Hiv and other infection in preg

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Hiv and other infection in preg

  1. 1. HIV and other infectious diseases affecting pregnancy DR NAZIMAH IDRIS Obstetrician & Gynecologist Hospital Alor Setar
  2. 2. • • • • HIV URINARY TRACT INFECTIONS HEPATITIS B GROUP B STREPTOCOCCUS
  3. 3. HIV • Magnitud of problem • Vertical transmissions • How does HIV and pregnancy affect each other • Our role in managing HIV infected pregnancies
  4. 4. AIDS IN MALAYSIA- A BRIEF HISTORY 18th April 1985 AIDS Task Force was established 22nd May 1985 AIDS gazetted as notifiable disease. April 1986 Screening of blood/blood products Dec. 1986 First documented case of AIDS
  5. 5. May 1988 AIDS - Plan of Action published HIV & AIDS - Info. for Health Professionals 8th Sept. 1988 Prevention & Control of Communicable Disease Act ( Act 342 ) was gazetted. HIV (all forms) requires notification 1989 HIV Screening of inmates in Correctional Institutions
  6. 6. 1992 - Ministerial level committee on AIDS was established. - Reorganization of AIDS Task Force Formation of 2 advisory committee i. National Technical Committee ( Chairman: DG) a. Patient’s Management sub-com. b. Prevention & Control sub-com. ii. National Coordinating Committee (Chairman: Secretary General, MOH)
  7. 7. Sept. 1993 AIDS/STD Section was created within the Disease Control Division of Public Health - To Coordinate National AIDS Programme 1993 Malaysian AIDS Council (MAC) was established - initiated by Ministry of Health Jan 1994 Guideline for the Clinical Management of HIV Infection in Adults
  8. 8. 15 Mac 1994 - Non-Nominal Notification of STDs & AIDS - New Notification Form was introduced April/May 1994 HIV Sentinel Surveillance among AN mothers / STD cases / TB Cases April 1995 AIDS Series 1-6 was published
  9. 9. TABURAN KES HIV/AIDS MALAYSIA, 1986 -1998 JUMLAH HIV : 28, 541 4500 JUMLAH AIDS : 2, 354 NUMBER OF HIV INFECTION 4000 1000 900 800 3500 700 3000 600 2500 500 2000 400 1500 300 1000 200 500 100 0 HIV AIDS 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 0 0 3 1 2 0 9 2 200 2 778 18 1794 2512 2507 3393 4198 4597 3924 4624 60 73 71 105 233 347 568 875 YEAR 0 NUMBER OF AIDS CASES 5000
  10. 10. Taburan Kumulatif Kes HIV/AIDS & Kematian 1989-1998 Negeri Kedah Mengikut Faktor Risiko (N=1725) Ibu-Bayi 1% P/Darah 0% T/Tahu 3% Homo/Bi 3% S/Dadah 82% Hetero 11%
  11. 11. Case 1 • 28 year-old G1P0, rapid screening positive, confirmed with Western Blot • Infection acquired from husband, IVDU, passed away • Seen at 18W, started AZT 300 mg bd • CD4 count: 448 • Now at 32W, mum and fetus doing well
  12. 12. Case 2 • 35 y/o G5P4 diagnosed HIV positive through antenatal screening • Infected through husband, former IVDU • Both went into depression, needed psychiatric care • Started treatment • Delivered vaginally at term • Status of baby pending
  13. 13. Magnitude of problem • • • • • • • • No. of people living with HIV/AIDS : 33.5m 95% in developing countries 16.4m women with HIV 16.3m people have died so far since beginning of epidemic 11m children orphaned 800 000 children infected with HIV yearly 90% of children get it from their mother (UNIAIDS/WHO Report on global HIV/AIDS epidemic, June 2001)
  14. 14. Prevalence of HIV in antenatal mothers • • • • Nigeria : 2.4% London : 0.19% Where are we? 0.03%(Japaraj et al, 1999)
  15. 15. Rates of vertical transmission • • • • • Europe : 20% USA : 30% Africa : 40% Malaysia : ? Can occur at any time during pregnancy, 60-75% during intrapartum, esp. with prolonged rupture of membrane, use of scalp electrodes, forceps, chorioamnionitis.
  16. 16. Rates of vertical transmission with treatment • PACTG 076 (1994) : AZT reduces vertical transmission rate from 25.5% to 8.3% • Perinatal HIV Group (1999) : AZT + LSCS reduces it further to 2% • McGowan (1999), Cooper ER (2000) : HAART causes more complete and durable viral suppression – reduces vertical transmission to 2%
  17. 17. How does HIV and pregnancy affect each other? • Pregnancy and HIV do not adversely affect each other, but…
  18. 18. • Advanced HIV disease in developing countries was associated with higher rates of adverse pregnancy outcomes, fetal mortality was mainly related to fetal HIV infection • In developed countries, no such phenomena observed (BJOG, 1998)
  19. 19. • Pregnancy has not been demonstrated to adversely impact the course of HIV infection • No rise in viral load or drop in CD4 count • Lymphocyte count may decrease
  20. 20. Managing HIV infected pregnancy • • • • • • • Confirm the diagnosis Counseling of couple Decision to terminate? Starting treatment Monitoring maternal and fetal wellbeing Labour and delivery After birth
  21. 21. Confirm the diagnosis • Detect HIV antibody – Western Blot • Detect Antigen – Viral culture, HIV DNA PCR, p24 antigen assay, HIV RNA PCR
