Herpes Simplex Virus 2 Infection during Pregnancy Table 5. Herpes Virus 2 Antibody-Positive Rate in Gravidas Investigator Nakubulwa, et al.33 Munjoma, et al.34 Kapranos, et al.35 Xu, et al.36 Sasadeusz, et al.37 Berntsson, et al.38 Ozdemir, et al.39 Current study Values are presented as a % (number). Country Uganda Zimbabwe Greece USA Australia Sweden Turkey Korea Herpes virus 2 antibody-positive 67.2 (168/250) 49.1 (167/340) 43.2 (41/95) 22.0 (138/626) 13.6 (186/1371) 10.4 (31/299) 8.2 (13/158) 17.0 (85/500) specific serologic testing can distinguish between primary, non-primary, and recurrent infections with certainty.11 About 75% of women with recurring genital herpes virus infec- tions suffer at least one recurrence during pregnancy whiles approximately 14% of them will show prodromal symp- toms or clinical recurrence during delivery.12,13 Thus, wom- en with a history of a herpes virus infection should be ex- amined for genital herpetic lesions during labor and delivery. In the late antepartum period, there may be fever and uri- nary symptoms associated with herpes virus infections, but often without local symptoms, which results in missed di- agnoses.3 Serologic testing for herpes virus 2 will identify gravidas with sub-clinical herpes virus 2 infections who were previ- ously undiagnosed.14 According to The American College of Obstetricians and Gynecologists recommendations, rou- tine HSV screening of gravidas is not recommended. A sur- vey conducted on a sample of 100 gravidas, regarding their knowledge and attitude on genital herpes, showed that 80% of them desired to be tested for HSV and 76% also encour- aged their sexual partners to be tested.15 Based on this study, an examination for herpes virus is readily accepted in gravi- das upon receiving education on genital herpes. Ideally, most, if not all gravidas are examined for herpes virus in- fection in addition to gravidas who are scheduled for a re- peat cesarean section. To evaluate the cost-effectiveness of different screening protocols for gravidas, several analyses have been made on how the incidence of neonatal herpes virus infections is reduced by those.16-20 As opposed to recurrent infections, primary genital her- pes infections present a higher risk for perinatal transmis- sion, as the mean duration of viral shedding for women with intreated primary HSV2 is 15 days.21 Moreover 90% of women with primary infections also showed cervical shedding by viral culture.21 However there is a 30-60% risk of vertical transmission to the neonate when there is a pri- mary outbreak during delivery.22 Herpes virus 1 accounts to about one-third to a half of cases of neonatal herpes,22,23 though amongst gravidas who suffer recurrent lesions during delivery, their transmission rate with a vaginal delivery is only of 3%.17 Beyond this, only 2 out of every 10000 gravidas with a history of recur- rent disease, but no visible lesions during delivery, are in risk of transmission.22,24 Maternal herpes virus acquisitions during pregnancy are, unfortunately, not addressed by antiviral suppression and cesarean delivery, which fail 70-80% of the time to prevent neonatal herpes infections. In cases in which the herpes vi- rus infections are sub-clinical, nearly 90% of these are not accounted by the methods mentioned above.4,23 Increased risk of spontaneous abortion has always been associated with herpes virus, though this has been found to be contradictory to recent studies.25 In the current study, however, the spontaneous abortion rate was correlated with a statistically significant increase in the herpes virus 2 anti- body-positive group, in comparison with the control group. The transplacental passage of the virus is rare, and herpes virus 2 infections are not associated with stillbirths.26 Neonatal chorioretinitis, microcephaly and skin lesions are very occasionally associated with primary outbreaks in the first trimester of pregnancy.27 Neonatal herpes virus in- fections can fall under 3 different classifications, those be- ing disseminated disease (25%) central nervous system dis- ease (30%), and disease limited to the skin, eyes, or mouth (45%).5 Though uncommon, neonatal herpes encephalitis is known as severe with a mortality rate of 4-14% and long term neurologic sequelate (56-69%).1,28-32 According to a large cohort study, gravidas are much less likely to transmit herpes virus infections to their infants when they give birth by cesarean section.22 Only 1.2% of infants, from gravidas with herpes virus infections detected at the time of delivery, received neonatal herpes infections when delivered by ce- Yonsei Med J http://www.eymj.org Volume 53 Number 2 March 2012 405