This document provides guidelines for managing HIV in pregnancy. It discusses screening all pregnant women for HIV and other infections. For HIV-positive mothers, it recommends prompt referral to a multidisciplinary team and starting combination antiretroviral therapy (cART) by 14 weeks of pregnancy to prevent mother-to-child transmission. The guidelines cover antenatal care, immunization, labor and delivery recommendations depending on viral load, and neonatal and postpartum management of HIV-positive mothers and exposed infants. The overall aim is to optimize care and reduce risk of HIV transmission through comprehensive antenatal and delivery protocols.
2. GUIDELINES FOR HIV IN
PREGNANCY
RCOG –GREEN TOP NO 39 MANAGEMENT OF HIV IN PREGNANCY
2010.
Malaysian Consensus Guidelines on Antiretroviral Therapy 2017
Sabah obstetric Shared Care Guidelines 2016.
SGH Labour Ward Manual 2016 Edition
3. HIV
(HIV) Human immunodeficiency virus is a retrovirus
that causes Acquired Immunodeficiency Syndrome
(AIDS)
Discovered in 1983
HIV has been divided into two primary strains
HIV-1 and HIV-2
HIV is a retrovirus that is believed to have evolved
from a simian immunodeficiency virus.
It is composed of two copies of positive single-
stranded RNA.
5. ETIOLOGY
The 3 main route of transmission is via;
o blood, blood products
o sexual contact
o mother to child in intrauterine infection, perinatal
transmission, or the mother’s milk.
6. Contents
Antenatal HIV management
Intrapartum HIV management
Postpartum HIV management
Neonatal HIV management
7. Antenatal screening
• All pregnant women are recommended screening for
HIV infection, syphilis, hepatitis B and genital infection.
• If a woman declines an HIV test, this should be
documented in the maternity notes, her reasons should
be sensitively explored and screening offered again at
around 28 weeks.
Rapid test has been selected as a screening test in
Malaysia.
A positive HIV rapid test result requires a confirmatory
test.
In high risk patients, a repeat test should be done after
12 weeks of the first test if the initial test is negative OR
before 36 weeks of gestation if the initial test is negative.
8. HIV positive mother
HIV positive mother should be referred promptly
for assessment and for their pregnancies to be
managed within a multidisciplinary team (HIV
physician, obstetrician, specialist midwife, health
advisor and paediatrician)
All women who are newly diagnosed HIV positive
should have an early assessment of their social
circumstances.
Women should be reassured that their
confidentiality will be maintained.
It is recommended that women with existing
children of unknown HIV status should have them
tested for HIV.
9. Notification if positive HIV
Under the Infectious Disease Act 342 (1988), health
care providers are legally bound to notify the local
health authority.
Women should be encouraged to disclose their HIV
status to their partner within two weeks.
Providers should recommend that their partners
receive HIV testing.
Health departments can assist patients by notifying,
counseling and providing HIV testing for partners
without disclosing the patient’s identity.
Advice about safer-sex practices and the use of
condoms, to prevent transmission of HIV and other
STDs.
12. Combination antiretroviral
therapy (cART)
Antenatal combination antiretroviral therapy (cART) is
now the recommended method for prevention of
maternal-to-child transmission (PMTCT).
cART must be started in all pregnant mothers who are
HIV+ regardless of CD4 count.
Ideally cART should be started at 14 weeks of
pregnancy. cART is still efficacious when started as late
as 28 weeks of pregnancy. The treatment of women
who start cART after week 28 must be discussed with an
ID physician. Strict adherence to cART must be stressed
throughout the pregnancy.
A viral load must be done between weeks 32-36 to
determine ongoing risk of transmission to the fetus. The
mode of delivery will also be determined by the result.
13. cART
Women with CD4 < 350
This group of women must be started on cART as soon as possible.
cART can be started even in the first trimester in women presenting with OIs or WHO
clinical stages 3 and 4. cART will be continued for life after delivery.
