outbreak of herpes at birth..help - page 2

HI, I need help....a girl I know had her baby about a month ago and she has Herpes. I know her doctor knew but I am unsure if she was on medicine the last month of her pregnancy or not...well now the... Read More

  1. by   NICU_Nurse
    this information is from the nicu-web:
    (http://neonatal.peds.washington.edu/...eb/hsv/hsv.stm)

    i copied most of it here, but there are some photos on the page if you're interested.

    1) disseminated neonatal herpes infection

    -presents usually at 9-11 days of age, but as late as 4 weeks.
    -widespread disease, including: pneumonitis, hepatitis, disseminated intravascular coagulation, with or without encephalitis, exanthem, or kerato-conjunctivitis.
    -symptoms include: irritability, seizures, respiratory distress, jaundice, bleeding, shock, and a characteristic vesicular rash.
    10-50% will not develop skin lesions during the course of their illness.(8)
    -encephalitis in 60 to 75%.
    -mortality without treatment is >80%, with treatment 57% (9), all but a few survivors impaired (abnormal neurologic status at one year 92% in untreated patients and 86% in treated patients with disseminated disease).


    2) central nervous system herpes in the neonate

    -70% of infants with neonatal herpes (including those with disseminated/cns disease).
    -symptoms include: irritability, seizures, poor feeding, bulging fontanel, thermal instability.
    -csf findings: hsv culture positive 25-40%, pleocytosis, and proteinosis.
    -may not have mucocutaneous lesions.
    -50% of untreated babies with localized cns disease die, 10% of treated infants with localized cns disease die.
    -75% survivors have psychomotor retardation, often with: microcephaly, hydranencephaly, porencephalic cysts, spasticity, blindness, or learning disabilities.
    -abnormal neurologic status at one year decreased from 83% to 50% in patients with local cns disease.

    3) mucocutaneous and ocular herpes

    -disease limited to skin or mucus membranes only. normal lp, cxr, and lft's. no evidence of cns or visceral organ involvement. -diagnosis by positive culture or fa for hsv.
    -usually presents at 15-17 days of age (as late as 4 weeks).
    -sites include: skin, mouth, and eyes.
    -progression from local infection with skin lesions to cns or disseminated disease decreased from ~70% to 5-20% with early treatment.

    treatment:

    a. treatment for mucocutaneous, ocular disease:
    -contact pediatric infectious disease specialist, or medcon, for latest recommendations.
    -treat with acyclovir 45 mg/kg/day i.v. divided q 8h for 14 days. in cases of herpes keratitis treat with topical trifluorothymidine in addition to acyclovir.
    -monitor cbc and lft's weekly; check creatinine qod and send plasma for pcr on days 0,2-3,5-7,12-14
    -at end of treatment repeat lp (csf for cell count, hsv pcr), send blood for hsv serology, and buffy coat hsv pcr. head ct or mri scan at end of therapy.

    b. treatment protocol for cns and/or disseminated disease
    -contact pediatric infectious disease specialist, or medcon, for latest recommendations.
    -treat with acyclovir 60 mg/kg/day i.v. divided q8h for 21 days.
    -laboratory: csf for cell count, viral and bacterial culture, and hsv pcr. peripheral blood for hsv pcr on days 0, 2-3, 5-7, 12-14, and 19-21. daily surface cultures until negative. weekly cbc and lfts. creatinine qod. monitor coags if lft's abnormal.
    ct scan with contrast or mri at beginning and end of therapy.
    -dilated ophthalmologic examination to assess chorioretinitis during first week and at 6 mo.
    -brainstem auditory evoked potential during initial admission. -repeat at 6 mo. if abnormal.
    -developmental follow-up at 6 and 12 months of age.
    -for any subsequent fever, neurologic symptoms, or skin lesions evaluate csf and blood pcr and scrape any skin lesions for hsv culture and pcr until 6 mo. old.
    -consider oral acyclovir prophylaxis from day 21 to 6 mo. while on oral acyclovir monitor monthly cbc and at 3 and 6 months a serum creatinine.

    c. asymptomatic hsv-exposed infants born to mothers with known or suspected primary hsv 1 or 2 , or first episode non-primary hsv-2 (i.e. culture (+) and seronegative)
    -contact pediatric infectious disease specialist, or medcon, for latest recommendations.
    -treat with acyclovir 45 mg/kg/day i.v. divided q8h for up to 14 days.
    -laboratory: csf for viral and bacterial culture, cell count and pcr. blood for hsv serology and pcr.
    -follow-up at 3, 6, and 9 mo. to assess clinical outcome and to determine whether patient was actually hsv infected (by development or persistence of hsv ab).


    i agree that upon admission, this baby will probably have some sort of septic workup run, including cultures. however, by not knowing, the length of time this child is undiagnosed will simply be prolonged. in this case, we are talking about jeapordizing the life of the child to protect the mother, and there are laws in place to attempt to prevent this, so it is no small thing. my personal opinion is that you should do what you feel is necessary, and if that includes urging the mother to report her status to the md, do it. if that includes placing a phone call to the hospital, do it. this child's life is going to be tremendously affected by exposure to hsv and lack of treatment.

    however, you did say that the girl's doctor was aware that she had hsv upon delivery- an active outbreak. perhaps you do not know all of the details surrounding the delivery? perhaps the girl was lying? either way, i'd say the first place to start might actually be with this girl herself. she needs to be presented with this information, about what hsv can do to a baby, and urged to speak candidly with the physicians. perhaps a little guilt trip will be all it takes for her to address these concerns with the md's.

    as an aside, as a mother this girl is now considered a legal adult (at least in my state she would be...pretty sure this is national). if her mother is in any way influencing decisions that could jeapordize her own or her baby's health, she does have options. they're not extravagant, but they do exist. ;>)

    kristi
    Last edit by NICU_Nurse on Mar 1, '03
  2. by   roxannekkb
    I agree with Kristie. It is important that the doctor is aware that the baby may have been exposed to herpes. The baby has no choice, he can't speak up for himself. A delay in diagnosis/tx can literally mean life or death, or at the least, save him from severe disabilities.

