USE OF ACICLOVIR/VALACICLOVIR IN PREGNANCY

Aciclovir is an antiviral agent used systemically for the treatment of herpes simplex and varicella-zoster infections, or topically for herpes simplex infections of the skin, mucous membranes and eye. Valaciclovir, a prodrug of aciclovir, is used systemically in the treatment or prophylaxis of herpes simplex, varicella-zoster and cytomegalovirus infections.

The Royal College of Obstetricians and Gynaecologists (RCOG) guidelines recommend that aciclovir be considered for all pregnant women who present with a first episode of genital herpes and in women ≥20 weeks gestation with chickenpox who present within 24 hours of the onset of rash. Use before 20 weeks may also be considered and intravenous aciclovir should be given to all pregnant women with severe chickenpox.

Public Health England (PHE) has also issued guidance in response to an ongoing shortage of varicella zoster immunoglobulin. It is recommended that immune naïve women with significant exposure to chickenpox or shingles after 20 weeks of pregnancy should be offered aciclovir 800mg QDS on days 7 to 14 post-exposure. Exposed women in the first 20 weeks of pregnancy should continue to be offered immunoglobulin therapy.

Overall, the available data do not suggest an increased risk of congenital malformation or preterm delivery following exposure to aciclovir during pregnancy. First episode genital herpes infection in pregnancy is a recognised risk factor for preterm labour, and there is some evidence that treatment with aciclovir can reduce the risk of preterm delivery. Limited data suggest no increased risk of low infant birth weight or intrauterine death relating to aciclovir exposure. Other pregnancy/infant outcomes have not been adequately studied to facilitate an evidence-based assessment of risk, although the known risks posed by the conditions that aciclovir is used to treat should be considered when discussing treatment options with the pregnant woman.

Human pregnancy data for valaciclovir are limited to one small study which provided no evidence of an increased malformation risk. However, ongoing research is ideally required to confirm this. Other fetal outcomes have not been assessed in women taking valaciclovir.

Exposure to aciclovir or valaciclovir at any stage in pregnancy would not usually be regarded as medical grounds for termination of pregnancy or any additional fetal monitoring. However, other risk factors may be present in individual cases which may independently increase the risk of adverse pregnancy outcome. Clinicians are reminded of the importance of consideration of such factors when performing case-specific risk assessments.