Louis A. Vontver

Neonatal herpes simplex virus infection in relation to asymptomatic maternal infection at the time of labor.

Abstract Background and Methods. To define the risk factors associated with neonatal acquisition of herpes simplex virus (HSV) infection, we prospectively obtained HSV cultures from the cervix and external genitalia of 15,923 pregnant women in early labor who were without symptoms or signs of genital HSV infection. Follow-up of the women with positive cultures for HSV and their HSV-exposed infants included serologic tests and serial cultures for HSV. Results. HSV was isolated from 56 of the women (0.35 percent), 18 of whom (35 percent) had serologic evidence of a recently acquired, subclinical first episode of genital HSV infection, and 34 of whom (65 percent) had reactivation of HSV. Neonatal HSV developed in 6 of 18 infants (33 percent) born to the women with a first episode of genital HSV, and in 1 of 34 infants (3 percent) born to the women with reactivation of HSV (P<0.01); neonatal HSV also occurred in three of the infants born to the 15,867 women with negative cultures. Neonatal HSV-2 occurred in 1...

Risk of recurrence after first episodes of genital herpes. Relation to HSV type and antibody response.

To define risk factors associated with recurrent genital herpes-simplex-virus infection caused by either Type 1 or 2 herpesvirus (HSV-1 or HSV-2), we prospectively studied 137 patients with a first symptomatic episode of the disease and 87 with a recurrent episode. First episodes were divided into 78 primary infections (no antibodies to HSV in acute-phase serum) and 59 nonprimary infections (antibodies present). HSV-1 infections were less frequent and less likely to recur than HSV-2 infections. Fifteen per cent of primary first episodes were caused by HSV-1, as compared with 3 per cent of nonprimary first episodes and 2 per cent of recurrent episodes. Moreover, during follow-up of first-episode patients, only 14 per cent of HSV-1 infections recurred, as compared with 60 per cent of HSV-2 infections. Recurrences were more likely to follow an index recurrent episode than an index first episode, whether primary or nonprimary, and were more likely to occur in men than in women. Among patients with primary HSV-2 infections, the probability of recurrence was directly related to the presence and titer of neutralizing antibody to HSV-2 in convalescent-phase serum.

Effects on Infants of a First Episode of Genital Herpes during Pregnancy

Although genital herpes simplex virus (HSV) infections occurring during pregnancy are known to be associated with neonatal and maternal complications, their frequency and contributing risk factors are not well understood. We prospectively followed 29 patients who acquired genital herpes during pregnancy, to evaluate the perinatal effects of the infection. The patients were classified on the basis of clinical or serologic criteria. Fifteen patients had a primary first episode of genital HSV Type 2 (HSV-2), and 14 had a nonprimary first episode. Although no patient had disseminated disease, 6 of the 15 with primary genital herpes but none of 14 with nonprimary first-episode infection had infants with serious perinatal morbidity (P less than 0.01). Four of the five infants whose mothers acquired primary HSV-2 in the third trimester had perinatal morbidity such as prematurity, intrauterine growth retardation, and neonatal infection with HSV-2. Perinatal complications occurred in one of five infants whose mothers acquired primary HSV-2 during the first trimester, as well as in one of five infants whose mothers had primary HSV-2 during the second trimester. Asymptomatic cervical shedding of HSV-2 was detected at 10.6 percent of weekly visits made after a primary first episode, as compared with 0.5 percent of visits after a nonprimary first episode (P less than 0.01). We conclude that infants born to women who acquire primary genital herpes during pregnancy are at high risk of exposure to HSV, either during premature labor at the time of the primary episode or subsequently because of asymptomatic cervical shedding of the virus. The 40 percent incidence of serious perinatal morbidity in such women suggests that studies of preventive measures such as the use of antiviral chemotherapy are warranted.

Recurrent genital herpes simplex virus infection in pregnancy: Infant outcome and frequency of asymptomatic recurrences☆☆☆

Eighty pregnant patients with a history of recurrent genital herpes simplex virus (HSV) infection were followed up with frequent genital examinations and cultures for HSV during their pregnancies. Recurrences of genital HSV during pregnancy were documented in 67 patients. Ninety-six percent of these had external genital lesions noted at some time during their pregnancy. One hundred eighty-six (93%) of the 199 recurrences of the disease were associated with external genital lesions. Of 13 episodes of asymptomatic viral shedding documented in this patient population, six were from the vulva alone, five were from the cervix alone, and two were from both the vulva and the cervix. Of 11 episodes of cervical HSV shedding, seven were asymptomatic and four were associated with external symptomatic lesions. Despite frequent recurrences of genital HSV infection during pregnancy, all study patients were delivered at term, and although they had a high rate of delivery by cesarean section (32.5%), the outcome of their infants was good.

