Herpes Simplex Virus, Pregnancy, and Breastfeeding

Herpes Simplex Virus (HSV) infection can affect newborn babies. The infection is associated with high mortality and morbidity in babies. HSV infection can also affect the infant's nervous system and eyes. 

In this article, we explore the effect of HSV infection on pregnancy and breastfeeding and discuss ways to reduce transmission to offspring.

What is the Herpes Simplex Virus?

Herpes Simplex Virus (HSV) is a viral infection that causes cold sores (small blisters) on the skin, mouth, and genital region. It is common and can be passed on via direct skin contact from one infected person to another.

There are two types of HSV virus:

• HSV type 1: the most common variant of HSV. It is commonly associated with cold sores on the mouth and lips.
• HSV type 2: a less common variant of HSV. HSV type 2 is associated with genital cold sores and tends to be passed on during sexual intercourse.

Caveat: With time, human evolution and changes in sexual orientation and habits, where one may engage in various forms of intercourse (oral, vaginal, anal intercourse), the types of HSV no longer determine the location of the cold sores.

What are the symptoms of Herpes Simplex Virus?

One can be asymptomatic even when carrying the HSV virus. However, one is symptomatic with HSV when one presents with symptoms of tiny blisters and erosions (cold sores) over the skin surface. These can commonly occur over the lip, mouth, genital mucosal region, or skin surface (hands/face).

Cold sores usually last 7-14 days and then slowly resolve. However, the virus remains dormant in a person’s nervous system. Symptoms may resurface when one has a poor immune system, which is known as reactivation of the disease.

Will Herpes Simplex Virus affect my pregnancy?

As mentioned, there is no cure for HSV infection. If a person has an HSV infection before, one may have further episodes during pregnancy due to changes in body physiology and immune system. 

We know that HSV can be infectious when it is active. If you acquired HSV infection for the first time during the early part of your pregnancy, you have a higher risk of miscarriage. As HSV is spread through skin contact, if you have a herpes outbreak over the genital region during your last few weeks of pregnancy, you have a risk of transferring the infection to your baby during vaginal delivery. Your obstetrician may offer you a caesarean section surgery rather than vaginal delivery if you have an HSV infection during the last six weeks of your pregnancy to reduce the risks of disease transmission to your infant.

Thankfully, with proficient medical care and effective medical treatment, most women with HSV can conceive uneventfully.

Can Herpes Simplex Virus infection occur on the nipple or breast?

Yes, it is possible, though nipple herpes infection constitutes only 2% of herpes infection cases that occur beyond the genital region. As it is rare, picking up such cases is tricky and often results in misdiagnosis and delay in treatment.

HSV over the nipple can be due to a new transmission vs reactivation of an old local infection over the region. HSV can be newly acquired from the baby to the mother (whereby the baby who is still sucking milk presented with oral herpes), or it can be acquired through oral sexual contact with a partner with mouth herpes. The other less common route of inoculation of disease is through a person’s infected hand (with herpes) to the nipple. 

Factors that may impede appropriate treatment for nipple HSV infection include:

• The patient’s hesitation to seek medical care is due to symptoms in sensitive body regions and the association of cultural barriers or personal embarrassment.
• Confusion of HSV rash with other dermatological conditions such as eczema, breast abscess, fungal infection, etc.

Reaching the diagnosis promptly is imperative to manage the symptoms and shorten the duration of the symptoms. Proper treatment of HSV nipple infection shortens the disruption of the breastfeeding process and prevents the spread of the disease to the infant.

Is it safe for a woman to breastfeed if she has symptoms of herpes?

If the cold sore rashes are not over the breast or nipple, it is safe to breastfeed your child. 

If the cold sore occurs over the breast or nipple, you should avoid breastfeeding from the affected breast. The breast milk produced from the affected (cold sore) breast should be discarded, as it can be contaminated when it comes into contact with the skin lesions.

The cold sore region should be covered to prevent the lesions from touching each other. Strict hand hygiene practices are recommended to prevent the spread of the herpes virus from mother to baby.

If the mother has a herpes rash over the breasts, is it safe for the mother to offer breast milk through manually expressed milk or pumped breast milk?

No, this is because breast milk can be contaminated with herpes lesions during manual expression or pumping. Breast milk from the affected breast side should be avoided and discarded until the herpetic lesions are completely healed. 

It is worth noting that the mother is still encouraged to continue expressing the breast milk (of the affected breast) to ensure continuous breast milk production (do not feed the baby). Proper hand hygiene is very important, and the breast pumps should be cleaned properly. 

The breast milk from the unaffected breast is safe to be fed to the baby.

When should I see a doctor about herpes?

If you suspect you are experiencing an HSV infection and you are pregnant or breastfeeding, you should reach out to your doctor to discuss treatment options. Your doctor will also give you practical advice on how to manage your symptoms and avoid spreading disease during your pregnancy or breastfeeding period.

How can I protect my baby against Herpes Simplex Virus infection?

• If you notice abnormal lesions over the breast, get checked by your doctor rather than assuming it is just a skin rash, irritation, or eczema rash.
• You should cover the area of cold sore/rash to prevent the area from coming into contact with your baby.
• Avoid kissing your baby until your cold sore over your mouth rash has completely healed.
• Avoid touching your cold sore rash with your hand.
• Strictly practice good hand hygiene after touching your cold sore (which you should not) and before touching your baby.

Is antiviral medication safe for breastfeeding?

Use antiviral medications such as acyclovir with caution, as a small amount can pass through into breast milk. For safety reasons, babies should be monitored for side effects such as vomiting, loose stools, skin rashes, irritability, and drowsiness. Valacyclovir can be considered, as it is converted into acyclovir before passing into breast milk.

Generally, topical use of antivirals is safer as they are less absorbed systemically; hence, there will be minimal concentration in breast milk.

You are encouraged to discuss with your physician the treatment options and advice on breastfeeding during a herpes infection.

What can I take home from this article?

• HSV infection can occur in infants.
• Infants with HSV can have long-term health complications, including death.
• There are effective methods to safeguard the child if the pregnant/breastfeeding mother is having an HSV infection.
• HSV should be one of the clinical differentials in noticing rash over the breasts or skin surface (not just the mouth and genital region).
• If you are at risk of exposure to HSV infection, you should consider getting checked and treated early to protect your loved ones and infants.

References

1. WAB Hammad et al. Herpes simplex virus infection in pregnancy – An update. Eur J Obstet Gynecol Reprod Biol. 2021, April: 259:38-45.
2. James SH, Sheffield JS, Kimberlin DW. Mother-to-Child Transmission of Herpes Simplex Virus. J Pediatric Infect Dis Soc. 2014 Sep;3 Suppl 1:S19-23.
3. Lawrence RA, Lawrence R. (2016) Breastfeeding: A guide for the medical profession, 8^th.
4. Brown Z. Brown Z. Herpes. Preventing herpes simplex virus transmission to the neonate. 2004 Aug;11 Suppl 3:175A-186A. 
5. C Pietrasanta et al. Herpesviruses and breast milk. Pediatr Med Chir. 2014 Jun 30;36(3):5.
6. El Hayderi L, Caucanas M, F. Nikkels A. Herpes Simplex Virus Infections of the Nipple. The Open Dermatology Journal. 2012: 6, 29-32.
7. https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/maternal-or-infant-illnesses/herpes.html#:~:text=In%20cases%20where%20a%20mother,until%20the%20lesions%20have%20healed