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MANAGEMENT OF HIV IN PREGNANCYDr. Ahmed Eltigani ElmahdiConsultant Obstetrician & GynaecologistCavan General Hospital, IRE...
PRECONCEPTUAL COUNSELING✴ Educate patients about perinatal transmission rate✴ To avoid unintended pregnancy✴ Counsel patie...
PRECONCEPTUAL COUNSELING✴ Couple who are serodiscordant should advised to use condoms✴ Couple who are serodiscordants wher...
ANTENATAL SCREENING✴ HIV screening is recommended as part of IDiPS Screening.✴ Women choice.✴ Negative at booking, high ri...
Pregnancies in diagnosed HIV positive womenin the UK & Ireland reported between 1989-2011
Children born to HIV positive womenand &reported by December 2011(Infection status and region of the first report)
Professional Approach to the Antenatal Care of Women Who are HIV Positive✴ Multidisciplinary Team.✴ Newly diagnosed HIV Po...
Intervention to Prevent Disease Progression in The Mother✴Highly Active Anti-Retroviral therapy (HAART).✴ Prophylaxis agai...
Possible Routes of Transmission
Intervention to Prevent Mother to ChildTransmission of HIV✴Brest feeding✴Anti-Retroviral Therapy• Women who require HIV tr...
Intervention to Prevent Mother to ChildTransmission of HIV✴ Mode of Delivery (decision should be made by 36 weeks of gesta...
Antenatal Care for pregnant women who areHIV Positive✴ Screening for Syphilis, Hepatitis B & Rubella✴ Additional tests for...
Management of Antenatal complications✴ Women who is HIV positive who becomes  acutely unwell in pregnancy✴ HIV-related com...
Management of preterm delivery & pretermpreterm prelabour rupture of membranes✴Genital infection screen✴ Usual Indications...
Management of Delivery✴A clear plan of care of ART & Mode of delivery should be in place✴ Maternal plasma viral load & CD4...
CONTINUE Management of DeliveryCaesarean Section✴ If IV ZDV indicated , the infusion should be started 4 hours before the ...
CONTINUE Management of DeliveryPlanned Vaginal Deliverya Should only be offered to women taking HAART who have a viral   l...
CONTINUE Management of DeliveryPrelabour rupture of membranes at term✴Delivery should be expedited if:  a. The viral load ...
CONTINUE Management of DeliveryProlonged pregnancy ✴Women on HAART ✴with plasma viral load < 50 copies/ml, the decision   ...
CONTINUE Management of Delivery   Vaginal Birth after caesarean section VBAC✴A trial of scar may be considered for a women...
CONTINUE Management of DeliveryHIV diagnosed in Labour
CONTINUE Management of DeliveryHIV diagnosed in Labour Women diagnosed HIV positive during labour  a. Paediatricians shoul...
Postpartum Management of women who areHIV positive✴ Women should be given advise about formula feeding✴ An immediate dose ...
BREAST FEEDING Replacement  feedingIf no AFASS then  exclusive breastfeeding for 6  months
Management of the Neonates✴ All neonates should be treated with anti-retroviral therapy within four  hours of birth✴ Most ...
Academic institutions and professional bodiesBritish HIV Association                             http://www.bhiva.orgChild...
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Hiv krt

  1. 1. MANAGEMENT OF HIV IN PREGNANCYDr. Ahmed Eltigani ElmahdiConsultant Obstetrician & GynaecologistCavan General Hospital, IRELANDKhartoum Feb 2012
  2. 2. PRECONCEPTUAL COUNSELING✴ Educate patients about perinatal transmission rate✴ To avoid unintended pregnancy✴ Counsel patients about safe methods to concieve✴ Choose anti-retrovials which is known to be effective in reducing perinatal HIV transmission✴ Attain stable, maximally suppressed viral load✴ Optimize medical and nutritional status
  3. 3. PRECONCEPTUAL COUNSELING✴ Couple who are serodiscordant should advised to use condoms✴ Couple who are serodiscordants where the female partner is HIV negative should be advised that assisted conception with either donor insemination or sperm washing is significantly safer than timed unprotected intercourse✴ Couple should be advised to delay conception until plasma viraemia is suppressed✴ Prophylaxis against PCP is no longer required✴ Apportunistic infections should be treated✴ All women who are HIV positive are recommended to have an annual cervical Cytology
  4. 4. ANTENATAL SCREENING✴ HIV screening is recommended as part of IDiPS Screening.✴ Women choice.✴ Negative at booking, high risk, repeat.✴ Documentation.✴ Fourth generation Laboratory.✴ Urgent, late booking > 26 weeks (24 hours).✴ Rapid HIV test, In Labour (20 minutes).
