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OBSTETRICS
OBSTETRICS
Acceptance of a Rapid Herpes Test in Labour:
Survey of Attitudes of Patients and Health Care
Providers
Julie van Schalkwyk, MD,1 Neda Amiri, BSc,1 Sayrin Lalji, MD,1 Carolyn Gardella, MD, MPH,2
Anna Wald, MD, MPH,3 Deborah Money, MD1
1
Department of Obstetrics and Gynaecology, Children’s and Women’s Health Centre of British Columbia, Vancouver BC
2
Department of Obstetrics and Gynecology, University of Washington, Seattle WA
3
Department of Medicine and Epidemiology, University of Washington, Seattle WA
Abstract Méthodes : Une étude transversale a été menée auprès de femmes
enceintes ambulatoires et de leurs fournisseurs de soins de santé
Objective: To determine the acceptability to pregnant women and (obstétriciens, médecins de famille et sages-femmes) au BC
their health care providers of a rapid test for genital herpes Women’s Hospital and Health Centre.
simplex virus (HSV) in labour.
Résultats : Chez les femmes enceintes sollicitées, 207 (92 %) ont
Methods: A cross-sectional survey was conducted with outpatient rempli le sondage; 90 % d’entre elles n’ont signalé aucun
pregnant women and their health care providers (obstetricians, antécédent d’herpès génital. Le dépistage rapide du VHS pendant
family physicians and midwives) at BC Women’s Hospital and le travail était considéré acceptable par 85 % des femmes
Health Centre. enceintes. Chez les 133 femmes qui planifiaient un accouchement
Results: Of pregnant women approached, 207 (92%) completed the vaginal, 63 % étaient disposées à envisager un accouchement par
survey; 90% reported no history of genital herpes. Rapid HSV césarienne et 53 % étaient disposées à envisager la prise
testing in labour was acceptable to 85% of pregnant women. d’antiviraux intrapartum, si la présence du VHS au sein du tractus
Among the 133 women who were planning a vaginal delivery, 63% génital en venait à être constatée. Chez les 51 fournisseurs de
were willing to consider delivery by Caesarean section and 53% soins de santé sondés, 98 % ont indiqué que le fait de savoir si
were willing to consider intrapartum anti-viral medications if HSV leur patiente présentait une infection au VHS nouvellement
was present in the genital tract. Of 51 health care providers acquise les intéressait, tandis que 84 % ont indiqué que le fait de
surveyed, 98% indicated interest in knowing if their patient had a savoir si leur patiente présentait une réactivation de l’infection les
newly acquired HSV infection, while 84% indicated interest in intéressait. Lorsque la présence du VHS au sein du tractus génital
knowing if the patient had a reactivation of infection. If HSV was de leur patiente était constatée, 36 % des fournisseurs de soins
detected in their patient’s genital tract, 36% indicated they would ont indiqué qu’ils recommanderaient la mise en œuvre d’une
recommend a Caesarean section, and 25% would consider césarienne, tandis que 25 % d’entre eux envisageraient le recours
antiviral medication as an investigational intrapartum treatment. à des antiviraux à titre de traitement intrapartum expérimental. Fait
Interestingly, both of these proportions increased if the patient had intéressant, ces deux proportions connaissaient une hausse si la
ruptured membranes for more than four hours. patiente connaissait une rupture des membranes remontant à plus
de quatre heures.
Conclusion: Most pregnant women and their health care providers
are receptive to the use of a rapid polymerase chain reaction test Conclusion : La plupart des femmes enceintes et de leurs
to detect genital HSV shedding in labour. This supports the fournisseurs de soins de santé sont ouverts à l’utilisation d’un test
development of HSV rapid testing and antiviral therapy trials in the d’amplification en chaîne par polymérase rapide visant à dépister
labour setting. l’élimination du VHS génital pendant le travail. Cela soutient
l’élaboration d’un test de dépistage rapide du VHS et la tenue
d’essais sur le traitement antiviral pendant le travail.