Women with CD4 > 350
These patients will also need cART for PMTCT. In this scenario commencement of cART
may be delayed until week 14 of pregnancy. Continuation of cART post-delivery
(Option B +) is recommended for patients with CD4 > 350 who are:
1. Motivated
2. In a serodiscordant sexual relationship
3. Unable to adhere to contraceptive methods
4. Co-infected with Hep B
5. Insist on breastfeeding
16. Clinical examination
Skin : dermatitis,folliculitis , kaposi sarcoma
Chest infection
Hepato—splenomegaly
Genital lesion and infection : herpes simplex and
carcinoma of cervix.
Laboratory monitoring
FBC, LFT, RP, ESR, CK (if on ZDV), IS, CD4 , VL and OGTT
(if on PI)
17. Antenatal care
Screening for Down syndrome and fetal
anomalies should be offered.
A detailed ultrasound scan for fetal anomalies
is important after first-trimester exposure to
HAART(exposed to potentially teratogenic
drugs)- between 18 + 0 and 20 + 6 weeks’
gestation ,In past theoretical increased risk of
anomaly due to first trimester ART exposure.
The combined screening (the ‘triple test’+ NT
scan)for trisomy 21 is recommended as this has
the best sensitivity and specificity and will
minimize the number of women who may need
invasive testing.
18. Immunization
Hepatitis B, pneumococcus and
influenza immunisation are
recommended for all individuals
who are HIV positive; these
immunisations can be safely
administered in pregnancy.
Varicella zoster and measles,
mumps and rubella vaccines are
contraindicated in pregnancy.
19. Women Who are Stable on cART Before
Pregnancy
In general the existing cART is to be continued
throughout pregnancy and after delivery.
Special effort must be made to determine the
current CD4 and Viral load during the early stages
of pregnancy.
Should the patient be experiencing virological
failure on her current regime, consultation with an ID
physician is strongly recommended.
20. Intrapartum Management of Women
Receiving cART During Pregnancy
In the past IV ZDV was recommended routinely for all women during
the intrapartum period regardless of viral load.
However current evidence suggests that intrapartum IV ZDV has no
additional benefit in prevention of vertical transmission in pregnant
women on cART with suppressed viral load.
21.
22.
23. Mode of delivery
A plan regarding mode of delivery should
be made at around 36 weeks following
detailed discussion with the mother
Pre-labor Elective Caesarean Section
(PLCS) at 38 weeks has been proven to
further reduce the risk of transmission. The
decision between performing PLCS or
allowing spontaneous vaginal delivery
(SVD) is based largely on the VL at 32-36
weeks of gestation and whether the
mother has received any ARVs in the
antenatal period.
24. Viral load at
32-36 weeks
Mode of
delivery
< 50 copies/ml May opt for
SVD
>50 copies/ml ELLSCS
25. ELLSCS
If intravenous ZDV is indicated, the infusion
should be started 4 hours before beginning the
caesarean section and should continue until
the umbilical cord has been clamped.
The surgical field should be kept as
haemostatic as possible and care should be
taken to try to avoid rupturing the membranes
until the head is delivered through the surgical
incision. The cord should be clamped as early
as possible after delivery.
A maternal sample for plasma viral load and
CD4 lymphocyte count should be taken at
delivery.
26. SVD
Only women with a plasma viral load of less than 50
copies/ml should be offered a planned vaginal
delivery.
Women taking HAART should continue their usual oral
HAART regimen through labour.
Invasive procedures such as fetal blood sampling and
fetal scalp electrodes are contraindicated.
If labour progress is normal, amniotomy should be
avoided unless delivery is imminent.
Amniotomy and possible use of oxytocin may be
considered for augmentation of labour.
If instrumental delivery is indicated, the use of forceps is
preferable to ventouse.
27. Women Who Present in Labour
With No Prior ARV Exposure
Urgent advice should be sought from the HIV physicians regarding
optimum HAART; delivery should be by caesarean section
For the woman who is diagnosed with HIV infection in labor who
has not received prior ARVs, start IV ZDV infusion (2mg/kg for the 1st
hour followed by 1mg/kg/h subsequently) immediately.
ART should be commenced immediately with fixed-dose AZT and
3TC with Raltegravir as the preferred 3rd agent because it rapidly
crosses the placenta. If Raltegravir is not available, NVP or EFV
should be used. After delivery, the ART can be switched to
recommended first line ART regimen for non-pregnant patients.
