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HIV in pregnancy

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A case based discussion

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HIV in pregnancy

  1. 1. HIV IN PREGNENCY A Case Based Discussion Dhammike Silva
  2. 2. BACKGROUND… 50%
  3. 3. BACKGROUND… 25% • 1/3 Late • CD4 count < 200 cells/ml at the time of diagnosis
  4. 4. BACKGROUND… anti-retroviral drugs has transformed the management since 1990s restoration of immune function increasing life expectancy renders viral loads undetectable reduces infectivity.
  5. 5. BACKGROUND… 2011 WHO Mother to child 1993 - 25.6% 2007- 2011- 0.57%
  6. 6. Viral load of >100,000 copies/ml - 40 % 1000 copies/ml - 1% At undetectable VL (<50 copies/ml) - < 1%
  7. 7. TRANSMISSION TO NEWBORN Intact placenta acts as a very effective barrier MTCT at the point of delivery is the commonest mode of transmission RISK FACT- high viral load at delivery, prolonged rupture of membranes, prematurity, vaginal laceration, vaginal ulceration due to herpes simplex infection or syphilitic ulcers, episiotomy, invasive fetal monitoring and instrumental delivery Post-partum exclusively due to breast feeding - up to 40% of
  8. 8. CASE HISTORY 25 yrs, P2 C0 MF 2.5 yrs Husband- works at a saloon, denied extramarital affairs, 3 tattoos + Index case- had an affair 5 yrs back with a three wheel driver, he was diagnosed to have HIV + in 2016 P1 – 2 months following marriage, not aware about HIV status 12 wk of POA HIV AB done, report not available T1 developed UTI & herpes zoster
  9. 9. CASE HISTORY P1- Premature delivery at 34/52, 1950 g PBU for 11 days Following 2/12 vaccination infant develop PUO At SCBU THK, HIV AB became + 1/52 following diagnosis infant died due to severe pneumonia at Peradeniya Hospital. (11/11/2015)  Soon after mother and father both diagnosed HIV +  2/12 following ( Jan 2016) mother started on ART
  10. 10. CASE HISTORY  Monthly regular follow up & on ART  five months following became pregnant while on ART  LMP - 15/5/2016  EDD – 22/2/2017  antenatal and STl regular follow- December/Jan both viral count undetectable  at 38+5 admitted for EL/LSCS as decided  EFW 2489 g, AFI & Doppler normal  Anaesthetic & neonatology referrals arranged on admission
  11. 11. CASE MX - ANTENATAL Started on ART ( Tenofovir, Emtricitabine, Efavirenz since 2015) No interruption Even while fasting
  12. 12. ANTENATAL STI screening yearly - The British HIV Association (BHIVA) Twice during pregnancy – 1st & 3rd trimesters chlamydia, syphilis, hepatitis, gonorrhoea and herpes could potentially be transmitted Test of cure should be performed following treatment for any bacterial STI’s Whooping cough vaccine and vitamin D should be offered to women regardless of their HIV status.
  13. 13. ART Viral load of less than 50 copies/ml (undetectable) and who do not breast feed - 0.5% chance of transmitting the virus Should commence ART by 24 POG Each week of ART reduces the odds of transmission by 8% MTCT are lower in women who became pregnant on ART Different types of ART used do not influence the rate of
  14. 14. ANTENATAL PROCEDURES RR of HIV transmission of 1.9 with antenatal procedures like Amniocentesis Cerclage laser therapy Amnioscopy (The French Paediatric HIV Infection Study Group ) ART regimen including raltegravir (associated with rapid viral load suppression) should be given along with single dose of nevirapine 2-4 hours prior to the procedure
  15. 15. CASE MX - MOD EL/LSCS at 38 POG MDT – Con. Venereologist, Obstetrician, Anaesthetist, Peadiatrcian  Sister/ Nursing officer of Infection control unit, OT, ICU  Spinal /Epidural not CI  Antibiotic routine prophylaxis  ARV without interruption on day of LSCS
  16. 16. Table preparati on
  17. 17. Protective Kits
  18. 18. Waste disposal
  19. 19. MOD Historically a planned EL/ LSCS was the method of choice for delivery Effective control of viral load with ART more and more women having vaginal deliveries. Decision regarding MOD - after review of viral load at 36 weeks. Planned vaginal delivery is recommended for women on ART with an undetectable viral load in the absence of obstetric complications (BHIVA guidelines)
