HIV clinical talk
Ms. Smith <ul><li>28yo female G3 P1011 who presents at 24wks gestation for prenatal care </li></ul><ul><ul><li>HIV+ diagno...
Plan of care for Ms Smith <ul><li>Draw prenatal lab panel including HBV, HCV and RPR </li></ul><ul><li>Draw baseline CD4/V...
Monitoring during Pregnancy <ul><li>CD4 q3months </li></ul><ul><li>VL 1 st  visit and q4wks while changing meds or until V...
Preconception Counseling <ul><li>Maximize maternal health—low VL, few medications, improve nutrition, avoid tobacco/alcoho...
Prenatal Testing <ul><li>ACOG and DC recommendations are for “opt-out” testing for HIV in pregnancy--all patients are test...
HIV Drug Counseling during Pregnancy <ul><li>No treatment at all—25% risk of transmission </li></ul><ul><li>ZDV alone (ant...
Transmission <ul><li>Mother-to-infant transmission accounts for most HIV infections among children </li></ul><ul><li>About...
Recommended Mode of Delivery <ul><li>ACOG recommends consideration of scheduled cesarean delivery at 38wks for HIV-1 infec...
Intrapartum Treatment <ul><li>ZDV intrapartum prophylaxis should be provided, regardless of the mode of delivery </li></ul...
Mode of Delivery <ul><li>Management of women originally scheduled for cesarean delivery who present with ruptured membrane...
Other Possible Treatment Options <ul><li>IV ZDV during labor and delivery and 6 week ZDV therapy for the newborn  </li></u...
Infant Treatment <ul><li>Oral administration of ZDV to the newborn (ZDV syrup at 2mg/kg/dose Q6hr) for the first 6 weeks o...
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Hiv and pregnancy

