How should I manage a first episode of genital herpes in a pregnant patient?

Management of a first episode of genital herpes in a pregnant patient:

• Advise the patient to attend a specialist sexual health service promptly for confirmation of diagnosis, treatment, screening for other STIs, and follow-up.
• Start oral antiviral treatment within 5 days of the onset of the first episode or while new lesions are forming. First-line treatment options include aciclovir 400 mg three times daily for 5 days or valaciclovir 500 mg twice daily for 5 days.
• Consider extending antiviral treatment up to 10 days if new lesions appear during treatment or healing is incomplete.
• Do not prescribe or advise topical antiviral treatments as they are less effective and may increase drug resistance risk.
• Advise on self-care measures such as saline bathing to ease symptoms, use of analgesia like paracetamol or ibuprofen if appropriate, applying topical petroleum jelly or lidocaine gel for dysuria, increasing fluid intake, and avoiding tight clothing to reduce irritation.
• Advise strict abstinence from sexual activity (including non-penetrative and oro-genital sex) while lesions are present to reduce transmission risk.
• Inform the patient about the risk of neonatal transmission, especially with a first episode in the third trimester, and the importance of notifying healthcare professionals immediately if pregnant or if pregnancy occurs.
• Arrange follow-up within 5–7 days to review symptoms, treatment response, and discuss transmission risk and recurrence.

This management approach is based on the British Association for Sexual Health and HIV (BASHH) guidelines, the Royal College of Obstetricians and Gynaecologists (RCOG) guideline on genital herpes in pregnancy, and expert consensus, ensuring safe and effective care for pregnant women with a first episode of genital herpes ¹.