Genital herpes in pregnancy: Risk factors associated with recurrences and asymptomatic viral shedding

One hundred forty-seven women with recurrent symptomatic genital herpes simplex virus acquired prior to the start of pregnancy (group 1) and 15 women whose first symptomatic episode of genital herpes was acquired during pregnancy (group 2) were followed weekly during the course of gestation. Among women with recurrent genital herpes antedating pregnancy, the mean number of recurrences per trimester increased from 0.97 to 1.26 to 1.63 in the first through third trimester, respectively (p less than 0.05 for comparison between each trimester). The median number of symptomatic recurrences of genital herpes during gestation was four in women in group 1 compared to one in women in group 2 (p less than 0.01). Asymptomatic viral excretion from the genital tract was, however, more common in women in group 2 (33%) than in women in group 1 (12.9%) (p less than 0.05). Herpes simplex virus was isolated at 5.5% of routine visits in group 2 women compared to 1% of routine visits among group 1 women. Logistic regression analysis indicated young age also was associated with more frequent asymptomatic viral shedding. Asymptomatic herpes simplex virus excretion was more common from the vulvar area than the cervix, and women in group 2 were more likely to shed virus from both sites simultaneously than women in group 1. Age and recent acquisition of genital herpes are risk factors for asymptomatic excretion of herpes simplex virus during pregnancy.

Clinical course and diagnosis of genital herpes simplex virus infection and evaluation of topical surfactant therapy

A prospective study of 37 men and 32 women with culture-proved genital herpes simplex virus (HSV) infection was undertaken to characterize the clinical manifestations of the disease and effects of topical therapy with Nonoxynol 9, a nonionic surfactant active in vitro against HSV. The duration of pain, lesions, and virus shedding was significantly longer in initial than in recurrent genital HSV infection. Cervical HSV shedding occurred in 11 of 13 initial infections versus two of 19 recurrences (p less than 0.001). Type 1 HSV caused seven of 29 initial and none of 40 recurrent infections (p less than 0.01). Clinical recurrences within six weeks were detected more often in men than in women and were unrelated to the menstrual cycle. The influence of coitus on recurrence is unclear. Papanicolaou smears were transiently abnormal (Class II) in four (12.5 per cent) of 32 female patients. Evidence of herpesvirus was detected cytologic smears from only 28 (41 per cent) of 69 culture-proved external lesions and three (23 per cent) of 13 culture-positive cervices. Serology was also of limited diagnostic value except in testing paired sera from initial infections. The topical therapy had no beneficial effect.

Recurrent genital herpes among women: symptomatic v. asymptomatic viral shedding.

To investigate whether asymptomatic shedding of herpes simplex virus occurs in women with recurrent genital herpes, six women with documented disease were followed up twice weekly with viral cultures and pelvic examination. During the study period of 1330 patient days and 452 patient visits, 26 episodes of genital herpesvirus infection were recorded. Twenty-three (88%) episodes were accompanied by signs and symptoms. Three (14%) of the culture-positive recurrences were asymptomatic. In one episode an asymptomatic lesion was noted, and in two instances viral shedding from the vulva or cervix occurred in the absence of visible herpetic lesions. Three of the six women had evidence of recurrent cervical herpesvirus infection. No relationships between menstrual cycle and sexual activity and the onset of recurrence were noted.

The Effects of Two Methods of Pelvic Examination Instruction on Student Performance and Anxiety.

The impact of two methods of pelvic examination instruction on student performance and anxiety was examined. Forty second-year medical students were randomly assigned either to an experimental group which received initial pelvic examination instruction from professional patients or to a control group which received this instruction from a gynecologist with a clinic patient. Results revealed no significant difference between experimental and control subjects in subsequent performance of the pelvic examination, on heart rate, or on perceived anxiety using one anxiety inventory. However, significant differences were found using a second anxiety instrument. The cost per student examination was twice as much for the clinic-patient group as for the professional-patient group. These findings are discussed in relation to prior research and instructional practices.

The Use of Mental Practice in Pelvic Examination Instruction.

The purpose of the research reported in this article was to test the effects of mental practice on clinical skill acquisition. The clinical skill to be acquired was the pelvic examination. Four instructional designs provided learning experiences for 160 second-year medical students at the University of Washington. The usual instructional sequence was the control, and three experimental sequences incorporated mental practice at premotor, postmotor, and combined premotor and postmotor stages of skill acquisition. Mental practice was facilitated by the use by students of audiotapes and headphones. Learner performance measures consisted of the evaluation of student ability to list the examination sequence, evaluations of an actual pelvic examination write-up, including both sequencing and findings, and observation ratings of skill performance. Mental practice produced better performance on the ability to list the examination sequence and the ability to record findings than no mental practice. Methods for providing mental practice created an orderly and efficient learning environment. Students found it helpful.

Ineffectiveness and toxicity of BCG vaccine for the prevention of recurrent genital herpes.

One hundred fifty-five patients with genital herpes were enrolled in a double-blind, placebo-controlled trial comparing 0.1 ml of intradermal BCG vaccine with placebo for the prevention of recurrent episodes of genital herpes. The mean rate or recurrence over 9 months of prospective follow-up was 0.528 recurrences per month in BCG recipients compared with 0.392 recurrences per month in placebo recipients (not significant). The BCG vaccine also failed to influence the duration of lesions in the first recurrent episode of genital herpes after vaccination. Six patients were given a second inoculation of BCG vaccine, and persistent cutaneous granulomas were noted in three of these six patients. Intradermal inoculation with BCG does not appear to affect the natural history of genital herpes, and repeated inoculations can be toxic.