  22. 22. Counseling of couple • • • • • By a knowledgeable staff Private area Maintain confidentiality Issues: Risk of disease to mother and fetus, risk of infection to partner • How to optimize management to get the best outcome • Social issues
  23. 23. Treatment • Consider: • Potential effects of the drug on the fetus and newborn • Adjustment in dosing and choice of drug in view of pregnancy • The effect of choice of drug on long-term effect of disease i.e. resistance
  24. 24. Goals of treatment • To preserve current and future health of mother • Prevent perinatal transmission • Ensure health of fetus and neonate
  25. 25. The treatment • National Consensus Guidelines on Antiretroviral therapy: Three part regimen of AZT • Antepartum: AZT 200 mg tds at 14-34W till delivery • Intrapartum: IV AZT 2 mg/kg in first hour, 1 mg/kg until delivery. Substitute with oral AZT 300 mg 3H if IV not available
  26. 26. Cont… • Induction of labour : Begin AZT at time of induction • Elective LSCS : Begin AZT 4H before surgery • Postpartum : Baby: Syrup AZT 2mg/kg 6H, begins 8-12H after birth, cont. for 6 weeks • Postpartum : Mother : Reassess treatment. To stop or start HAART.
  27. 27. Monitoring - Mother • Clinical – general wellness(Karnofsky score), opportunistic infection, drug side effects, drug compliance • CD4/CD8 cell count – 3 to 6mthly • Viral load assays – first done after 2 mths Rx, expect 2 log reduction (100 fold) by 2mths, rpt. 3 mthly or earlier • Others: FBC, LFT, Renal fx, ESR, CK, serum amylase
  28. 28. Monitoring - fetus • As in others
  29. 29. Labour & Delivery • Vaginal vs El. LSCS • Vaginal – risk of transmission, esp. with poor management • Elective LSCS – able to reduce transmission rate, but increases risk to mother and staff
  30. 30. Cont. • To reduce transmission during vaginal delivery: • Start IV therapy • Avoid prolonged exposure to maternal body fluid – delay ARM, dry the baby after birth • Avoid invasive procedure – fetal scalp electrode, instrumentation, episiotomy
  31. 31. After delivery • Baby – start Rx, no breastfeeding, Paeds follow-up • Mother – review treatment, physician follow-up
  32. 32. Other infections • Hepatitis B • Urinary tract infections • Group B Streptococcus
  33. 33. Hepatitis B • Course of disease not affected by pregnancy • Risk of transmission to fetus and health staff • Fetal transmission : more if mother with acute hepatitis in late pregnancy or carrier of HBVe antigen • Highly contagious, hazard of blood borne transmission during attendance at delivery, 30x more than HIV.
  34. 34. • 1 ml of blood from hepatitis B infected person may contain up to 100 million infectious viral particles as compared to HIV which ranges from few hundred to about 10, 000 • Dried blood - HBV may remain viable for up to 1 week whereas the amount of HIV would have been reduced up to 90 - 99% • Get immunized!
  35. 35. Hepatitis B • Screening • Antenatal Mx
  36. 36. Screening • • • • Universal vs selective At risk : -at risk of HIV -exposed to blood products, self or partners • -prison inmates, self or partners • -acute or chronic liver dis., self or partners
  37. 37. Pregnancy management • • • • Obstetrically, as in any other patients Contact tracing Counseling on risk to fetus The baby: HBV immunoglobulin at birth, concurrent immunization with vaccine, repeat at 1st and 6th month of age
  38. 38. Urinary tract infections • Significant risk factor for Low Birth Weight infants and prematurity • Pregnancy changes in urinary tract -> urinary reflux -> UTI • Asymptomatic bacteriuria : 5-9%, if untreated, 15-45% develop acute cystitis and pyelonephritis
  39. 39. Should we screen for asymptomatic bacteriuria? Universal screening Vs Selective screening -hx of LBW babies -hx of premature labour -other at risk patients e.g. diabetics
  40. 40. Group B Streptococcus • Clinical significance: causes preterm delivery, neonatal sepsis and neonatal death • Can be found in up to 1/3rd of pregnant women • 1/3rd infants colonized • Of these, <1% develop early onset disease • USA: 1600 cases, 80 deaths annually, leading cause of infection-related death in newborns in USA
  41. 41. Screening for GBS • Method: Vaginal swabs, diagnostic kit using latex particles coated with antibody • Problems with detection: • -only 10% of organisms are recovered from swabs • -single swab is inadequate – cervical swabs detects 30%, anorectal swab 80% • -carriage is intermittent • -need to swab more than once to increase isolation rates
  42. 42. Cont. • To prevent one case of early onset neonatal GBS disease, 3000 women need to be screened, 1000 treated. • Screening at present not justified • Future: screening to detect specific antibodies against GBS antigens, vaccine to induce antibody formation
  43. 43. THANK YOU

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