Obgyn · Year 3 · from Obgyn

Case 3: Primary Genital Herpes in Pregnancy

Patient Demographics

  • Age: 26 years
  • Sex: Female
  • Occupation: Elementary school teacher
  • Gestational Age: 34 weeks

Chief Complaint

"I have extremely painful sores on my genital area and it hurts to urinate."

History of Present Illness

The patient, currently 34 weeks pregnant with her first child, presents with a 4-day history of multiple painful genital lesions. The pain began as tingling and burning in the vulvar area, followed by the appearance of small blisters that have now ruptured into painful ulcers. She reports severe pain with urination (dysuria), describing it as "like pouring acid on the sores." She has noticed bilateral inguinal lymph node swelling and tenderness. She also reports fever, body aches, and malaise for the past 2 days. She denies any prior history of genital herpes or similar lesions. Her pregnancy has been uncomplicated until now. She has been in a monogamous relationship with her husband for 3 years; however, her husband reports a history of "cold sores" on his lips.

Past Medical History

  • G1P0, current pregnancy at 34 weeks
  • No prior genital herpes diagnosis
  • No other STIs
  • No chronic medical conditions

Physical Examination Findings

  • Vital Signs: Temperature 38.1 degrees Celsius, HR 98 bpm, BP 112/70 mmHg
  • General: Uncomfortable-appearing pregnant woman
  • Abdomen: Gravid uterus consistent with 34 weeks, soft, non-tender, fetal heart tones 145 bpm
  • Inguinal Lymph Nodes: Bilateral tender inguinal lymphadenopathy
  • External Genitalia: Multiple bilateral grouped vesicles and shallow ulcers on the labia majora and minora, perianal area spared, lesions on erythematous base, some vesicles intact, others ruptured with shallow ulcer base, significant edema of vulvar tissues
  • Speculum Examination: Deferred due to severe pain; cervix visualized without visible lesions

Diagnostic Workup

  • HSV PCR from Lesion Swab: Positive for HSV-2
  • HSV Type-Specific Serology (IgG): HSV-1 IgG positive, HSV-2 IgG negative (indicating primary HSV-2 infection as patient has not yet seroconverted)
  • Complete Blood Count: WBC 9,800/microL (normal), Hemoglobin 11.2 g/dL
  • Urinalysis: Unable to obtain clean catch due to severe dysuria; catheterized specimen normal
  • Fetal Non-Stress Test: Reactive, reassuring

Diagnosis

Primary Genital Herpes Simplex Virus Type 2 (HSV-2) Infection at 34 weeks gestation

  • Classified as primary infection based on:
  • First clinical episode
  • Negative HSV-2 IgG indicating no prior exposure
  • Severe systemic symptoms typical of primary infection

Management Plan

Antiviral Treatment:

  1. Acyclovir 400 mg orally three times daily for 7 to 10 days (extended course for primary episode)
  2. If unable to tolerate oral intake due to pain: IV acyclovir 5 mg/kg every 8 hours
  3. Acyclovir is safe in pregnancy (FDA Category B)

Symptomatic Management:

  1. Sitz baths with warm water for comfort
  2. Topical lidocaine 2% gel for pain relief
  3. Oral analgesics (acetaminophen)
  4. If unable to void: Foley catheter placement may be necessary for urinary retention
  5. Adequate hydration

Suppressive Therapy:

  1. Begin daily suppressive therapy at 36 weeks gestation (acyclovir 400 mg three times daily) to reduce risk of recurrence at delivery and viral shedding
  2. Continue until delivery

Delivery Planning:

  1. Serial assessment for lesions as delivery approaches
  2. Cesarean delivery is indicated if:
  • Active genital lesions present at onset of labor
  • Prodromal symptoms (tingling, burning) present at labor onset
  1. Primary infection near term carries highest risk of neonatal transmission (30-50% if vaginal delivery with active lesions)
  2. Discuss with patient that cesarean delivery significantly reduces but does not eliminate neonatal herpes risk

Partner Counseling:

  1. Husband likely source given history of oral HSV (HSV-1 can cause genital herpes through oral-genital contact)
  2. Counsel on transmission risk and suppressive therapy for partner
  3. Avoid sexual contact until lesions completely healed

Neonatal Considerations:

  1. Pediatrics notification of maternal HSV status
  2. If vaginal delivery occurs, neonatal HSV surveillance
  3. Highest risk period is primary maternal infection at delivery

Clinical Image

Image Description: Clinical photograph of primary genital herpes showing multiple grouped vesicles on an erythematous base on the vulvar surface. Some vesicles have ruptured to form shallow, painful ulcers with irregular borders. The surrounding tissue shows significant edema. Primary episodes typically present with more numerous bilateral lesions compared to recurrent episodes.

Attribution: Image for educational purposes demonstrating primary genital herpes presentation. Similar images available in medical literature and Wikimedia Commons.

Summary of Key Learning Points

  1. PID with TOA requires hospitalization, IV antibiotics with anaerobic coverage, and close monitoring with consideration for drainage if no improvement at 48-72 hours
  1. Disseminated gonococcal infection presents with the classic triad of dermatitis, tenosynovitis, and migratory polyarthralgia; more common in women, especially during menstruation
  1. Primary genital herpes in pregnancy requires:
  • Antiviral treatment for the acute episode
  • Suppressive therapy starting at 36 weeks
  • Cesarean delivery if active lesions or prodrome at labor onset
  • Highest neonatal transmission risk with primary infection near term
  1. Partner notification and treatment is essential for all STIs to prevent reinfection and ongoing transmission
  1. NAAT testing is the gold standard for chlamydia and gonorrhea diagnosis; test all exposure sites (cervix, pharynx, rectum) based on sexual history

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