A 36-year-old woman, gravida 3 para 2, at 38 weeks gestation comes to the emergency department due to regular, painful contractions. The contractions began an hour ago, immediately after the patient had a "gush" of fluid. She has had no vaginal bleeding, and fetal movement has been normal. The patient's last prenatal visit was 6 weeks ago. She has no known medical conditions and does not use alcohol, tobacco, or illicit drugs. Vital signs are normal. Fetal heart rate tracing shows a baseline of 140/min with multiple accelerations and no decelerations. Contractions occur every 2 minutes on tocodynamometer. Pelvic examination shows a cluster of clear vesicles with an erythematous base on the right labium minus. Speculum examination shows a pool of clear fluid in the posterior vagina. The cervix is 6 cm dilated and 100% effaced with the fetal head at 0 station. Which of the following is the best next step in management of this patient?

Question

A 36-year-old woman, gravida 3 para 2, at 38 weeks gestation comes to the emergency department due to regular, painful contractions.  The contractions began an hour ago, immediately after the patient had a "gush" of fluid.  She has had no vaginal bleeding, and fetal movement has been normal.  The patient's last prenatal visit was 6 weeks ago.  She has no known medical conditions and does not use alcohol, tobacco, or illicit drugs.  Vital signs are normal.  Fetal heart rate tracing shows a baseline of 140/min with multiple accelerations and no decelerations.  Contractions occur every 2 minutes on tocodynamometer.  Pelvic examination shows a cluster of clear vesicles with an erythematous base on the right labium minus.  Speculum examination shows a pool of clear fluid in the posterior vagina.  The cervix is 6 cm dilated and 100% effaced with the fetal head at 0 station.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_da04_3bac_bc81_abd8390e3c2f_MD0003_00 This patient has an active genital herpes simplex virus (HSV) infection, which typically presents as painful vesicles on an erythematous base that evolve into shallow open ulcers or erosions. Maternal HSV infection can cause neonatal infection, which can be devastating due to significant morbidity (eg, seizures, developmental delay, blindness) and mortality. painful vesicles HSV can be vertically transmitted transplacentally (typically with a primary infection); however, the most common route of transmission is during vaginal delivery because the fetus is exposed to HSV during passage through the birth canal. The risk of transmission is proportional to the amount of viral shedding, which is highest during prodromal symptoms and active lesions. Therefore, patients with either prodromal symptoms or active genital HSV lesions at delivery (eg, active labor, as in this patient) cannot undergo vaginal delivery and require an immediate cesarean delivery. (Choice A) Vertical HSV transmission risk increases with the duration of membrane rupture; therefore, tocolytic administration is not recommended. (Choices B and C) In contrast to this patient, individuals who have a history of genital HSV but have no prodromal symptoms or active lesions at delivery can undergo vaginal delivery because maternal viral shedding and the risk of vertical transmission are minimal. (Choice E) Fetal scalp electrodes are avoided in patients with HSV because they cut the fetal skin and create a possible portal for HSV, thereby increasing the risk of vertical transmission. (Choice F) Women who have a history of genital HSV receive prophylactic antiviral therapy (eg, acyclovir, valacyclovir) from 36 weeks gestation until delivery to reduce the risk of active lesions at delivery and the need for cesarean delivery. In contrast, initiating antiviral therapy at delivery is unlikely to have an immediate effect on viral replication; therefore, it is not indicated as it does not decrease the risk of neonatal HSV infection. Educational objective: Cesarean delivery is indicated in women with active genital herpes lesions at delivery to reduce the risk for neonatal herpes simplex virus infection. References: Herpes simplex virus infection during pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/25454993) Preventing herpes simplex virus in the newborn. (http://www.ncbi.nlm.nih.gov/pubmed/25459782) Herpes simplex virus and pregnancy: a review of the management of antenatal and peripartum herpes infections. (http://www.ncbi.nlm.nih.gov/pubmed/22112524)

A 36-Year-Old Woman, Gravida 3 Para 2, at 38 Weeks