Neonatal Herpes Encephalitis, Meningitis, and Birth Injuries
There are maternal infections (such as herpes simplex virus (HSV) and Group B Strep (GBS)) that are extremely dangerous when passed on from mother to child. In a baby, these infections can cause encephalitis and meningitis, respectively. Signs present themselves 1-20+ days after birth, and clinical tests can confirm the presence of HSV. When these infections are left untreated, or are treated in an untimely manner, than can cause severe brain damage or even death. Treatment is aimed at suppressing the virus or bacterial infection. Localized infections can heal fairly well, but untreated or untimely treated infections of the central nervous system are lethal in some cases and leave survivors with permanent disabilities. To prevent this, physicians screen at-risk mothers and provide recommendations for preventing infections during the final stages of the pregnancy. Doctors should also administer a preventative treatment of acyclovir or valacyclovir in the third trimester to all women with genital herpes (another name for HSV infections), or antibiotics in the case of bacterial infections (such as group B strep). Timely treatment should also be given to the newborn after birth. To prevent the infection, infants should be delivered via C-Section to prevent exposure, or else be immediately treated with IV acyclovir or antibiotics as soon as they are born.
Herpes simplex virus (HSV) encephalitis is a viral infection in the brain that babies can get from their mothers during delivery. When HSV is transmitted from mother to baby, it is known as neonatal herpes encephalitis. HSV can lead to meningitis, brain damage and cerebral palsy. Other complications that can occur during pregnancy include premature rupture of the membranes and preterm birth. Neonatal HSV infection, defined as infection in a newborn within 28 days after birth, is a devastating consequence of untreated or unmonitored genital herpes. Whether caused by HSV type 1 or type 2, neonatal HSV infection has severe consequences if treated improperly. More than 30% of pregnant women in the United States have genital infection with HSV. Thus, it is imperative that HSV is monitored and managed appropriately, as the infection can be passed from the mother to the baby during delivery.
Causes of Neonatal Herpes Encephalitis and Meningitis
Most neonatal infections result from exposure to HSV in the genital tract during birth, although in utero and postnatal infections occasionally occur. HSV manifests itself in three forms: skin, eye, and mouth herpes (SEM), disseminated herpes (DIS), and central nervous system herpes (CNS), the final can lead to encephalitis. There often is overlap of two or more of these types of herpes, and both DIS and SEM can progress to CNS herpes.
If a mother has primary (initial / first time infection) HSV genital type 1 or 2 at the time of vaginal delivery, the risk of transmitting the virus to the baby is approximately 50%. Mothers with primary infections at delivery are 10-30 times more likely than women with a recurrent infection to transmit the virus to their babies.
Risk Factors for Neonatal Herpes Encephalitis
First-time infection of a mother is the most important factor for the transmission of genital herpes from mother to newborn. In addition, a pregnant woman who acquires genital herpes as a primary infection in the latter half of pregnancy, rather than prior to pregnancy, is at greatest risk of transmitting HSV to the baby.
Risk factors for neonatal HSV include the following:
- First-time maternal infection in the third trimester
- Use of invasive instruments, such fetal-scalp electrode monitoring or forceps and vacuum extractors
- Delivery before 38 weeks
- Maternal age less than 21 years
Signs and Symptoms of Neonatal Herpes Encephalitis
Symptoms of neonatal herpes encephalitis typically present between four and eleven days after the baby is delivered. The following are signs and symptoms of neonatal HSV encephalitis.
- Rapid onset of fever
- Seizures and tremors
- Lethargy and irritability
- Feeding poorly
- Unstable temperatures
- Fontanelle bulging (soft spot of the skull)
- Focal neurologic signs
- Impaired consciousness
- Body stiffness and/or crying that cannot be soothed or may worsen when the baby is picked up or handled
- SEM herpes: Characterized by external lesions and no internal involvement
- DIS herpes: Affects internal organs, especially the liver
A neonatal diagnosis is determined by the following:
- Positive cerebral spinal fluid (CSF) viral cultures
- Positive immunoglobulin G against herpes simplex virus from neonatal blood
- Positive polymerase chain reactions (PCR) for herpes simplex virus from CSF
Treatment for Neonatal Herpes Encephalitis
The virus progresses rapidly and death occurs within 10 – 14 days if left untreated. Long term brain injuries are common a come result of HSV in babies.
All babies with suspected or diagnosed HSV must be treated with intravenous (IV) acyclovir. Prompt treatment is crucial, especially in cases of disseminated infections. SEM HSV infections are treated for 14 days, whereas CNS or DIS infections require 21 days of therapy.
Although high dose IV acyclovir for a sufficient period has been proven to be effective, neonatal HSV infection is still associated with high residual lethality and morbidity because in some infants acyclovir only suppresses, but does not eradicate, the virus.
Localized HSV usually heals without negative outcomes, whereas the CNS form is can be lethal in about 6% of cases. Approximately 69% of babies with CNS infection are left with permanent disabilities. The DIS infection is lethal in 31% of cases and approximately 17% of babies are left with permanent disabilities.