Résumé
J Obstet Gynaecol Can 2008;30(9):776–780
Objectif : Déterminer l’acceptabilité, auprès des femmes enceintes
et de leurs fournisseurs de soins de santé, d’un test de dépistage
rapide du virus de l’herpès simplex (VHS) génital pendant le INTRODUCTION
travail.
eonatal herpes simplex virus infection can be devastat-
Key Words: Neonatal herpes, herpes simplex virus, HSV, genital,
N ing. The rate of vertical transmission may be as high as
1 in 1500 deliveries.1 Infected neonates risk significant mor-
pregnancy, prevention
bidity (60% develop neurologic sequelae) and mortality
Competing Interests: None declared.
(60% who develop disseminated disease will die).2 Vertical
Received on November 15, 2007
transmission is high (30–50%) during a maternal primary
Accepted on March 17, 2008
infection, and a small risk (2–4%) still exists if there is
776 l SEPTEMBER JOGC SEPTEMBRE 2008
Acceptance of a Rapid Herpes Test in Labour: Survey of Attitudes of Patients and Health Care Providers
recurrent disease during vaginal delivery.3 Genital HSV METHODS
shedding occurs in the presence of signs and symptoms of Ethics approval for the study was obtained from the Behav-
genital herpes, but it can also occur without signs or symp- ioural Research Ethics Board of the University of British
toms. More than 60% of neonatal infections occur in the Columbia and the Children’s and Women’s Research
absence of recognized maternal disease, often in the setting Review Committee at the Children’s and Women’s Health
of a subclinical newly acquired infection.4 There is currently Centre of British Columbia.
no clinically available method to identify women who have
HSV in the genital tract at the time of labour. The survey of patient attitudes was conducted through the
outpatient department of BC Women’s Hospital and
The prevention strategies for neonatal HSV target women Health Centre, Vancouver BC, and in the offices of health
with known genital herpes and centre on maternal prophy- care providers. Pregnant women of any gestational age were
lactic antiviral therapy near term to decrease the likelihood approached for this study. Women who were under 18
of genital lesions and/or shedding at the time of vaginal years of age or who were unable to understand and read
delivery. Caesarean section is recommended if lesions or English were excluded. The two-part patient survey
symptoms are present at the time of labour.5 Unfortunately, included a brief information sheet on HSV in pregnancy
50% to 60% of neonatal cases occur in infants born to (Appendix 1) to ensure a basic common knowledge. This
women without a known history of genital HSV informed subjects that completion of the survey implied
infection.6–8 their consent for study participation. The second part con-
The current standard for HSV diagnosis—viral culture of sisted of a multiple-choice, self-administered questionnaire
swabs from genital ulcers—is limited by poor sensitivity. to assess the subject’s knowledge of and attitudes toward
PCR technology has been developed for rapid diagnosis of HSV testing in pregnancy and labour (Appendix 2). Health
a number of infectious agents.9–12 A recent feasibility study care providers, including obstetricians, family physicians,
has shown that a real-time HSV PCR is highly reproducible, and midwives, were approached to complete a separate sur-
provides results in less than four hours, and has a higher vey (Appendix 3) at hospital rounds and clinic service areas.
detection rate and is more labour efficient than viral culture The survey was anonymous and self-administered.
techniques.13 Rapid technology to identify women shedding Questions in both surveys addressed the acceptability of the
HSV in labour could define the women who are at risk of testing, choice of delivery method, and use of antiviral
vertical transmission. Women with a positive genital tract medication based on rapid testing results. Completed
HSV PCR test could be offered Caesarean section, and neo- questionnaires were entered into an Excel database. The
nates could be monitored for early signs and symptoms of cross-sectional survey data were analyzed using descriptive
HSV infection and treated accordingly. As an alternative to statistics.
Caesarean section, women found to be shedding HSV
could be considered for experimental intrapartum antiviral RESULTS
therapy.
