Original Article
The Acquisition of Herpes Simplex Virus during Pregnancy
N Engl J Med 1997; 337:509-516August 21, 1997
- Abstract
Background
The acquisition of genital herpes during pregnancy has been associated with spontaneous abortion, prematurity, and congenital and neonatal herpes. The frequency of seroconversion, maternal symptoms of the disease, and the timing of its greatest effect on the outcome of pregnancy have not been systematically studied.
Methods
We studied 7046 pregnant women whom serologic tests showed to be at risk for herpes simplex virus (HSV) infection. Serum samples obtained at the first prenatal visit, at approximately 16 and 24 weeks, and during labor were tested for antibodies to HSV types 1 and 2 (HSV-1 and HSV-2) by the Western blot assay, and the results were correlated with the occurrence of antenatal genital infections.
Results
Ninety-four of the women became seropositive for HSV; 34 of the 94 women (36 percent) had symptoms consistent with herpes infection. Women who were initially seronegative for both HSV-1 and HSV-2 had an estimated chance of seroconversion for either virus of 3.7 percent; those who were initially seropositive only for HSV-1 had an estimated chance of HSV-2 seroconversion of 1.7 percent; and those who were initially HSV-2–seropositive had an estimated chance of zero for acquiring HSV-1 infection. Among the 60 of the 94 pregnancies for which the time of acquisition of HSV infection was known, 30 percent of the infections occurred in the first trimester, 30 percent in the second, and 40 percent in the third. HSV seroconversion completed by the time of labor was not associated with an increase in neonatal morbidity or with any cases of congenital herpes infection. However, among the infants born to nine women who acquired genital HSV infection shortly before labor, neonatal HSV infection occurred in four infants, of whom one died.
Conclusions
Two percent or more of susceptible women acquire HSV infection during pregnancy. Acquisition of infection with seroconversion completed before labor does not appear to affect the outcome of pregnancy, but infection acquired near the time of labor is associated with neonatal herpes and perinatal morbidity.
Media in This Article
Table 1
Frequency of Antenatal HSV Seroconversion among 7046 Initially HSV-Susceptible Women.Table 2
Frequency of Symptoms and Trimester of Infection among Women with HSV Seroconversion during Pregnancy.Article Activity
- Article
The prevalence of genital infection with herpes simplex virus (HSV) and its most serious complication, neonatal herpes, has increased during the past two decades.1-6 Neonatal HSV infection most commonly results from contact between the newborn and either HSV type 1 (HSV-1) or HSV type 2 (HSV-2) that is present in the birth canal of an asymptomatic mother during labor and delivery.7-9 The consequences of neonatal infection with HSV are frequently catastrophic; death of the infected neonate or severe neurodevelopmental disability is common.10 HSV can be asymptomatically present in the genital tract at the time of labor as a consequence of the reactivation of disease or the acquisition of genital herpes during pregnancy.8,9,11
Previous studies have suggested that genital HSV infection acquired during pregnancy is associated with preterm labor, intrauterine growth retardation, and spontaneous abortion.7,12,13 However, there have been few prospective studies of the frequency and consequences of genital HSV infection acquired at different times during pregnancy. Therefore, we used serologic and virologic methods to study the acquisition of HSV infection among pregnant women.
Methods
Subjects, Setting, and Procedures
We obtained serum samples at the first prenatal visit and at the time of labor to test for the presence of antibodies against HSV-1 and HSV-2 in 8538 women receiving prenatal care at University Hospital in Seattle between January 1989 and December 1993 and at Madigan Army Hospital in Tacoma between August 1990 and December 1993. In addition, serum samples obtained for routine prenatal tests at 14 to 18 weeks and at 24 to 28 weeks of gestation were saved and tested when indicated to define more precisely the time of seroconversion. When the women entered the labor room, swabs for culture of HSV were obtained from the external genitalia and cervix.8 Isolation and typing of HSV were performed as previously described.14 Infants born to women from whom HSV was isolated during labor were enrolled in ongoing studies.7
Antibodies to HSV-1 and HSV-2 were detected by Western blot assays.15-19 All serum samples from an individual woman were analyzed simultaneously. For all women whose initial serum sample was positive for HSV-1 but in whom antibodies to HSV-2 later developed, seroconversion was confirmed by absorption-blot assay.19 The medical records of all women who became seropositive for HSV-1 or HSV-2 were reviewed for symptoms of genital HSV during pregnancy.
Consent was obtained for the appropriate portions of the study protocol, including the review of medical records and the follow-up of infants, according to the guidelines of the human-subjects review board of the University of Washington.