    First, you do need to get all of the details straight. Then I would urge the mother to talk to the doctor. If all else fails, you can call the hospital, if you believe (after getting all the facts down pat) that the baby was exposed.

    In the 3 cases I mentioned before, the mom's had no idea that even had herpes. Their outbreaks were internal, on their cervix. Never had visible blistering. What an awful way to find out.
  3. by   lpnga
    Thanks to everyone....I printed this all out and took it to the mother....and to those who think I should stay out of it..SORRY...but this is the wrong person to say that to...if it keeps the child from any more harm then I will do what I FEEL IS RIGHT......I do think if anyone else was in this situation you would almost have to tell...but who cares if the mother gets embarrassed? NOT ME....Also I don't know if the doctor that delivered the baby told the nurse to write it down on charts or any of that.but I do know that the ped is not aware of it...The hospital that the child is at is not a childrens hospital and I as well as others know this is not a hospital with high ratings...
  4. by   Q.
    Agree with the other NICU nurses. You're doing what's right lpnga.
  5. by   MishlB
    Without knowing the whole situation it's hard to say. My comments may have sounded cruel, but that was not my intention. Didn't you say the doctor was aware that the mother has herpes? And if so, don't you think they would be aware of the risks? You said she had an outbreak at the time of delivery. How do **you** know all of this? If she did have an active episode, don't you think the doctor would recognize it? In reading your previous posts, you sound a little confused. All I am saying is you have to be careful about who you say what to, this is a CONFIDENTIALITY thing, and YES, I realize there are dangers to a baby, but you made it sound like ONLY YOU could prevent a problem. If this young mother is so ignorant about health risks, maybe she should be talked to, not the whole hospital. Just my opinion.
    Last edit by MishlB on Mar 1, '03
  6. by   Sourdough
    I also agree that you did the right thing lnpga...your gut instincts and common sense served this situation well.
  7. by   MishlB
    The person originally posting this question is a CNA, not an LPN. Read previous posts, very enlightening.
  8. by   lpnga
    yes I am a cna.....i am in school. for my rn...when i became a member to this website I was in school for my lpn....who cares......you get on my nerves ..why are you so worried about everyone else? why does it matter about my other post or threads...i just want advice.....It is hard to find people here that I know at home to help with advice and give a imput on what they think is best for me and my family...so yes i post here....get a life mishlb and leave me alone
  9. by   lpnga
    mishlb why don't we go and read all of your post "very enlightening" all you do is tell everyone "it's none of our business" or "it's none of your business" on the post you left to the thread of Jessica it came straight off the internet that is not what someone said..it was there to keep people up to date with the latest news.,.....
  10. by   MishlB
    I have no problem with anyone reading what I have written. You, on the other hand, post here under the false pretense that you are an LPN (lpnga), and you are not. I still do believe you have no place in reporting this woman's STD status to anyone who will listen. Apparently YOU are the one worried about everyone else. I just state my opinion, which is what this message board is for, and if you don't like the opinion or if I "get on your nerves", oh well, ignore me.
  11. by   lpnga
    I would love to ignore you..so stop posting where I post a thread....and if it saves the childs life then it is so worth it...........and no I was not posting a FALSE name..at the time I was in school for my LPN....and I live in GA...I have tried to change my name but can"t......and yes this is here for opinions but all you do is tell people it is none of their business well if it is not my business then she should not have told me her condition and I was posting here for help onwhat to do......as well as any other question that i have posted it is for opinions and that is what makes the world go around..differences...
  12. by   Lausana
    Mishlb, many people have user names stating what they are working for, I really don't see any relevence other than trying to put the OP down, she didn't state this from a nurse point of view.

    I agree you did the right thing lpnga! Even if it's something different, if I were you I don't think I could've sat there wondering and not doing something. Mom's 16--she isn't going to be aware of a lot of things and is going to need guidence. I also wouldn't disagree to making a call to the hospital...if there is something this doc didn't know about it's worth sharing if it helps the little one. Hopefully your talking to mom will be positive!
  13. by   nell
    I agree that lpnga has done the right thing on a number of accounts:

    1. She sought more information in a situation in which she has some knowledge (knows HSV is dangerous to babies) but doesn't know everything (she isn't finishe with her nursing education yet) but is in a position to prevent morbidity or mortality to an innocent infant.

    2. She has stated that she took the info provided by Kristi to the mother.

    3. She will take the info to the appropriate person(s) if the mother fails to act in the best interests of the child (what 16 year old can comprehend a decade or so of caring for an extremely disabled - blind/retarded/immunocompromised, etc.- child).

    Even if the OB knew about the HSV status, the Pedi may not have access to or requested the baby's/mom's birth charts.

    I once provided home care services for a child who had been exposed to HSV at birth. The mother repeatedly told the MDs that she had HSV, but nothing was done. This was at a large teaching hospital with very high-level services. By the time this child was ill, it was too late - tho his life was saved, he required home nursing care 16 hours/day + home visits for IVs etc.

    He died a few months ago at age 8.

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