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Hiv & pregnancy

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  • 1. HIV AND PREGNANCY By Dr.Dharmesh G Patel (M.D.Obs & Gyn.)
  • 2. HISTORY AIDS(Acquired Immunodeficiency Syndrome) was first found in male homosexual in 1981 in USA In India,first HIV infection was reported in 1986 from prostitute in Chennai. India has the largest HIV population in the world compared to any single nation. States with high prevalence of India include Tamilnadu,Maharashtra,Karnataka,Andhra Pradesh & Manipur.
  • 3. MODES OF TRANSMISSION Sexual contact with an infected partner.Most common mode of transmission Blood born- Infected blood & blood products Parenteral Transmission- Sharing infected needles Occupational exposure- By needle stick injury or contamination with patient’s blood or body fluids. Perinatal Transmission- From the infected mother to the fetus or newborn.
  • 4. HIV Screening during Pregnancy Why:ART reducing the perinatal transmission How :All the antenatal patients should undergo HIV testing It cannot be made compulsary It should not be done for any patient without prior counselling and consent
  • 5. Advantages of HIV screeing     Patient can choose the option of MTP. Planned optimal care if continuation of pregnancy. Implementation of strategies to reduce risk of fetal transmission. Future planning can be done by couples.
  • 6. Disadvantages of HIV screening    Psychological trauma- reduced by counselling. Risk of social isolation. Risk of marital disharmony.
  • 7. Effects of HIV on pregnancy     Spontaneous abortion Preterm labour and preterm babies IUGR Perinatal mortality Incidence of perinatal transmission :15 to 35% Transmission of HIV-2 is less frequent(1-4%) than for HIV-1(14-35%)
  • 8. Perinatal Transmission Antepartum transmission :- across the placenta 10-50% Intraparturm transmission :- during delivery as mentioned below • direct contact with maternal blood &vaginal secretions while passing through the birth canal. •Ascending infection from the vagina or cervix to the fetal membranes & amniotic fluid •Absorption in fetal neonatal digestive tract, •Maternal fetal microtranfusion during uterine coutractions in labour, 40-80% Postpartum transmission :- through breast feeding 10-20%
  • 9. Risk factors of transmission             High viral load Low CD4 count Placental abruption Vit. A deficiency Invasive fetal monitoring Vaginal delivary Maternal P24 antigenemia Other STDs presence Preterm delivary Advanced maternal age Memberanes ruptured >4 hrs Breast feeding
  • 10. Management of HIV in pregnancy Antepartum :• Most patients will be asymptomatic. • Patient requires obsteric care + HIV care. Consult HIV specialist. • MTP option is offered. • Nutritional supplement including micronutrients. • Routine antenatal investigation + Baseline CBC, LFT,RFT. • Investigations of STDs, TB, Toxoplasmosis, Cytomegalovirus. • CD4 count & vital load in each trimester. If CD4 count < 200, prophylactic Antibiotics are indicated. • Counsel against unprotected coitus. • USG- Routine + Fetal well being assessment. • Avoid invasive procedures.
  • 11. Anti Retroviral Therapy(ART) 1. ACTG 076 regimen:- (AIDS Clinical Trial Group) Zidovudine(AZT) Reduction of transmission:- 25.5% to 8.3% 2. CDC Thai regimen :Zidovudine(AZT) Reduction of transmission:- 50% 3. HIV NET 012 regimen:- Nevirapine Reduction of transmission:- 47% 4. PETRA study:- Zidovudine(AZT) + Lamuvidine(3TC) Reduction of transmission :- 69%
  • 12. ACTG 076 regimen Antepartum : oral AZT 100 mg 5times a day starting anytime from 1434 wks & continued till delivery. Intrapartum : I/V AZT 2mg/kg. over 1 hour then 1 mg/kg/hour from onset of labour until delivery. Postpartum : To the neonate, 2mg/kg birth weight every 6 hours for 6 weeks beginning 8-12 hours after birth.
  • 13. CDC Thai regimen : Antepartum : Oral AZT 300 mg twice daily starting at 36 wks gestation. Intrapartum : Oral AZT 300 mg every 3 hourly from onset of labour till delivery. HIV NET 012 regimen : NVP 200 mg tablet at the onset of labour. NVP 2 mg/kg (single dose) to the newborn within 72 hours of birth. PETRA study : Post exposure prophylaxis with triple therapy for 4 weeks. AZT 200 mg tid + Lamivudin 150 mg bid + indinavir 800 mg tid.
  • 14. Universal work precautions        Wear double gloves, goggles, plastic apron, long gown, mask, cap & overshoes (gum boots). Protection from blood & amniotic fluid splash. Minimal use of needles & sutures. If needle stick injury occurs, remove the gloves, let the injury site bleed, wash it throughly with soap & water & start Zidovudine prophylaxis 1 to 2 hours of injury as per protocol. Proper disinfevtion of gowns, gloves, masks, caps, goggles & shoes. This is advised even if they are disposable. Immediate immersing in bleaching powder solution is recommended. Eventhrough delivery may be allowed in the same labour from proper disinfection of floor, labour table & mattresses or rubber used, is also done. Proper disposal of blood, placenta, cord & deadbody (SB) by incineration.
  • 15. INTRAPARTUM MANAGEMENT     Elective LSCS reduces perinatal transmission upto 50-80%. When labour has started or membranes have ruptured LSCS still debated. LSCS may increase the morbidity to immunocompromised mother. During Delivery:• to take precaution for personal safety,to prevent spread,to decrease perinatal transmission. • Avoid ARM • Avoid Vaginal tears • Avoid Instrumental delivery • Restrict Episiotomy • Avoid fetal scalp electrode/ fetal blood sampling
  • 16. POSTPARTUM MANAGEMENT       Wash newborn after birth,especially face. Mouth suction is avoided,no mouth to mouth breathing Avoid hypothermia Anti Retroviral Therapy (ART) All vaccines are given to asymptomatic children.While only inactivated vaccines are recommended for symptomatic children New born testing ELISA TEST false positive upto 18 months Before that to consider newborn positive 2 tests must be positive from HIV 1 culture,p-24 antigen,PCR
  • 17. BREASTFEEDING Risk of transmission :- 10 to20% Developing countries there is more risk of neonatal death due to Infectious diarrhoea and dehydration in bottlefed babies. Also apart from it other advantages of BF to mother and child So, WHO recommened that breastfeeding to be given to the child born from mother who is HIV positive

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