This document discusses the case of a 25-year-old HIV-positive pregnant woman. It provides background on her diagnosis and treatment history, as well as the management of her current pregnancy. Key points include planning a cesarean delivery at 38 weeks given her undetectable viral load on antiretroviral therapy. The newborn will receive post-exposure prophylaxis with nevirapine and exclusive formula feeding is recommended to prevent HIV transmission through breastfeeding. Testing of the newborn will occur within 48 hours and at intervals through 18 months to monitor HIV status.

1. HIV IN PREGNENCY
A Case Based
Discussion
Dhammike Silva

3. BACKGROUND…
50%

4. BACKGROUND…
25%
• 1/3 Late
• CD4 count <
200 cells/ml
at the time of
diagnosis

5. BACKGROUND…
anti-retroviral drugs has transformed the management
since 1990s
restoration of immune function
increasing life expectancy
renders viral loads undetectable
reduces infectivity.

6. BACKGROUND…
2011
WHO
Mother to
child
1993 - 25.6%
2007- 2011-
0.57%

7. Viral load of >100,000 copies/ml - 40 %
1000 copies/ml - 1%
At undetectable VL (<50 copies/ml) - < 1%

8. 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

9. 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

10. 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

11. 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

12. CASE MX - ANTENATAL
Started on ART ( Tenofovir, Emtricitabine, Efavirenz
since 2015)
No interruption
Even while fasting

13. 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.

14. 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

15. 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

16. 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

17. Table
preparati
on

18. Protective
Kits

19. Waste
disposal

20. 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)

21. 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

22. 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.

23. 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

24. 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)

25. 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

26. CASE- MX OF NEWBORN

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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)

35. 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

36. 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

37. ETHICS…

38. THANK YOU ……..