Preventing Neonatal Herpes Encephalitis: Reducing Transmission of HSV Infection
In order to avoid the majority of neonatal herpes cases, identification of the at risk mother is crucial. The first and most important step is the determination of the pregnant woman’s serostatus (whether the woman has the antibody for HSV) to establish her susceptibility to the infection during early pregnancy. Current recommendations of the American College of Obstetricians and Gynecologists (ACOG) do not include routine HSV seroscreening, but ACOG does acknowledge that seroscreening may be beneficial in selected populations or couples. The most effective measure to prevent perinatal herpes infections is to avoid viral exposure to the neonate when primary genital herpes develops in late pregnancy (the risk of severe neonatal infection is small in recurrent episodes).
A history of HSV infection in all pregnant women and their partners should be obtained at the first prenatal visit. Women with a negative personal history of HSV, and especially those with a positive history in the male partner, should be strongly advised to have no oral or sexual intercourse at the time of recurrence in order to avoid infection (in particular, during the third trimester of gestation). Furthermore, use of condoms throughout pregnancy should be recommended to minimize the risk of viral acquisition, although the male partner has no active lesions. Condoms are not a complete barrier for the genital region. Thus, prophylactic administration of acyclovir or valacyclovir in the third trimester of pregnancy should be provided to all pregnant women with genital herpes during pregnancy.
A careful examination of the vulva, vagina and cervix should be performed on any woman who presents with signs or symptoms of HSV
infection at the onset of labor. Artificial rupture of membranes should be avoided. All pregnant women who have a suspected active genital HSV infection or prodromal symptoms of HSV infection should undergo C-section. On the other hand, when genital herpes lesions are not present, C-section is not required but lesions near the genitals should be covered with an occlusive dressing before vaginal delivery. It is important to remember that fetal scalp electrodes monitoring during labor and vacuum or forceps delivery should be used only if necessary, since these practices increase the risk of HSV transmission. It is also imperative that all pregnant patients be given informed consent so they can make important decisions regarding their pregnancies.
Neonates born to women with active genital lesions, with a confirmed or suspected HSV infection should be:
- Managed with contact precautions to avoid direct contact with skin and mucosal lesions, excretions, and body fluids
- Immediately treated with IV acyclovir
In short, the measures to prevent transmission of HSV to newborns include the following:
- A C-section delivery should be performed on mothers with active lesions during delivery.
- Infants delivered vaginally by mothers with active genital herpes must be closely observed and treated with acyclovir.
- In pregnant women with genital herpes, supressive acyclovir should be initiated at 36 weeks’ gestation and maintained up to and during delivery, regardless of delivery mode.
Neonatal Herpes Encephalitis and Medical Malpractice
Listed below are issues that may constitute negligence:
- Failure to diagnose HSV in the pregnant woman
- Failure to diagnose and treat HSV in the infant
- Failure to properly deliver the baby of an infected mother in order to avoid risks of infection in the baby, which includes failure to perform a C-section when indicated, as well as utilization of delivery instruments and other invasive tools, such as a fetal-scalp electrode.
- Failure of the physician to obtain adequate informed consent, which includes advising the mother of the risks and alternatives of delivery methods, such as vaginal birth versus C-section delivery.
It is crucial that the physician take a thorough history of the pregnant woman, and this includes asking about HSV infection and risk factors. If any of the risk factors for HSV are present, the physician should test the mother for HSV. If a mother has HSV, all measures must be taken – and standards of care followed – in order to prevent spread of the infection to the baby. If the baby is at risk of infection, he or she must be monitored closely after delivery, and if any signs of HSV are present, the baby must be treated and tested for the infection. Failure to promptly treat an infant with HSV and failure to follow the standards of practice listed above constitute negligence. If this negligence leads to injury in the baby, it is medical malpractice.
Legal Help for Victims with Injuries from Neonatal Herpes Encephalitis and Meningitis
Michigan Birth Injury Attorneys with a National Presence
Birth injury cases require specific, extensive knowledge of both law and medicine. For the best case outcomes, it’s critical to find an attorney and a law firm that focus specifically on pregnancy, birth injury, and newborn cases. Reiter & Walsh, P.C. was established to focus exclusively on birth injury cases. Our birth trauma team is based in Michigan, but we handle cases throughout the United States. We’ve handled hypoxic-ischemic encephalopathy cases in Michigan, Ohio, Washington D.C., Pennsylvania, Tennessee, Arkansas, Mississippi, Texas, Wisconsin, and more. Our birth injury team is also equipped to handle cases involving military medical malpractice and federally funded clinics.
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Video: Neonatal Herpes Encephalitis Attorney Discusses Birth Injuries
Watch a video of birth injury / neonatal herpes encephalitis attorneys Jesse Reiter & Rebecca Walsh discussing birth injuries.
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The above information is meant only to be an educational resource. It is not meant to be, and should not be, interpreted as medical advice.