Iός Απλού Ερπητα-HVS

Συστάσεις για την αντιμετώπιση της λοίμωξης από τον ιό του Απλού Έρπητα HSV

Το ιστορικό των γυναικών σχετικά με τον έρπητα των γεννητικών οργάνων θα πρέπει να αξιολογείται στην αρχή της εγκυμοσύνης.

Οι γυναίκες με γνωστές και επαναλαμβανόμενες προσβολές από τον ιό του απλού έρπητα των γεννητικών οργάνων (HSV) θα πρέπει να ενημερώνονται σχετικά με τους κινδύνους μετάδοσης του HSV στα νεογνά τους κατά τον τοκετό. Κατά τον τοκετό , στις γυναίκες αυτές θα πρέπει να προσφέρεται Καισαρική τομή αν υπάρχουν πρόδρομα συμπτώματα ή αν υπάρχουν ενδεικτικές αλλοιώσεις που υποδηλώνουν λοίμωξη από HSV.

Στις γυναίκες με γνωστές υποτροπιάζουσες λοιμώξεις των γεννητικών οργάνων από HSV θα πρέπει να χορηγείται ακυκλοβίρη ή valacyclovir στις 36 εβδομάδες κύησης για να μειώσετε τον κίνδυνο των κλινικών βλαβών και εξάπλωση του ιού κατά τη στιγμή του τοκετού και ως εκ τούτου να μειώσει την ανάγκη για Καισαρική τομή.

Οι γυναίκες με πρωτογενή έρπητα των γεννητικών οργάνων κατά το τρίτο τρίμηνο της εγκυμοσύνης έχουν υψηλό κίνδυνο μετάδοσης του HSV σε νεογνά τους και θα πρέπει να ενημερώνονται σχετικά και θα πρέπει να προσφέρεται Καισαρική τομή για να μειωθεί ο κίνδυνος μετάδοσης

Το 60-70% των περιπτώσεων ενδοµήτριας και περιγεννητικής ερπητικής λοίμωξης οφείλεται στον ερπητοϊό τύπου 2, που ευθύνεται κυρίως για λοιµώξεις του ουρογεννητικού συστήµατος. Ωστόσο, τα τελευταία χρόνια αυξάνεται η συχνότητα αποµόνωσης του ερπητοϊού τύπου 1 σε λοιµώξεις του ουρογεννητικού συστήµατος. Ο ιός µεταδίδεται στο βρέφος συνήθως κατά τον τοκετό, από µολυσµένες κολπικές εκκρίσεις σε συµπτωµατική ή ασυµπτωµατική λοίµωξη της µητέρας, ή σπανιότερα µετά τον τοκετό από πάσχοντες του περιβάλλοντός του. Η ενδοµήτρια µετάδοση είναι σπάνια (4- 9% των περιπτώσεων συγγενούς ερπητικής λοίµωξης), αλλά είναι ιδιαίτερα βαριά. Η συχνότητα προσβολής του κυήµατος σε πρωτοπαθή λοίµωξη της µητέρας κατά την κύηση είναι 40-60%, ενώ σε υποτροπιάζουσα λοίµωξη από τον ίδιο τύπο (1 ή 2) του ιού είναι µόλις 3%.

Κλινική εικόνα.

  1. Σε ενδοµήτρια λοίµωξη από τον ιό του απλού έρπητα µπορεί να προκληθεί αυτόµατη αποβολή, πρόωρος τοκετός ή γενικευµένη νόσος. Οι κλινικές εκδηλώσεις της γενικευµένης νόσου εµφανίζονται στη γέννηση και αφορούν κυρίως το δέρµα (φυσαλίδες, ουλές, δερµατικές επασβεστώσεις, ελλείψεις δέρµατος), τα µάτια (χοριοαµφιβληστροειδίτι- δα, µικροφθαλµία, κερατοεπιπεφυκίτιδα, καταρράκτη, δυσπλασία του αµφιβληστροειδή) και το ΚΝΣ (υδρανεγκεφαλία, εγκεφαλική και παρεγκεφαλιδική νέκρωση). Στα βρέφη που επιζούν παραµένουν µόνιµα νευρολογικά υπολείµµατα.
  2. Η περιγεννητική µετάδοση του ιού του απλού έρπητα προκαλεί νεογνική λοίµωξη, που µπορεί να εκδηλωθεί (α) σαν εντοπισµένη λοίµωξη του δέρµατος ή των βλεννογόνων (20%), (β) σαν εντοπισµένη λοίµωξη του ΚΝΣ µε ή χωρίς εκδηλώσεις από το δέρµα ή τους βλεννογόνους (30%) και (γ) σαν γενικευµένη λοίµωξη, µε εκδηλώσεις από πολλά όργανα (λήθαργο, πυρετό ή αστάθεια θερµοκρασίας, επιπεφυκίτιδα, διάχυτη ενδαγγειακή πήξη, πνευµονία, ηπατίτιδα, εγκεφαλίτιδα). Οι κλινικές εκδηλώσεις εµφανίζονται µεταξύ 9ης και 20ης ηµέρας ζωής .

Η πρόγνωση της νόσου είναι βαριά αν παραµείνει χωρίς θεραπεία, µε υψηλή θνητότητα (50-80%) και υψηλή συχνότητα νευρολογικών υπολειµµάτων στους επιζώντες (µέχρι 100%).

Πρόληψη και αντιµετώπιση λοίµωξης κυήµατος και νεογνού από τον ιό του απλού έρπητα.

  1. Αντιµετώπιση της νόσου στην έγκυο Ακυκλοβίρη (ασφαλής στο τέλος της κύησης)
  2. Προληπτικά µέτρα στην κύηση και τοκετό

Ι. Προσεκτική εξέταση της εγκύου για ορατές βλάβες

ΙΙ. Καλλιέργεια κολπικού επιχρίσµατος όταν υπάρχουν : ερπητικές βλάβες, ιστορικό υποτροπιάζοντα έρπητα, έρπητας γεννητικών οργάνων σεξουαλικού συντρόφου

ΙΙΙ. Τοκετός: (α) Καισαρική τοµή, αν την τελευταία εβδοµάδα προ του τοκετού βρεθούν ερπητικές βλάβες κόλπου – περινέου ή αποµονωθεί ο ιός από τον κόλπο. (β) Κολπικός, αν δεν υπάρχουν οι παραπάνω προϋποθέσεις.

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