HSV Screening: Are Wesley Obstetricians Following the Guidelines? Dawn Boender, PGY4 Taylor Bertschy, PGY3

Transcription

1 HSV Screening: Are Wesley Obstetricians Following the Guidelines? Dawn Boender, PGY4 Taylor Bertschy, PGY3

2 Goals To increase obstetrician knowledge regarding HSV screening Institute clinical changes at WMC (order set) Objective Pretest Objectives Posttest

3 QI Project Reviewed by Joann Paul, director of Quality and Infection Control at WMC. Reviewed by the University of Kansas School of Medicine Wichita Human Subjects Committee 2 Institutional Review Board on May 20, 2014 and is considered to be not human subjects research. This project involves evaluating the current knowledge of obstetricians regarding the recommendations for maternal HSV testing from the pediatrician s standpoint. This project seeks to educate providers on the recommendations and reassess knowledge following education of providers.

4 Pretest

5 Why The Change? Recommendations by the American Academy of Pediatrics Guidance on Management of Asymptomatic Neonates Born to Women with Active Genital Herpes Lesions Pediatrics, Volume 131, Number 2, February 2013 Collaboration with Pediatrics and NICU But it s not much of a change

6 HSV Infections Double-stranded DNA virus Most genital infections are HSV-2, but HSV-1 is increasing 1/3 to 1/2 of neonatal herpes are HSV-1 (ACOG)

7 HSV Infections First episode primary: No evidence of antibodies 57% develop neonatal HSV disease Lower transplacental antibodies Higher shedding First episode nonprimary: Past infection of the other viral type (serologic) 25% develop neonatal HSV disease Recurrent infection: Past infection of the same viral type 2% develop neonatal HSV disease

8 HSV Infections

9 Neonatal Classification Disseminated disease: multiple visceral organs Present at days CNS disease: +/- skin lesions Present at days SEM: skin, eye, mouth Present at days

10 Stats If women are seropositive for HSV-1, estimated chance of acquiring HSV-2 from partner during pregnancy is 1.7% 2/3 of women who acquire genital HSV during pregnancy remain asymptomatic 60-80% of women with HSV-infected infants have no clinically apparent genital HSV infection at time of delivery and no past history

11 Stats 20-25% of adults have HSV-2 HSV-1 now accounts for 20-50% of genital herpes ACOG lists up to 80% of new infections Only 5-15% of individuals with HSV recognize their infection

12 Newborn Acqusition Intrauterine (5%) Intrapartum (85%) Postpartum (10%)

13 Transmission Factors Type of infection (primary vs recurrent) Maternal HSV antibody status Duration of rupture Integrity of mucocutaneous barriers Mode of delivery

14 Diagnosis of Genital HSV PCR Assay: May not be available at all hospitals May be available in 1 day Viral culture: Low sensitivity, declines as heals Takes 2-5 days for results Antigen detection: Not recommended by CDC May not distinguish HSV-1 from HSV-2

15 Preventing Neonatal HSV Cesarean section Active lesions Prodromal symptoms Oral acyclovir or valacyclovir Reduces, does not eliminate!

16 Women In Labor HSV PCR and culture If positive, determine if HSV-1 or HSV-2 HSV-1 and HSV-2 IgG antibody status AOCG: All suspected herpes virus infections should be confirmed through viral or serological testing.

17 Women In Labor

18 Women In Labor

19 Women In Labor

20 Women In Labor

21 Algorithm for Neonates

22 Algorithm for Neonates

23 Review What the pediatricians need: First episode primary First episode non-primary Recurrent infection How we can help Clearly document history in prenatal record Order HSV PCR/Culture Further analysis (1 or 2) Antibody status

24 Thank-You Questions?

25 Posttest

26 References American College of Obstetricians and Gynecologists. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. No 82 June Management of Herpes in Pregnancy. Obstet Gynecol. 2007; 109(6): Kimberlin, David W, Baley, Jill. (2013). Guidance on Management of Asymptomatic Neonates Born to Women with Active Genital Herpes Lesion. Pediatrics, Volume 131, Number 2,