HIV in Pregnancy Topic

7/27/2019 HIV in Pregnancy Topic

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HIV in Pregnancy


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Introduction

HIV


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Naturalhistory The principal target = T lymphocytes

Specific at CD4 surface antigen (receptor for

the virus)

Monocyte-macrophages may be infected

Incubation period days to weeks


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Acute retroviral syndrome Fever

Night sweats

Fatigue

Rash

Headache

Lymphadenophathy

Pharyngitis

Myalgias

Arthralgias

Nausea and vomiting

Diarrhea

lasts < 10 days


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6

Number of People with

HIV/AIDS by Region

North America

890,000

Caribbean

330,000

Latin

America

1.4 million

Western Europe

500,000

Sub-Saharan

Africa22.5 million

Eastern Europe &

Central Asia

270,000 East Asia& Pacific

560,000

South and

South East Asia

6.7 million

Australia and New Zealand

12,000

North Africa &

Middle East

210,000

Source: UNAIDS/WHO 1998.


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HIV in Pregnancy


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Pregnancy on HIV

infection Pregnancy

: slightly immunosuppressive

: minimal effect on CD4 count

: minimal effect on HIV RNA level

: does not have significant effecton the clinical or immunologicalcourse of HIV infection (Minkoff2003)

Maternal morbidity and mortality

: not increased

HIV infection onpregnancy

Slightly increase rate of

-preterm birth

-IUGR

-PROM

Fetal and neonatal infection

varies from 25-40 percent


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Adverse Pregnancy Outcomes and Relationship to HIV Infection

PregnancyOutcome

Relationship to HIV Infection

Spontaneousabortion

Limited data, but evidence of possible increased risk

Stillbirth No association noted in developed countries;evidence of increased risk in developing countries

Perinatal mortality No association noted in developed countries, but datalimited; evidence of increased risk in developing

countriesNewborn mortality Limited data in developed countries; evidence of

increased risk in developing countries

Intra-uterine growthretardation

Evidence of possible increased risk

Anderson 2001.


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Adverse Pregnancy Outcomes and Relationship to HIV Infection

(continued)

Pregnancy Outcome Relationship to HIV Infection

Low birth weight Evidence of possible increased risk

Preterm delivery Evidence of possible increased risk, especially w/

more advanced diseasePre-eclampsia No data

Gestational diabetes No data

Amnionitis Limited data; more recent studies do not suggestan increased risk; some earlier studies foundincreased histologic placental inflammation,particularly in those with preterm deliveries

Oligohydramnios Minimal data

Fetal malformation No evidence of increased risk

Anderson 2001.


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Maternal and Perinatal Transmission


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Maternal and Perinatal Transmission

Antenatal

In utero by transplacental passage

Intranatal

Exposure to maternal blood and vaginal secretions

during labor and delivery

Postnatal

Postpartum through breastfeeding

Source

: UNAIDS/WHO 1996; UNAIDS/WHO 1998.


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Risk factors for vertical transmission1. Preterm birth

2. Prolonged membrane rupture

increase rate from 15 to 25% in ROM > 4 hr3. Placental inflammation, chorioamnionitis,concurrent syphylis


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4. Maternal plasma HIV RNA level

0

5

10

15

20

25

30

35

1st Qtr 400-3000 3000-40000 40000-

100000

>100000

1

Most important factor,

HIV RNA viral load > 100000 copies/ml : risk > 30 %

HIV RNA viral load < 400 copies/ml : risk 1 %


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5. Stage of disease

6. CD4+ T-cell count

7. Mode of delivery

cesarean section vs vaginal delivery

8. Breast feeding(risk 30-40%)


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Prevention mother to child


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Prevention mother to child Antepartum

Antenatal HIV screening

Antiretroviral therapy

Intrapartum

Elective Caesarean section

Post partum

Avoiding breast feeding

Reduced from 25-30% to less than 2 %


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Transmission rateTransmission rate

No ARV 20%

AZT alone 10.4%

HAART

2%

HAART+C/S


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Monitoring

CD4 count at initiation then CD4 count every 3

months

HIV RNA levels at 4 weeks after initiation of

treatment then HIV RNA levels monthly until

undetectable, then every 3 months

HIV RNA level at GA 36 weeks


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ARV


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Antiretroviral therapy

Drug Category


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Drug CategoryNucleoside reverse transcriptase inhibitors

Abacavir

Didanosine

Emtricitabine

LamivudineStavudine

Tenofovir

Zalcitabine

Zidovudine

Non-nucleoside reverse transcriptase inhibitors

Delavirdine

EfavirenzNevirapine

Protease inhibitors

Amprenavir

Atazanavir

Fosaprenavir

Indinavir

Lopinavir/ritonavir

Nelfinavir

Ritonavir

Saquinavir

Fusion inhibitors

Enfuvirtide

C

B

B

CC

B

C

C

C

CC

C

B

C

C

C

B

B

B

B


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Antepartum


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Antepartum care History taking +Physical examination

Oral health, Ophthalmic,PV

Investigation

CBC with Platelet, BUN/Cr ,LFT, CD4, Viral load Syphilis , hepatitis B C, rubella , TB

CXR ,U/S

Screen DMARV hyperglycemia Immunization

Hepatitis B , Pneumococal , Influenza

C/I : live vacc.