  5. 5. Pregnancies in diagnosed HIV positive womenin the UK & Ireland reported between 1989-2011
  6. 6. Children born to HIV positive womenand &reported by December 2011(Infection status and region of the first report)
  7. 7. Professional Approach to the Antenatal Care of Women Who are HIV Positive✴ Multidisciplinary Team.✴ Newly diagnosed HIV Positive.✴ Confidentiality.✴ Disclose Their HIV status.✴ Avoid Inadvertent Disclosure.✴ Safe Sex Practice.✴ Women with Existing Children of Unknown HIV Status.✴ Women Refuse Interventions to Reduce the risk of Vertical transmission.✴ National Study of HIV in Pregnancy & Childhood (www.nshpc.ucl.ac.uk).✴ Antiretroviral Pregnancy Registry (www.apregistry.com)
  8. 8. Intervention to Prevent Disease Progression in The Mother✴Highly Active Anti-Retroviral therapy (HAART).✴ Prophylaxis against Pneumocystitis Carinii Pneumonia (PCP).
  9. 9. Possible Routes of Transmission
  10. 10. Intervention to Prevent Mother to ChildTransmission of HIV✴Brest feeding✴Anti-Retroviral Therapy• Women who require HIV treatment for their own health, HAART.• Women who do not require treatment for their own health, HAART.• Women who do not require treatment for their own health, & have: a. Plasm viral load of less than 10000 copies/ml. b. Planned to be delivered by Caesarean Section, Zidovudine (ZDV) monotherapy 250mg orally, and IV at delivery
  11. 11. Intervention to Prevent Mother to ChildTransmission of HIV✴ Mode of Delivery (decision should be made by 36 weeks of gestation)• Elective Caesarean Section at 38 weeks a. Women taking HAART who have plasma viral load > 50 copies/ml b. Women taking ZDV monotherapy as an alternative to to HAART C. Women with HIV & Hepatitis C virus infection• Planned Vaginal Delivery (women taking HAART & have Plasma viral load < 50 copies/ml.• Elective Caesarean Section at 39 weeks Obstetric indication or Maternal request (plasma viral load <50 copies/ml
  12. 12. Antenatal Care for pregnant women who areHIV Positive✴ Screening for Syphilis, Hepatitis B & Rubella✴ Additional tests for Hepatitis C, Varicella Zoster, Measles & Toxoplasma✴ Women Taking HAART at booking should be screened for G.Diabetes✴ Vaccination (Hepatitis B & Pneumococcal, Influenza, Varicella Zoster, Measles, Mumps & Rubella)✴ Genital Infection Screening at booking & 28 weeks✴ Screening for Aneuploidy✴ Invasive Diagnostic Testing✴ Dating and Anomaly Scans✴ Monitoring of Plasma Viral Load & Drug Toxicities✴ A plan of care for ART & Mode of delivery should be made at 36 weeks
  13. 13. Management of Antenatal complications✴ Women who is HIV positive who becomes acutely unwell in pregnancy✴ HIV-related complications should also be considered is a cause of of acute illness in pregnant women whose HIV status is unknown
  14. 14. Management of preterm delivery & pretermpreterm prelabour rupture of membranes✴Genital infection screen✴ Usual Indications for steroids✴ Risk of preterm delivery associated with HAART✴ Threatened preterm labour✴ Established Preterm labour (choice of anti-retroviral therapy)✴ PPROM occurs after 34 weeks✴ PPROM occurs before 34 weeks
  15. 15. Management of Delivery✴A clear plan of care of ART & Mode of delivery should be in place✴ Maternal plasma viral load & CD4 count should be taken at delivery✴ Women taking HAART should have their medication administered < or>
  16. 16. CONTINUE Management of DeliveryCaesarean Section✴ If IV ZDV indicated , the infusion should be started 4 hours before the beginning of the CS and and should continue until the U.C has been clamped✴ Good Haemostasis & avoid rupturing the membranes until the head is delivered through the surgical incision✴ Peripartum Antibiotics