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Hiv and pregnancy

  1. 1. HIV clinical talk
  2. 2. Ms. Smith <ul><li>28yo female G3 P1011 who presents at 24wks gestation for prenatal care </li></ul><ul><ul><li>HIV+ diagnosed 2007, during her last pregnancy </li></ul></ul><ul><ul><ul><li>No HIV medications since last pregnancy, followed by ID providers 3-4x a year. </li></ul></ul></ul>
  3. 3. Plan of care for Ms Smith <ul><li>Draw prenatal lab panel including HBV, HCV and RPR </li></ul><ul><li>Draw baseline CD4/VL, CBC/Chem 10 and LFTs, GAART </li></ul><ul><li>Refer back to HIV medicine for followup </li></ul><ul><li>Frequent Prenatal visits </li></ul><ul><li>Counseling </li></ul>
  4. 4. Monitoring during Pregnancy <ul><li>CD4 q3months </li></ul><ul><li>VL 1 st visit and q4wks while changing meds or until VL undetectable </li></ul><ul><li>If elevated VL—GAART </li></ul><ul><li>SE monitoring—CBC, LFTs, Chem 10 </li></ul><ul><li>Early GTT esp if obese, PI use </li></ul><ul><li>1 st trimester sono dating </li></ul><ul><li>2 nd trimester anatomy </li></ul><ul><li>Additional fetal monitoring controversial </li></ul>
  5. 5. Preconception Counseling <ul><li>Maximize maternal health—low VL, few medications, improve nutrition, avoid tobacco/alcohol/drugs (AVOID Efavirenz for patients who may get pregnant). </li></ul><ul><li>Treat opportunistic infections </li></ul><ul><li>Immunize </li></ul><ul><li>Effective contraceptives until planning pregnancy </li></ul><ul><li>Review perinatal transmission risks, risk reduction and potential effects </li></ul>
  6. 6. Prenatal Testing <ul><li>ACOG and DC recommendations are for “opt-out” testing for HIV in pregnancy--all patients are tested unless they decline </li></ul><ul><li>Retesting in the 3 rd trimester is recommended for women at high risk for acquiring HIV infection, in areas of high HIV prevalence (DC) and for women who declined testing earlier in pregnancy </li></ul><ul><li>If no 3 rd trimester results, NEED rapid testing on Labor and Delivery </li></ul>
  7. 7. HIV Drug Counseling during Pregnancy <ul><li>No treatment at all—25% risk of transmission </li></ul><ul><li>ZDV alone (ante/intra/post) will decreased rate of transmission to 5-8% (no longer recommended 2 nd to drug resistance). </li></ul><ul><li>Combination therapy, HAART (antepartum with ZDV intra and post), will decrease transmission <2%. </li></ul><ul><li>If VL >1000 at term (or time of delivery), scheduled C section at 38wks. </li></ul>
  8. 8. Transmission <ul><li>Mother-to-infant transmission accounts for most HIV infections among children </li></ul><ul><li>About 1/3 of vertical transmission occurs during the antepartum period and 2/3 occurs during labor and delivery </li></ul><ul><li>Transmission is more common in preterm births and increased duration of rupture of membranes </li></ul><ul><li>More advanced disease is also linked with higher transmission rates </li></ul><ul><li>More advanced disease can be measured clinically by the presence of AIDS defining conditions, lower CD4 counts, or high plasma HIV RNA levels </li></ul>
  9. 9. Recommended Mode of Delivery <ul><li>ACOG recommends consideration of scheduled cesarean delivery at 38wks for HIV-1 infected pregnant women with HIV-1 RNA levels >1,000 copies/mL near the time of delivery, regardless of the type of antiretroviral therapy the women is receiving </li></ul><ul><li>In women at very low risk for transmission, such as those with low or undetectable viral loads, the additional benefit provided by elective cesarean section may be marginal </li></ul><ul><ul><li>If vaginal delivery is chosen, AROM and invasive procedures that may cause a break in the infants skin should be avoided </li></ul></ul>
  10. 10. Intrapartum Treatment <ul><li>ZDV intrapartum prophylaxis should be provided, regardless of the mode of delivery </li></ul><ul><ul><li>During labor, IV administration of ZDV in a 1 hour initial dose of 2mg/kg, followed by a continuous infusion of 1mg/kg/hr until delivery, for ideally 3hrs prior to delivery </li></ul></ul><ul><li>Other antiretroviral medications taken during pregnancy should not be interrupted near the time of delivery, regardless of route of delivery </li></ul>
  11. 11. Mode of Delivery <ul><li>Management of women originally scheduled for cesarean delivery who present with ruptured membranes must be individualized based on duration of rupture, progress of labor, plasma HIV-1 RNA level, current antiretroviral therapy and other clinical factors </li></ul><ul><li>The longer the time since the membranes ruptured, the greater the percentage of eventual transmissions that will have occurred before a surgical procedure can be undertaken </li></ul>
  12. 12. Other Possible Treatment Options <ul><li>IV ZDV during labor and delivery and 6 week ZDV therapy for the newborn </li></ul><ul><li>Single oral dose of nevirapine give to the mother at the onset to labor and a single oral dose given to the infants at 48-72 hrs of age </li></ul><ul><li>Oral administration of ZDV combined with lamivudine (3TC) given to the mother during labor and to the infant for the first week of life—NOT recommended if IV ZDV available </li></ul><ul><li>Combination of the 2-dose intrapartum/infant nevirapine regimen with IV ZDV during labor an delivery and 6 week ZDV therapy for the newborn </li></ul>
  13. 13. Infant Treatment <ul><li>Oral administration of ZDV to the newborn (ZDV syrup at 2mg/kg/dose Q6hr) for the first 6 weeks of life, beginning at 8-12 hours after birth </li></ul><ul><ul><li>IV dosage for full-term infants who cannot tolerate oral intake is 1.5mg/kg IV Q6hr </li></ul></ul><ul><ul><li>Check a CBC prior to administration of ZDV </li></ul></ul><ul><ul><li>Repeat testing of CBC following completion of 6-week ZDV regimen and at 12 weeks of age </li></ul></ul><ul><li>Screened for HIV infection at birth, 2 weeks, 1-2 months and 3-6 months of age, looking for HIV DNA </li></ul><ul><li>Prophylaxis for PCP (bactrim) should be started following completion of ZDV therapy at 6 weeks of age </li></ul>

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