Re: OB: HSV prophylaxis near term
From: William D. McIntosh, MD (wdmcintoshmd@pol.net)
Mon Jun 29 17:41:52 1998
>
> What is your evidence for the benefit of either of these interventions?
>
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> Bob Woolley
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> St. Paul, Minnesota
>
Treatment with acyclovir in late pregnancy is gaining credence, but the jury is not all in.
Please see below.
--
William D. McIntosh, MD
1847
> Authors:
> Scott LL , Sanchez PJ , Jackson GL , Zeray F , Wendel GD Jr
> Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, USA.
> Obstet Gynecol 1996 Jan;87(1):69-73
>
> Article Number: UI96123201
>
> Abstract: OBJECTIVE: To determine if suppressive acyclovir therapy given to term gravidas experiencing a first episode of genital herpes simplex virus
> (HSV)-infection during pregnancy decreases the need for cesarean delivery for that indication. METHODS: Forty-six pregnant women with first episodes of genital
> herpes during pregnancy were randomly assigned to receive oral acyclovir 400 mg or placebo, three times per day, from 36 weeks' gestation until delivery as part
> of a prospective, double-blind trial. Herpes simplex virus cultures were obtained when patients presented for delivery. Vaginal delivery was permitted if no clinical
> recurrence was present; otherwise, a cesarean was performed. Neonatal HSV cultures were obtained and infants were followed-up clinically. RESULTS: None of
> the 21 patients treated with acyclovir and nine of 25 (36%) treated with placebo had clinical evidence of recurrent genital herpes at delivery (odds ratio [OR] 0.04,
> 95% confidence interval [CI] 0.002-0.745; P = .002). No woman treated with acyclovir had a cesarean for herpes, compared with nine of 25 (36%) of those
> treated with placebo (OR 0.04, CI 0.002-0.745; P = .002). No patient in either treatment group experienced asymptomatic genital viral shedding at delivery. No
> neonate had evidence of herpes infection or adverse effects from acyclovir. CONCLUSION: Suppressive acyclovir therapy reduced the need for cesarean for
> recurrent herpes in women whose first clinical episode of genital HSV occurred during pregnancy. Suppressive acyclovir treatment did not increase asymptomatic
> viral shedding and was not harmful to the term fetus.
> Scott LL , Alexander J
> University of Texas Southwestern Medical School, Department of Obstetrics and Gynecology, Dallas
> 75235-9032, USA.
> Am J Perinatol 1998 Jan;15(1):57-62
>
> Article Number: UI98133837
>
> Abstract: The objective of this paper is to determine whether acyclovir suppression provides a greater cost savings over no medical therapy in the management of
> recurrent genital herpes (HSV) in pregnancy. Estimates of the risk of HSV recurrence and cesarean delivery rates in acyclovir-treated and -untreated patients and
> frequency of neonatal acyclovir treatment were derived from literature reviews, prospective surveillance, and practices at our institution. Estimates of costs were
> derived from average hospital and outpatient clinic charges at our institution. Calculations were run separately for four different groups of patients: women whose
> first diagnosis of genital herpes occurred during the pregnancy, women whose diagnosis antedated pregnancy and who had infrequent recurrences, women whose
> diagnosis antedated pregnancy and had frequent recurrences, and all women with a history of genital herpes regardless of timing of diagnosis or frequency of
> recurrences. Suppressive acyclovir treatment of all term pregnant women with a history of genital herpes resulted in an estimated savings of $183.00 per patient or
> $36,600,000 per year. Women with their first episode of herpes diagnosed during pregnancy or with frequent recurrences benefitted even more, achieving a
> savings of $455.00 and $391.00 per patient, respectively. Assuming that prenatal acyclovir treatment is safe for the fetus, utilizing this management for all patients
> with recurrent HSV in pregnancy could immediately save $183 per patient. On a national level, this translates to $36,600,000 per year just in reduced obstetrical
> costs. If indirect costs associated with cesarean deliveries had been included in these calculations, the estimated savings would be even more substantial.
> Authors:
> Brocklehurst P , Kinghorn G , Carney O , Helsen K , Ross E , Ellis E , Shen R , Cowan F , Mindel A
> Academic Department of Genitourinary Medicine, UCL Medical School, London.
> Br J Obstet Gynaecol 1998 Mar;105(3):275-80
>
> Article Number: UI98194180
>
> Abstract: OBJECTIVE: To evaluate the efficacy and safety of a suppressive course of acyclovir in late pregnancy in women with recurrent genital herpes infection
> on the incidence of viral shedding, herpes lesion development and caesarean section for recurrent genital herpes. DESIGN: Double-blind, randomised placebo
> controlled clinical trial. SETTING: A department of genitourinary medicine in Sheffield and an antenatal clinic in London. POPULATION: Pregnant women with
> recurrent genital herpes infection at < 36 weeks of gestation. METHODS: Participating women were given acyclovir 200 mg four times a day (or matching
> placebo) from 36 weeks of gestation until the time of delivery. Women were seen weekly and viral cultures were obtained from the cervix and vulva. Decisions
> regarding mode of delivery were left to the discretion of the attending obstetrician. MAIN OUTCOME MEASURES: Delivery by caesarean section for recurrent
> genital herpes infection. Number of episodes of recurrent genital herpes infection and number of episodes of asymptomatic viral shedding during the treatment
> period. In addition blood was taken at two weekly intervals to determine acyclovir levels. RESULTS: The total number of women recruited was 63 (31 received
> acyclovir and 32 received placebo). The number of women undergoing delivery by caesarean section for recurrent herpes at the time of delivery was 12 (19%).
> The odds ratio for delivery by caesarean section in women taking acyclovir, compared with those taking placebo, was 0.44 (95% CI 0.09-1.59). The odds ratio
> for clinical recurrences during treatment was 0.10 (95% confidence interval 0.00-0.86) and the odds ratio for clinical recurrence or asymptomatic shedding during
> treatment was 0.32 (95% CI 0.05-1.56). CONCLUSION: This trial was unable to demonstrate that acyclovir can significantly decrease the number of caesarean
> section deliveries; however, the number of clinical recurrences was significantly reduced. Two episodes of asymptomatic virus shedding both occurred in women
> taking acyclovir. At the present time there is little evidence to suggest that acyclovir should be used outside randomised controlled trials for the suppression of
> recurrent genital herpes infection during pregnancy.
