Herpes: Confusion Between Obstetricians and Gynecologists

December 14, 2007

What is herpes? Do cures for herpes exist? Well, it depends whom you ask...

Lately there's been a lot of confusion between the two sister specialties of obstetrics and gynecology over herpes.

The obstetricians have always feared this virus (herpes simplex), because if a mother had a lesion at the time of the delivery, about half of babies born vaginally caught it, and out of those one half died. Although anti-herpes drugs like acyclovir are now being given to infected newborns and things aren't quite that bad anymore, it's still felt that all one need to do is perform a C-section to provide a delivery route that by-passes the infected vaginal tissue. Problem solved, right?

Not quite. Managed care, buoyed by support from the American College of Obstetricians and Gynecologists, attacked the high C-section rates in the U.S., and along with protocols to reduce the numbers, a herpes rationale was developed as well:

Herpes cultures would be obtained every week in the last month until delivery. If there were no positive cultures and if there were no active lesions, a woman could deliver vaginally with safety. Problem solved, right?

Not quite. The field of gynecology, ignoring any obstetrical implications, saw herpes as a sexually transmitted disease only. Strangely silent about pregnancy, gynecology literature began to demonstrate that a person infected with herpes could shed the virus silently with no evidence of an active lesion. So all herpes patients are now told they can possibly infect their partners anytime, lesion or not. They are all told to use condoms all of the time for the highest safety.

Meanwhile, we obstetricians, who happen to read the same articles the gynecologists read because we are they, become confused, since we now come to understand that a woman can give a baby herpes even without an outbreak. And since the herpes cultures are notoriously inaccurate with a lot of false negatives, we the obstetricians wonder that if we the gynecologists say always use a condom, then shouldn't we also be saying always have a C-section?

We Combined OBGYNs Speak with Forked Tongues.

A pregnant woman comes to me and says she has herpes outbreaks about twice a year. I tell her the newest guidelines: if there's no active lesion within two weeks of delivery, then she can deliver vaginally. But then I tell her I'm also in touch with my gynecology side, which implies a C-section if she wanted to do everything she possibly could to avoid infecting the baby. And then I add that nearly a third of babies who get infected do so after C-section, which makes no sense since the baby gets infected by traversing the vagina and outside skin. She asks me what should she do?

I tell her that the right answer is that there is no right answer. That silent shedding of virus, while feared in gynecology, is ignored in obstetrics. And I tell her that screening cultures are not helpful and have been abandoned. I give the patient two choices: either believe the obstetricians and take only a very slight chance that the baby may get herpes, or believe the gynecologists and take no chances by having what will probably be an unnecessary surgery. Now thinking is finally moving toward reconciling these two opposite viewpoints, which is good for me since I'm both an obstetrician AND a gynecologist.

Now I'm beginning to see in the literature giving pregnant women Acyclovir (a medicine for herpes) during the last month of pregnancy to diminish the theoretical silent shedding, and if there are no active lesions, allow vaginal delivery. This is still considered investigational, but at last something makes sense.

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