  20. 20. MOD MTCT rates of <0.5% in women with plasma viral load <50 cp/ml taking ART, irrespective of MOD (Published cohort data from the UK and other European countries ) viral load is > 400 copies/ml at 36 weeks a planned caesarean section is recommended regardless of the ART agents
  21. 21. TOD The timing of LSCS is a balance between … Where the indication is to prevent MTCT, at 38-39 weeks Women with an undetectable viral load and ROM at term - should have immediate IOL risks of transient tachypnoea of the newborn labour occurring before the scheduled caesarean section.
  22. 22. INTRAPARTUM CARE There are theoretical reasons why a low traction forceps may be preferred to a ventouse delivery (with potential lower rates of fetal trauma) - no data /evidence Use of fetal scalp electrodes/fetal blood sampling , safe if viral load undetectable
  23. 23. LATE PRESENTERS… If a woman presents after 28 weeks and is subsequently found to be infected with HIV - should start treatment without delay. If a woman presents in labour & not on treatment, should be given a stat dose of nevirapine ( rapidly crosses the placenta , effective concentrations are achieved within 2 hours and then maintained in the neonate for up to 10 days)
  24. 24. CASE- MX OF NEWBORN Clean the eyes with saline at delivery Clamp cord as soon as possible Cover umbilical cord with a swab- prevent blood spurting Avoid suction baby’s mouth & pharynx Towel dry, bath as soon as possible, done at theatre
  25. 25. CASE- MX OF NEWBORN
  26. 26. NEONATAL POST EXPOSURE PROPHYLAXIS Antiretroviral treatment to the newborn is an example of preexposure prophylaxis should be decided before the delivery The choice of the drugs given to the baby depends on the mother’s antiretroviral drug history and known resistance mutations Monotherapy is usually sufficient, should be given for 4 weeks
  27. 27. CASE – NEONATAL PEP Syrup nevirapine started daily Dosing according to BW As soon as possible, 1st dose given at theatre Once daily for 6 weeks
  28. 28. NEONATAL POST EXPOSURE PROPHYLAXIS 2 situations where triple combination (i.e. ART) neonatal PEP is advised: mother is found to be HIV positive after delivery (whereby treatment needs given within 72 hours), when there is detectable maternal viraemia at birth. In addition Pneumocystis pneumonia (PCP) prophylaxis should be started at 4 weeks- all HIV infected infants infants with an initial positive HIV DNA/RNA test infants whose mothers viral load at 36 weeks or delivery is >1000 copies/ml
  29. 29. BREAST FEEDING Women who breast feed may transmit HIV There may be wide variations between plasma and breast milk viral load Risk high if– viral load in plasma and breast milk is high, premature delivery breastfeeding is prolonged nipples are cracked
  30. 30. BREAST FEEDING Current standard of care in the UK is to avoid breastfeeding in HIV positive mothers Mixed feeding is thought to double the risk of HIV transmission secondary to inflammation of gut
  31. 31. CASE MX- BREAST FEEDING Mother agreed on exclusive formula feeding Educated in maintaining sterility in preparation Cabergoline to mother Messures to prevent mastitis & breast abscess formation Mother is provided separate container to discard breast milk Should discard as clinical waste
  32. 32. CASE- NEWBORN TESTING 2 cc blood, EDTA bottle Within 24 hours Sent for RNA PCR Sample send to reference laboratory, national STD/AIDS control programme, Colombo
  33. 33. TESTING OF INFANTS All infants born to HIV positive mothers should be tested for HIV HIV DNA PCR (or HIV RNA testing however this may require more blood volume to test) should be performed during the first 48 hours 2 weeks post infant prophylaxis (6 weeks of age) 2 months post infant prophylaxis (12 weeks of age)
  34. 34. TESTING OF INFANTS HIV antibody testing for seroreversion (loss of maternal antibodies) should be performed at age 18 months. Diagnosis of in utero transmission can be made by the identification of proviral DNA through amniocentesis or from the cord blood/newborns blood sample at birth
  35. 35. IMUNIZATION… BCG vaccination delayed, until HIV status ascertain at 8 weeks At age of 2,4,6 months- hexavalent which include IPV is preferred Other schedule as routine
  36. 36. ETHICS…
  37. 37. THANK YOU ……..

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