Prior to initiating a study of rapid HSV PCR in the labour Pregnant Women’s Attitudes
and delivery room, an assessment of acceptability among In total, 207 of 226 women (91.5%) who were approached
care providers and patients was needed. Rapid testing agreed to complete the survey. Ten percent of women indi-
would prove useful only if patients and care providers cated a known history of genital herpes, and 90% denied
found it acceptable and if test results would influence clini- prior history.
cal management. Therefore, we surveyed obstetrical
patients and care providers to determine their attitudes When asked about mode of delivery, 87% expected a vagi-
regarding a rapid HSV test during labour. To evaluate the nal delivery, while 13% planned to have a Caesarean section
acceptability of such an assay, we conducted a survey of (primary or planned repeat). Sixty percent of the women
pregnant women and their care providers. had prenatal care provided by an obstetrician, 35% by a
family physician, and 5% by a midwife.
Eighty-five percent of respondents were willing to undergo
a rapid HSV PCR test during labour. When responses were
stratified by history of genital HSV, 96% of women with a
ABBREVIATIONS known history of genital herpes, compared with 84% of
women without a history, found such a test acceptable. Of
HSV herpes simplex virus
those who would not accept the test, five of 31 (16%) were
PCR polymerase chain reaction
planning to have a Caesarean section.
SEPTEMBER JOGC SEPTEMBRE 2008 l 777
OBSTETRICS
Patients were asked for their preferred mode of delivery or Health care providers were interested in knowing if the
labour management if the test results indicated that they shedding was related to a primary or recurrent infection;
had HSV in the genital tract during labour. More than 87% this is an important factor in the degree of vertical transmis-
indicated the results would influence their choice. If testing sion risk.3
during labour was positive, 51% would consider delivery by Unfortunately, rapid PCR testing for HSV in genital sam-
Caesarean section and 37% would consider undergoing ples cannot distinguish between primary or recurrent infec-
antiviral therapy (with or without Caesarean section). Of tion in the absence of rapid serological testing. Several
note, 8% wished to proceed with a vaginal delivery in the point-of-care HSV serologic tests have been developed, but
presence of a positive HSV PCR. unfortunately none are available for clinical use in Canada.15
These point-of-care tests are sensitive and specific and
Health Care Providers’ Attitudes would be a useful adjunct to rapid PCR testing. Together,
Fifty-one health care providers were surveyed: 47% were these two technologies would help distinguish between
obstetricians, 35% were midwives, and the remaining 18% women who have newly acquired genital herpes and those
were family physicians. The mean number of deliveries who have reactivation of pre-existing HSV infection.
attended annually by each care provider was 112 (range: Women who have newly acquired HSV infection in the
20–500). third trimester have an extremely high risk of having a child
All but one health care provider indicated that they would with neonatal herpes, and most authorities recommend
like to know if their patient had a primary HSV infection at delivery by Caesarean section for such women.16 Women
the time of labour, and 84% indicated that they would be who reactivate HSV in labour have a 2% to 4% risk of trans-
interested in knowing if their patient had a recurrent infec- mitting infection to the neonate. Strategies for management
tion. If HSV shedding was detected in labour, 36% indi- besides our current approach of advising Caesarean section
cated that they would recommend Caesarean section, and are needed for women with recurrent lesions or prodromal
25% would consider antiviral therapy as an experimental symptoms in labour. Surprisingly, some women (8%)
treatment. Of note, the frequency of both of these manage- would elect to proceed with vaginal delivery even with HSV
ment strategies increased if the patient had ruptured mem- detected in the genital tract, suggesting that informed con-
branes for more than four hours. sent for vaginal delivery of women with recurrent HSV may
be reasonable. Therefore, we feel HSV serotesting to deter-
DISCUSSION mine the stage of infection is a necessary adjunct to viral
detection for guiding clinical management; we hope it is an
The only management option currently available to mini- adjunct that will be available in the future.
