When a woman acquires her first episode of genital herpes during pregnancy, both the timing of acquisition and the gestational age at delivery directly shape the clinical approach. The priority is preventing viral shedding and active lesions at the time of delivery to reduce neonatal risk.
The structured approach involves initiating daily suppressive antiviral therapy from a defined point in gestation. The start of therapy is adjusted earlier for women at heightened risk of premature delivery. For cases where primary infection occurs in the third trimester, mode of delivery requires specific consideration — particularly when symptoms arise in the weeks immediately before the expected delivery date. The complete timing thresholds, sequencing, and decision algorithm are set out in the full protocol.
DOI: 10.1111/jdv.20450
Management of the woman should be in line with her clinical condition and will often involve the use of either oral or intravenous aciclovir in standard doses (Figure 4).
Daily suppressive aciclovir 400 mg three times a day from 36 weeks gestation may prevent HSV lesions at term and hence the need for delivery by caesarean section (1, A).
In countries where the risk transmission in premature neonates is particularly high, suppressive therapy should be started at an earlier time such as from 32 weeks gestation and from 22 weeks in those identified as being at particularly high risk of premature delivery.
Caesarean section should be considered for all women, particularly those developing symptoms within 6 weeks of delivery, as the risk of viral shedding in labour is very high (1, A).
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