Definitions
Seroconversion was defined as the appearance of antibodies to HSV in the serum sample obtained at the time of labor that were not present at the initial prenatal visit.20-23 This change indicates that HSV was acquired long enough before delivery to permit the development of antibodies to HSV, a process that usually requires four to six weeks. Primary HSV infection was considered to have occurred when there were no detectable antibodies to HSV in the first prenatal serum sample but antibodies to either HSV-1 or HSV-2 were found in the sample obtained at the time of labor. A non-primary first episode was defined as the presence of antibodies to HSV-1 in the initial prenatal serum sample, with antibodies to both HSV-1 and HSV-2 in the sample obtained at the time of labor. No woman who had antibodies to HSV-2 in the initial prenatal serum sample had antibodies to both HSV-2 and HSV-1 in the sample obtained at the time of delivery.
Among women with symptomatic disease, the date of acquisition of genital HSV infection was defined as the date of the first reported genital lesions. Among those with subclinical disease, the date of infection was defined as the midpoint between the time of the negative test for the particular HSV antibody and the time of the first positive antibody test. Infection was considered subclinical if a review of the woman's obstetrical records did not indicate any evidence of vulvovaginitis during pregnancy. The first trimester was defined as the period from conception to 12 completed weeks of gestation, the second trimester as that from the beginning of week 13 through week 28, and the third trimester as that from the beginning of week 29 to the onset of labor. Premature labor was defined as labor occurring before 259 days, or 37 weeks, from the first day of the woman's last menstrual period.24
Statistical Analysis
The frequency of seroconversion was calculated as the ratio of the number of women who had HSV seroconversion to the number at risk for seroconversion. Because the mean interval between the first prenatal visit and the onset of labor was less than the length of a normal pregnancy, the frequency of seroconversion was adjusted for a 40-week gestation period on the assumption that the rate of seroconversion was uniform throughout pregnancy. This method may result in the underestimation of the true frequency of seroconversion because the interval between conception and the first prenatal visit may be a period of normal or increased sexual activity that then declines as pregnancy progresses.25
Categorical variables were compared between groups by means of the chi-square or Fisher's exact test. Rates of seroconversion were compared by permutation tests.26 Standard errors for these rates were estimated with bootstrap resampling.27 Two-group comparisons of distributions of continuous variables were performed by Mann–Whitney tests. All statistical tests were two-sided. Odds ratios for seroconversion, with 95 percent confidence intervals, were estimated from the results of logistic-regression analyses. Odds ratios indicating the influence of demographic variables on the rate of seroconversion were estimated by multivariate analysis. Odds ratios for behavioral variables came from univariate analyses, because missing data greatly reduced the number of women who could be included in a multivariate analysis incorporating these variables.
Results
Characteristics of the Study Population
Of the 17,125 women who delivered babies at the two study hospitals, 15,434 (90 percent) had serologic testing for HSV at the time of labor. Serum samples obtained during labor were not available from 1691 women (10 percent) because of oversight on the part of physicians, lost specimens, or the women's refusal to allow blood sampling. Serum samples from the first prenatal visit were available for 8538 of the 15,434 women (55 percent). Serum samples were not obtained at the first prenatal visit for 6896 women because the women were referred to the study centers within 30 days of delivery (26 percent of those with missing prenatal samples), no prenatal care was received (7 percent), or prenatal care was received elsewhere (22 percent). In addition, 16 percent of women had already had their initial prenatal visit when we began the study and were thus ineligible for enrollment. The remaining 29 percent of the women with missing prenatal samples either registered for care late in pregnancy, declined to have blood drawn, or did not have the serologic tests because of the physician's oversight.
The demographic characteristics and HSV serologic status of the 8538 women from whom serum samples were obtained both at the first prenatal visit and at the time of labor were similar to those of the 6896 women for whom results of serologic testing for HSV were available only at the time of labor.
Frequency of Antenatal Seroconversion
At entry, 2033 of the 8538 women (24 percent) were HSV-negative; 4074 (48 percent) were seropositive for HSV-1; 939 (11 percent) were seropositive for HSV-2; and 1492 (17 percent) were seropositive for both HSV-1 and HSV-2. Of the 7046 women (83 percent) in whom serologic tests showed susceptibility to HSV infection during pregnancy, 94 (1.3 percent) became seropositive for HSV-1 or HSV-2; 64 (68 percent) acquired antibodies to HSV-2, and 30 (32 percent) acquired antibodies to HSV-1 before the onset of labor (Table 1Table 1
Frequency of Antenatal HSV Seroconversion among 7046 Initially HSV-Susceptible Women.). The median interval between the first prenatal HSV test and the HSV test at the time of labor was 196 days (range, 26 to 280) for the entire study group and 202 days (range, 26 to 257) for the 94 women in whom seroconversion occurred.The estimated rate of seroconversion during pregnancy, adjusted for a 40-week gestation, was 2.1 percent. The adjusted rate of seroconversion among the initially HSV-seronegative women was 3.7 percent; among those who were initially HSV-1–seropositive, 1.7 percent became HSV-2–seropositive. Although the rates of HSV-2 seroconversion among initially HSV-seronegative women were similar to those among HSV-1–seropositive women (1.4 percent vs. 1.7 percent), the rate of HSV-1 seroconversion among those who were HSV-seronegative was significantly higher than that among those who were HSV-2–seropositive (2.3 percent vs. 0, P = 0.001), suggesting that prior HSV-2 infection prevented the acquisition of HSV-1 (Table 1).