mize the risk of vertical transmission of HSV after the onset
of labour is to offer Caesarean section when prodromal CONCLUSION
symptoms or lesions are present.5 Prophylactic acyclovir
The results of this study indicate that using new rapid PCR
initiated at 36 weeks’ gestation and continuing until delivery
technology during labour to improve the detection of geni-
minimizes the risk of recurrence and the need for Caesarean
tal HSV and decrease neonatal HSV disease is feasible, and
section because of HSV infection.14 These strategies are
that a clinical study would have a favourable reception from
only useful if the diagnosis of genital HSV is known, and
patients and care providers. Such technology will challenge
most women with genital herpes are unaware that they have
us to provide appropriate interventions for those who test
it. Viral shedding in the genital tract is the cause of almost all
positive.
neonatal HSV infections4; therefore, it would be ideal to
identify shedding at the onset of labour to target potential ACKNOWLEDGEMENT
interventions for women who are truly at risk of transmit-
ting HSV to their infant. PCR technology represents a This study was supported in part by National Institutes of
means of identifying such women. Health grants P01 AI30731 and K24 AI071113.
In our study, over 80% of pregnant women and all but one REFERENCES
of their health care providers would accept rapid HSV test- 1. Sullivan-Bolyai J, Hull HF, Wilson, C, Corey L. Neonatal herpes simplex
ing in labour if it were clinically available. Women with virus infection in King County, Washington: increasing incidence and
known HSV were more likely to accept the test, probably epidemiologic correlates. JAMA 1983;250:3059–62.
reflecting their increased knowledge or understanding of 2. Whitley R, Arvin A, Prober C, Corey L, Burchett S, Plotkin S, et al.
Predictors of morbidity and mortality in neonates with herpes simplex virus
HSV. Most pregnant women felt that a positive HSV result infections. N Engl J Med 1991;324:450–4.
would influence their chosen mode of delivery or labour 3. Kimberlin DW. Neonatal herpes simplex infection. Clin Microbiol Rev
management, as did most of the health care providers. 2004;17:1–13.
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Acceptance of a Rapid Herpes Test in Labour: Survey of Attitudes of Patients and Health Care Providers
4. Brown ZA, Wald A, Morrow RA, Selke S, Zeh J, Corey L. Effect of the standard culture method for screening for group B streptococcus
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11. Scaramozzino N, Ferrier-Rembert A, Favier AL, Rothlisberger C, Richard S,
5. ACOG Practice Bulletin. Clinical management guidelines of Crance JM, et al. Real-time PCR to identify variola virus or other human
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6. Kropp R, Wong T, Cormier L, Ringrose A, Burton S. Neonatal Herpes and real-time polymerase chain reaction. Emerg Infect Dis 2006;12:428–32.
Simplex virus infections in Canada: results of a 3-year national prospective
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Tenant-Flowers M, et al. Diagnosis of genital herpes by real time PCR in
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double-blind, randomized, placebo-controlled trial of acyclovir in late
8. Yeager A, Arvin A. Reasons for the absence of a history of recurrent genital pregnancy for the reduction of herpes simplex virus shedding and cesarean
infections in mothers of neonates infected with herpes simplex virus. delivery. Am J Obstet Gynecol 2003;188(3):836–43.
Pediatrics 1984;73:188–93.
15. Wald A, Ashley-Morrow R. Serological testing for herpes simplex virus
9. Bergseng H, Bevanger L, Rygg M, Bergh K. Real-time PCR targeting the sip (HSV)-1 and HSV-2 infection. Clin Infect Dis 2002;35(Suppl 2):S173–S182.
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women at delivery. J Med Microbiol 2007;56:223–8. 16. American Academy of Pediatrics. Herpes Simplex. In: Pickering LK, Baker
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Appendix 1
SUBJECT and CARE PROVIDER FACT SHEET obvious lesions. Babies infected by HSV during birth can
become infected and get very ill; possibly die.
