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Editorial Comment: Possible Neonatal Herpes Simplex Virus (HSV) Acquired Postpartum from Maternal Oral HSV Reactivation after Neuraxial Morphine

Bauchat, Jeanette MD

doi: 10.1213/XAA.0000000000000014
Case Reports: Case Report

Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois,,

Neonatal herpes is rare, with approximately 1500 cases reported a year in the United States, of which 10% (150 cases) are postnatally acquired via a caregiver with herpes labialis (cold sores) caused by herpes simplex virus (HSV-1).1,2 The literature is sparse on postnatally acquired neonatal herpes from mothers with recurrent HSV-1 herpes labialis because these are a fraction of neonatal herpes cases and are typically isolated to the skin, eyes, and/or mouth (SEM disease).1,3–5 Infant morbidity and mortality is 0% with SEM disease treated with antiviral drugs.3,4 These excellent outcomes from neonatal SEM disease are likely due to factors such as transplacental transmission of maternal HS1 antibodies, particularly with recurrent infections, identifiable cutaneous lesions on the infant, increased awareness of neonatal herpes by neonatologists, advancements in polymerase chain reaction techniques to detect HSV infection, and prompt treatment with antiviral therapy.1,5,6

The seroprevalence of HSV-1 is 63% in the U.S. pregnant population.7 There are nearly 1.3 million cesarean deliveries performed annually; seventy percent to 95% of these women will receive a neuraxial anesthetic technique with neuraxial opioids as recommended by the American Society of Anesthesiologist’s Practice Guidelines for Obstetric Anesthesia.8–10 The rate of postnatally acquired HSV remains extremely low despite the extensive use of neuraxial morphine for cesarean delivery and the associated risk of herpes labialis reactivation.11

Mothers should be made aware that HSV reactivation occurs after cesarean delivery with or without the use of intrathecal morphine.12 Anesthesiologists, obstetricians, and nurses should attempt to elicit a history of herpes labialis from women undergoing cesarean delivery and advise them to monitor themselves for signs of reactivation, request antiviral treatment if reactivation is suspected, and adhere to strict hand hygiene while refraining from kissing infants’ mucous membranes or open wounds (e.g., fetal scalp monitoring site) even without evidence of reactivation. Prophylactic valacyclovir treatment can reduce the presence of HSV DNA in saliva, but treatment for all women with herpes labialis undergoing cesarean delivery is not cost effective given the rarity of postnatally acquired neonatal herpes; and it may also promote HSV resistance to antiviral drugs.13,14 Mothers with a history of HSV and their health care providers should be educated about monitoring their infants for herpes lesions so that prompt evaluation and treatment with antiviral drugs can be administered, ensuring an excellent outcome.3,4 Nonmaternal caregivers and health care providers who have cold sores should not handle neonates because infants born to HSV seronegative mothers may develop systemic and central nervous system neonatal herpes which imparts the highest morbidity and mortality despite antiviral treatment.3,4,15

In this issue of A & A Case Reports, De Guzman et al.16 report the first suspected case of postnatally acquired neonatal herpes infection after maternal reactivation of herpes labialis (cold sore) after intrathecal morphine for cesarean delivery. The mother immediately recognized probable herpes lesions on her infant, and the infant received appropriate therapy with an excellent outcome. I agree with the authors’ call for querying patients regarding herpes labialis in our preanesthetic evaluation. If the history is positive, we need to follow this with education for mothers and health care providers about monitoring both the mother and infant for signs of HSV lesions. I also agree with the authors’ call for further research on HSV reactivation rates with confirmatory studies on HSV reactivation rates after varied intrathecal morphine doses, in different patient populations, and other neuraxial opioids. However, neuraxial morphine is currently the most effective, cost effective, easy to administer, long-acting analgesic for postcesarean delivery analgesia, and this case report should not discourage obstetric anesthesiologists from using it.17

Jeanette Bauchat, MD

Department of Anesthesiology

Northwestern University Feinberg School of Medicine

Chicago, Illinois

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