  17. 17. CONTINUE Management of DeliveryPlanned Vaginal Deliverya Should only be offered to women taking HAART who have a viral load < 50 copies/mlb. when a women presents in labour her plan of carecare should be reviewed and recent vir.al loadresults should be confirmed as < 50 copies/mlc. HAART should be administered throughout labourd. Invasive procedures such as FBS & FSE are contra indicatede. If labour progress is normal amniotomy when delivery is imminentf. Amnitomy and possible use of oxytocin may considered for augmentationg. If instrumental delivery is indicated, low cavity forceps preferable to vacuum
  18. 18. CONTINUE Management of DeliveryPrelabour rupture of membranes at term✴Delivery should be expedited if: a. The viral load < 50 copies/ml b. No obstetrics contraindication AUGMENTATION MAY BE CONSIDERED✴ Broad-spectrum iv antibiotics should be administered if there evidence of genital tract infection or chorioamnionitis
  19. 19. CONTINUE Management of DeliveryProlonged pregnancy ✴Women on HAART ✴with plasma viral load < 50 copies/ml, the decision regarding induction of labour should be individualised ✴There is no contraindication to membrane sweep or to use of PGE2
  20. 20. CONTINUE Management of Delivery Vaginal Birth after caesarean section VBAC✴A trial of scar may be considered for a women on HAART whose plasma viral load is < 50 copies/ml
  21. 21. CONTINUE Management of DeliveryHIV diagnosed in Labour
  22. 22. CONTINUE Management of DeliveryHIV diagnosed in Labour Women diagnosed HIV positive during labour a. Paediatricians should be informed b. HIV physician urgent advise regarding optimum HAART c. Delivery by Caesarean Section, and where possible, this should be timed with respect to anti-retroviral administration
  23. 23. Postpartum Management of women who areHIV positive✴ Women should be given advise about formula feeding✴ An immediate dose of oral Cabergoline should be given to suppresslactation✴ Women taking HAART should have their medication administered✴ Guidance about contraception should be given✴ MMR & Varicella Zoster immunisation may be indicated, according to the CD4 lymphocytes count
  24. 24. BREAST FEEDING Replacement feedingIf no AFASS then exclusive breastfeeding for 6 months
  25. 25. Management of the Neonates✴ All neonates should be treated with anti-retroviral therapy within four hours of birth✴ Most neonates should be treated with ZDV monotherapy but those with at high risk of infection should be treated with HAART✴ Prophylaxis against PCP is recommended only for neonates at high risk of HIV infection✴ Infant should be tested at: 1 day, 6 weeks and 12 weeks “if all these tests are negative and the baby is not breast feeding= Neg”
  26. 26. Academic institutions and professional bodiesBritish HIV Association http://www.bhiva.orgChildren’s HIV Association http://chivauk.org/Collaborative HIV Paediatric Study (CHIPS) http://www.chipscohort.ac.uk/Royal College of Obstetricians and Gynaecologists http://www.rcog.org.uk/Royal College of Paediatrics and Child Health http://www.rcpch.ac.uk/British Paediatric Surveillance Unit http://bpsu.inopsu.com/Health Protection Agency http://www.hpa.org.uk/Health Protection Scotland http://www.hps.scot.nhs.uk/Institute of Child Health http://www.ich.ucl.ac.uk/University College London http://www.ucl.ac.uk/Charities and support organisationsTerrence Higgins Trust http://www.tht.org.uk/Positive Nation http://www.positivenation.co.uk/Positively UK http://www.positivelyuk.org/National AIDS Trust http://www.nat.org.uk/Body and Soul http://www.bodyandsoulcharity.org/HIV in young persons network (HYPNet) http://www.networks.nhs.uk/networks/page/873Neonates born to women who are HIV infected are reported to the National Study of HIVin Pregnancy and Childhood: http://www.nshpc.ucl.ac.uk

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