Herpes Simplex Viral Shedding in the Genital Tract
Greater than 60% of adults are herpes simplex virus (HSV) Both HSV I, but more often HSV II, can cause significant
type I positive and 20% percent of adults have herpes virus disease in the newborn. Although it is estimated that many
type II. more are exposed at the time of delivery, approximately
1/3000 newborn babies are born with infection
At the time of initial infection in the genital tract (by HSV 1
or HSV 2), the virus may be present in large quantities. It is In women with known genital HSV, medication (Acyclovir)
at this time that there is greatest risk to the newborn of neo- can be given during the last four weeks of pregnancy to help
natal herpes (30-50%). The risk is still present but lower reduce recurrences and viral shedding at the time of
(2-4%) with recurrent disease, even in the absence of delivery.
Appendix 2
HERPES VIRUS STUDY 2. In the past several months, there has been a lot of
Survey of Attitudes toward Rapid Herpes Testing in discussion in the media about mode of delivery in
Labor and Mode of Delivery a normal healthy pregnancy. If you could choose
Pregnant Patient Questionnaire the method of delivery for your baby, would you
have a:
Date: ______________________ (day/month/year)
a. Vaginal delivery.
A new rapid test has been developed to look for herpes virus in
laboring women. This survey has been designed to ask women if they b. Cesarean section (for the first time).
would be interested in this information and how it might influence c. Planned repeat cesarean section.
their delivery. Thank you for answering the following questions.
Please circle one response per question. 3. This survey is about herpes in pregnancy.
Do you have or have you ever had genital herpes?
1. Who is taking care of you during this pregnancy?
(Circle all that apply) a. Yes
a. Doula b. No
b. Midwife Genital herpes is a common infection amongst sexually active
c. GP women. There is a risk of transmission to your baby at the time of
d. Obstetrician vaginal delivery. The risk is up to 50% in women who have
SEPTEMBER JOGC SEPTEMBRE 2008 l 779
OBSTETRICS
acquired herpes infection at the end of their pregnancy. It is much 6a. If a new test was able to show that you had
lower (2-4%) in women who have recurrent genital herpes. In those herpes virus in the genital tract, would this
situations where active herpes infection is diagnosed immediately prior information influence how you would want to
to or during labour, delivery by caesarean section is offered to decrease deliver your baby?
the risk of transmission to the fetus. Many women do not know
a. Yes
that they have herpes and have no symptoms. A rapid test has been
developed to detect herpes virus in laboring women. b. No
4. If the new rapid test were offered today, would 6b. If yes, would you be (Circle all that apply):
you be willing to have a vaginal swab for herpes
virus testing when you come to the hospital in a. More likely to consider vaginal delivery.
labor? b. More likely to consider cesarean section.
a. Yes c. More likely to consider antiviral medication during
b. No vaginal delivery.
5. If the new rapid test were offered today, would Thank you for your time.
you be interested in knowing whether you are
infected with herpes?
a. Yes
b. No
Appendix 3
HERPES SIMPLEX VIRUS (HSV) STUDY time of labor? Risk of vertical transmission is 2-4%
in recurrent infections.
Survey of Attitudes toward Rapid HSV Testing in a. Yes
Labor and Mode of Delivery
A Questionnaire for Health Care Providers b. No
Date: ______________________ (day/month/year) 5. What would you do if a rapid PCR test detected
HSV in the genital tract of your patient who
1. Are you a: presents in labor?
a. Midwife a. Proceed with vaginal delivery.
b. Arrange for cesarean section.
b. Family doctor
c. Consider IV Acyclovir as an experimental treatment
c. Obstetrician to reduce vertical transmission and proceed with
2. Approximately how many deliveries do you attend vaginal delivery.
each year?________________ d. Other _______________________
3. Would you want to know if your patient has primary 6. If the rapid PCR test was positive for HSV and the
HSV shedding in the genital tract at the time of woman was known to have ruptured membranes
labor? Risk of vertical transmission is 50% in for more than four hours, how would you proceed?
primary infections. a. Proceed with vaginal delivery.
a. Yes b. Arrange for cesarean section.
c. Consider IV Acyclovir as an experimental treatment
b. No to reduce vertical transmission and proceed with
4. Would you want to know if your patient has vaginal delivery.
recurrent HSV shedding in the genital tract at the Thank you for your time.
780 l SEPTEMBER JOGC SEPTEMBRE 2008