Frequency of Subclinical and Clinical HSV Infection
Among the 94 women who became HSV-seropositive during the prenatal period, 60 (64 percent) had subclinical infections (Table 2Table 2
Frequency of Symptoms and Trimester of Infection among Women with HSV Seroconversion during Pregnancy.). The frequency of subclinical seroconversion was similar among those who acquired HSV-1 (22 of 30 [73 percent]) and those who acquired HSV-2 (38 of 64 [59 percent]). All 26 women with clinical symptoms of HSV-2 infection and 6 of 8 with symptomatic HSV-1 infection had genital lesions. Overall, 32 of the 34 women who had seroconversion and symptomatic infection had genital infections; 4 received antiviral therapy.Time of Acquisition of HSV
Of the 34 women with symptomatic infection, 7 (21 percent) acquired HSV in the first trimester, 15 (44 percent) in the second, and 12 (35 percent) in the third. Of the 60 women with subclinical HSV, 11 (18 percent) were infected in the first trimester, 3 (5 percent) in the second, and 12 (20 percent) in the third (Table 2). In three women, infection was known only to have occurred in the first or second trimester. In 22 women, infection occurred in the second or third trimester. In nine women, interim serum samples were not available to permit us to identify the trimester of HSV infection. Thus, of the 60 women in whom the trimester of infection was known, 18 (30 percent) acquired HSV infection in the first trimester, 18 (30 percent) in the second, and 24 (40 percent) in the third.
Demographic, Behavioral, and Obstetrical Characteristics of the Women with Seroconversion
We compared the demographic, behavioral, and obstetrical characteristics of the 94 women who had HSV seroconversion with those of 6009 women who did not have seroconversion (Table 3Table 3
Demographic and Behavioral Characteristics of Women Who Had HSV Seroconversion and Women with Similar Serologic Profiles Who Did Not Have Seroconversion.). In addition, the 49 initially HSV-seronegative women who became seropositive for HSV-1 or HSV-2 and 45 HSV-1–seropositive women who became seropositive for HSV-2 were compared with HSV-seronegative women who remained HSV-seronegative and HSV-1–seropositive women who did not acquire HSV-2. Younger age, not being married, and the occurrence of other sexually transmitted diseases were associated with seroconversion.Overall, 25 of the 94 women who became seropositive for HSV during pregnancy (27 percent) underwent a cesarean section (6 because of the presence of active genital lesions), as compared with 17 percent of the women who did not have seroconversion (P = 0.02). Among the 32 women who acquired symptomatic genital HSV during pregnancy, 10 (31 percent) delivered their infants by cesarean section; 6 of these women had active, recurrent genital lesions at the time of delivery. Among the 60 women who acquired subclinical HSV infection, 15 (25 percent) delivered by cesarean section. The frequency with which fetal-scalp electrodes and intrauterine pressure catheters were used during labor and delivery was similar among the 94 women who had seroconversion (56 percent and 52 percent, respectively) and the 6009 women who did not (62 percent and 50 percent).
Effects of Seroconversion to HSV Positivity on Neonates
There were no significant differences in the frequency of complications between the 94 infants born to mothers who had HSV seroconversion and the infants of the 6009 women who did not seroconvert (Table 4Table 4
Outcome of Pregnancy among Women Who Had Seroconversion as Compared with Women with Similar Serologic Profiles Who Did Not Have Seroconversion.). There were no cases of herpes among the neonates of the 94 women who seroconverted. On the basis of a binomial probability calculation, we are 95 percent confident that the chance that a woman who becomes seropositive during pregnancy will infect her newborn with HSV is less than 3.2 percent. Of the 94 women with seroconversion, cultures for HSV were performed at the time of labor in 71. Of these, five (7 percent) were positive.Relation of Neonatal Herpes to Initial Episodes of Genital HSV at the Time of Labor
Nine women acquired a genital HSV infection near the onset of labor, five of whom had lesions at the time of labor (Table 5Table 5
Characteristics of HSV Infection Acquired near the Time of Labor and Neonatal Outcome.). Since they had not completed HSV seroconversion by the time of labor, they were excluded from the main study cohort. During labor, all had either no detectable antibodies to HSV or antibodies that were different from the HSV type isolated from the genitalia. Serologic and virologic evidence indicated that seven of these nine women had a non-primary first episode of HSV-2 infection and the other two had a primary genital HSV-1 infection.Neonatal HSV infection developed in four of the nine infants born to these women — both of the infants born to mothers who had primary genital HSV-1 and two of the seven born to mothers with non-primary first episodes of infection (Table 5). The frequency of neonatal HSV infection was significantly higher among the infants of women with first episodes of HSV near the time of labor (4 of 9) than among those born to women who acquired their infection earlier and had seroconversion before the onset of labor (0 of 94, P<0.001).
