingly apt to be infected if the membranes have been ruptured for more than four to six hours. In the presence of active genital herpes at birth, the risk of the infant contracting herpes is minimized by using the Caesarean section if the membranes are intact or have only recently ruptured. The critical period seems to be four to six hours, and by 24 hours infection of the infant is usually present.
The risk of infant infection at birth is greater for primary infections than for recurrent infections. This is because the concentration of virus is greater and the infectious period is longer for primary episodes. Also the risk that the newborn will be exposed to an infected cervix during birth is greater during primary infection than recurrence.
It is felt that infants born to mothers with a history of recurrent herpetic infections acquire some passive antibodies to the virus. This immunity is not as great as acquired immunity, but it probably plays some role in decreasing the risk of infection.
There is, in extremely rare cases, a herpesvirus disease in which the virus reaches the fetus through the placenta. The fetus becomes infected before birth by what is believed to be virus from the mother’s blood or an ascending infection. This is not completely understood, and is so unusual that it is not something you should be concerned with. The problem to be dealt with is keeping the newborn from exposure to herpes at the time of birth and just thereafter. Learn about natural herpes treatments.
INFECTION CONTROL MEASURES
Mothers and other responsible family members should be educated as soon as possible regarding HSV and the risks it poses to the newborn. This risk is present in the hospital as well as at home. You should be building an understanding by now of what safety measures are helpful and by the end of this book you will, I hope, have a good working knowledge of what is important for the protection of the infant. We have talked of avoiding sexual contact late in pregnancy (the last six weeks), including oral sex. For those of you who will not abstain, the use of condoms, jellies, and foams is advised.
Tell your obstetrician about your herpes early on in your association. Disclose to him anything in your past that you may suspect had anything to do with herpes or any STD, EVEN
IF IT WAS 20 YEARS AGO AND YOU’VE HAD NO RECURRENCE SINCE. If anything unusual happens between your initial contact with him and before term, relay to him the facts. Remind him of your history of herpes, if any, as you near term. If your physician dismisses such information or does not seem to take it seriously, you may want to consult another who does. You must have an obstetrician knowledgeable about the disease and its implications for the newborn.
Avoid handling the infant without taking proper precautions if you have an active lip or facial lesion. This goes for the rest of the family as well. Do not let the baby come in contact with the sores. Wash your hands thoroughly before touching the baby. Be aware that virus can be given off for over a week during recurrent infections. For the first six months I recommend placing some sort of protective covering over active lesions not covered by clothing, while the baby is being handled. The infant’s immune system is far from complete during this time, and it is easy to forget your lesion while playing with your new child. It is not worth the consequences to have the newborn wave his arm and accidentally contact your sore. An ounce of prevention in this situation is worth more than a pound of cure. Of course, even after the sixth month, you must continue to keep the child from contacting sores caused by herpes.
An infant’s fingernails and toenails will sometimes be better developed than his immune system. Keep the nails trimmed to prevent accidental scratching, which could break the natural barrier of the skin. Besides washing your hands, wash any objects you suspect of having become contaminated, with a 10% solution of Clorox.
Pap tests are now being recommended every six months instead of once a year by some physicians. We’ll take a closer look at these tests in the next chapter.
Pregnant mothers should work with and confide in their obstetricians. Be honest in giving your history and remember to mention any peculiarities during your pregnancy. Keep in mind your prodromal signs and report any herpes outbreaks. An outbreak during pregnancy is not necessarily reason for alarm. There is no reason for you not to have a perfectly normal childbirth and enjoy your child in a normal way after arriving at home. You may even nurse your child, provided there are no active lesions on your breasts and you practice the precautionary hygiene we spoke of here. It is most important to get over your fear of herpes and discount the wild scare stories prevalent in the media.