MMR , varicella , JE Prevention of opportunistic infection

Anteretroviral administration

Nutrition support / vitamin supplementation


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Antenatal HIV screening

All pregnancy

Screening is performed using an ELISA test

Positive, is confirmed with either a Western blot or

immunofluorescence assay (IFA)

Rapid HIV test can detect HIV antibody in 60 minutes

Negative rapid test does not need to be confirmed.

Positive rapid test should be confirmed with a Western blot or IFA test

women at high risk for acquiring HIV during pregnancy, repeat

testing in the 3rd trimester


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Intrapartum


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Intrapartum care ARV during labor periodminimum viral load

Mode of delivery

Labor augmentation is used when needed toshorten the interval to delivery / but avoid ARM

Avoid methergin

Minimize obstetrics procedure No fetal scalp blood sampling

Forceps extraction Vacuum extraction

Avoid episiotomy


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Intrapartum care Cesarean section

decrease vertical transmission one-halfcompared with vaginaldelivery

No ANC ,

No ARV or on ARV< 4 wk.

Poor ARV adherance

Combined cesarean section with ARV reduced the risk 87 %

Scheduled C/S is recommended at 38 wk

viral load > 1000 copies/ml recommended C/S viral load < 1000 copies/mldata insufficient to estimate

benefit of C/S (ACOG 2000)


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Postpartum


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Postpartum careARV

Mother:

AIDS, HIV infection with CD4 350 ; stop ARV , monitoring CD4

Baby:

ARV 1 / 6 weeksIfdeliveryoccursbeforetreatmentisgiven, thenewborncan

receiveprophylaxisfor6weekswithzidovudine, orinsomecases

combinationantiretroviraltreatment


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Postpartum careInfant regimen

ANC

GA>35wk : AZT syrup 4 mg/kg/dose 12 . 4

GA 30-35wk : AZT syrup 2 mg/kg/dose 12 . 2 8 . 2

GA


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Infant regimen

No ANC

NVP syrup 4 mg/kg 24 . 2-4

AZT syrup 4 mg/kg/dose 12 .

3TC syrup 2 mg/kg/dose 12 . 4-6

AZT + 3TC NVP 2

ARV 48 hr.

Postpartum care


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Postpartum management of infants born to

HIV infected women Wear gloves while exposed to blood or body secretions.

Clamp and cut umbilical cord carefully to reduce blood splash contamination.

Dry and clean infants skin with a warm cloth to reduce contamination with maternal blood

or secretions before transferring to the nursery.

Avoid unnecessary use of gastric tube to prevent mucosal trauma.

Give infant formula and completely avoid breastfeeding or mixed feeding.

Start ARV drug(s)

Give vitamin K and routine vaccinations for infants, including BCG vaccine and HBV vaccine.


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Breast feeding

Not recommended

(Infant formula is provided without charge

for 18 months by Thai MOPH.)


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HIV diagnosis for infants born to HIV-infected mothers and

comprehensive care for HIV-infected

infants1) ARV drugs for infants need to be provided as recommended

2) HIV-infected mothers need to receive counseling on infant formula

feeding. Infant formula is provided without charge for 18 months by

ThaiMOPH.

3) Infants need to be assessed for signs and symptoms of HIV infection

and side effects from ARV drug(s).

4) Infants need to receive appropriate vaccination.


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PCP prophylaxis HIV PCP 2-3 CD4

co-trimoxazole (TMP-SMX) 150 mg/m2 TMP 1

-

2 3

HIV

6

12

Comprehensive care for HIV-infected women


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Comprehensive care for HIV infected women

and family during the postpartum periodMedical care during the postpartum period

1) Standard postpartum care

pay attention on

puerperal infection,

side effects from ARV drugs,

provision of medication to inhibit lactation and prevent breast

engorgement or mastitis,

postpartum check up at 4-6weeks after delivery, including cervical

Pap smear (annually)

2) General health promotion Nutritional

support and exercise, should also be provided.

3)All postpartum women should be referred to internists for standard

HIV treatment and care

Psychological management


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y g g

postpartum depression, psychosocial support for child

rearing, and long-term family care.

Caring for male partner

Assess HIV status of male partner

Voluntary HIV counseling and testing should be offered

Refer infected-male partner for standard HIV treatment and care

health promotion including:

Promotion of safer sex practices

Advice on how to live happily with an HIV-infected partner.

repeat HIV testing every 6 months.

Family planning services and contraceptive counseling


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Family planning services and contraceptive counseling

The aim is to prevent unintended pregnancy and HIV transmission to HIV-

uninfected partner.

assess future pregnancy wishes in HIV-infected women and partners and

provide family planning services.

1) planning to have children receive pre-conceptual counseling on

MTCT risks

their long-term healthand possible effects of ARV drugs on the fetus.

Couples should carefully weigh risks and benefits.

Couples who decide to have children should be advised on ways to

reduce risk of HIV transmission to infants and partners

HIV discordant couples in which

-the woman + refer to obstetrician for intrauterine insemination

-the man + sperm wash

HIV concordant couple long-term HAART unprotected SI at ovulation


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2) planning not to have children

contraception counseling using dual methods of contraception which

include consistent condom use plus others

Advice about

interactions between oral contraceptive pills and ARV, e.g. NVP or

some PI drugs that may reduce the efficacy of birth control pills.

HIV in Pregnancy Topic

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