Discussion
We estimate that HSV was acquired by 2 percent or more of susceptible women during pregnancy. Among the infants of 94 women who became seropositive for HSV before labor, there were no cases of neonatal herpes or any increase in pregnancy-related morbidity. However, among the infants born to nine women who acquired HSV infection at or near the time of labor, neonatal HSV developed in four, of whom one died and one had long-term neurologic sequelae.
The absence of definable morbidity in association with HSV seroconversion before the onset of labor is comforting and yet surprising. Previous studies have demonstrated an association between first episodes of genital HSV infection and preterm labor, intrauterine growth retardation, and spontaneous abortion.7,12,13 These observations have all come from studies based on cultures and serologic tests performed at the time of labor. We studied seroconversion prospectively during pregnancy in a large, well-defined cohort, comparing pregnancy outcomes among women with and without seroconversion. Although our study involved more than 8000 women and 94 cases of HSV seroconversion, the frequency of complications of pregnancy was low both among women who had seroconversion and among those who did not. Thus, it is possible that HSV may have some effect on pregnancy that could be demonstrated only by larger cohort studies.
Of 60 women for whom we could identify the trimester when HSV was acquired, 30 percent became infected in the first trimester, 30 percent in the second, and 40 percent in the third — suggesting that the risk of acquisition is relatively uniform during pregnancy. However, since the frequency of coitus is higher in early pregnancy and declines thereafter, the actual risk of HSV seroconversion may decline as the pregnancy advances.25
Among the eight women in whom seroconversion to HSV-1–positivity was accompanied by clinical symptoms, six had genital lesions and two had only oropharyngeal lesions. Several studies have demonstrated an increase in the prevalence of genital HSV-1 in recent years, especially among patients with recently acquired HSV infection.1,2,6,19,20 Perhaps this increase results from a perception among young couples that oral–genital sex is “safe.”
The two cases of neonatal HSV-1 infection underscore the importance of recognizing that neonatal herpes can result from infection with either viral subtype and that the prevention of genital HSV-1 infection in the third trimester is important in terms of the health of the neonate. Lastly, although 7 percent of the infants born to mothers who became HSV-seropositive before the onset of labor but had subclinical viral shedding at the time of labor were exposed to HSV during delivery, none acquired HSV infection. In contrast, four of the nine infants born to mothers who lacked type-specific antibodies to the homologous virus acquired HSV infections. This finding underscores the potential role of type-specific antibodies in protecting against HSV transmission.
The absence of discernible perinatal morbidity among the babies born to women in whom seroconversion occurred during pregnancy suggests that routine antiviral chemotherapy may not be necessary for women who acquire HSV well before the onset of labor. Selected women who are highly symptomatic or in whom there is evidence of disseminated infection may require antiviral chemotherapy. Cases such as these were extremely uncommon in our study population.
Our study also suggests that efforts to reduce the high morbidity associated with neonatal HSV infection should be concentrated on preventing the maternal acquisition of HSV infection in the latter part of pregnancy. Serologic testing for HSV in the latter half of pregnancy could identify women who are susceptible to HSV infection, so that serologic testing of their partners and appropriate counseling as to the risk of acquiring genital herpes could be undertaken. Such counseling should promote awareness of the risk of acquiring genital HSV-1 infection from oral–genital contact among those who are seronegative for both HSV-1 and HSV-2. Abstinence from intercourse or the use of condoms during the last trimester could also be recommended when the woman is at risk for acquiring HSV-1 or HSV-2.
Supported by a grant (AI-30731) from the National Institute of Allergy and Infectious Diseases.
The opinions expressed in this article are solely those of the authors and do not necessarily reflect those of the Department of the Army or the Department of Defense.
Source Information
From the Departments of Obstetrics and Gynecology (Z.A.B., D.H.W., S.B.), Laboratory Medicine (S.S., R.L.A., L.C.), Statistics (J.Z.), and Medicine (L.C.), University of Washington, Seattle; and the Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, Wash. (J.K., A.M., M.H.).
Address reprint requests to Dr. Brown at Box 356460, University of Washington, Seattle, WA 98195-6460.
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