The Pediatrician caring for the newborn must be notified to ensure
appropriate post exposure ARV prophylaxis for the infant.The HIV
exposed infant should receive 6 weeks of oral zidovudine and 3
doses of nevirapine at birth, 48 hours later and 96 hours after the
2nd dose.
32. Preterm delivery
Initial assessment.(Hx , PE and IX)
The multidisciplinary team should be involved so that a clear
plan of care.
Indications for steroids apply.
A genital infection screen should be undertaken.
Tocolysis may be initiated as appropriate.
Urgent advice-from the HIV physicians and paediatricians
about the choice of anti-retroviral therapy. Infants born below
32 weeks of gestation are at increased risk of HIV but may be
unable to tolerate oral medication.
Anti-retroviral therapy administered to the mother just before
and during delivery will provide prophylaxis for the neonate
33. PPROM in HIV
PPROM-Before 34 weeks –decision as to whether to
expedite delivery should be made after
multidisciplinary team consultation, involving the HIV
physicians and paediatricians.
Steroids should be administered in the usual way.
Genital infection screening
Oral erythromycin should be started
Consider IV broad-spectrum antibiotics.
Evidence of chorioamnionitis and fetal distress are indications for prompt
delivery.
In other cases, the multidisciplinary team discussion will consider the
adequacy of maternal HAART, plasma viraemia and the presence of any
other pregnancy or HIV-related comorbidities. The timing of delivery will
take into consideration the risk of complications associated with
prematurity, the availability of neonatal facilities and the risk of perinatal
HIV transmission.
34. PPROM in HIV
PPROM After 34 weeks
delivery should be expedited.
A genital infection screen should be
undertaken and consideration should be given
to starting intravenous broad-spectrum
antibiotics.
At this gestation, the small risk of neonatal
morbidity and mortality associated with
prematurity is outweighed by the risk to both
mother and neonate of chorioamnionitis and
the risk of perinatal HIV transmission.
35. PROM in HIV
delivery should be expedited.
Broad-spectrum intravenous antibiotics should be
administered if there is evidence of genital infection
or chorioamnionitis.
36. VBAC in HIV
A trial of scar may be considered for women taking
HAART whose plasma viral load is less than 50
copies/ml.
Scar rupture occurs in approximately 1/250 (0.004%)
women who labour after a previous caesarean
section.
37. How should women diagnosed in
late pregnancy but before the
onset of labour be managed?
Women diagnosed with HIV late in pregnancy should
have a rapid multidisciplinary team assessment and
HAART should be commenced as soon as possible.
With improved turnaround times for viral load testing, a
woman diagnosed HIV positive beyond 32
weeks may still have her pregnancy managed with a
view to planned vaginal delivery if she
commences HAART and achieves a viral load of less
than 50 copies/ml by 36 weeks. If the viral load
is greater than 50 copies/ml at 36 weeks, she should be
scheduled for an elective caesarean section
at 38 weeks, should continue her HAART regimen and
be given intravenous ZDV at delivery.
38. Postpartum and Prepregnancy
management
Breastfeeding contraindicated
Cabergoline 1mg
Couples who are serodiscordant for HIV infection and who choose
to have sexual intercourse should be advised to use condoms.
Serodiscordant couples 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.
Couples are recommended to delay conception until plasma
viraemia is suppressed, prophylaxis against PCP is no longer
required and any opportunistic infections have been treated.
Folate supplementation should be administered.
All women who are HIV positive are recommended to have yearly
cervical cytology.
High risk factors include
Women whose past or present sexual partners were HIV infected,
bisexual or IVDU
• Women seeking treatment for sexually transmitted disease (STD)
• Commercial sex worker.
• Women with past or present history of intravenous drug use
• Women with history of blood transfusion before 1986
• Unprotected vaginal or anal intercourse with more than one sex partner.
Bacterial vaginosis is associated with around a two-fold increased risk of preterm delivery & have been shown to stimulate HIV in vitro.
Delivery by elective caesarean section at 38 weeks to prevent labour and/or ruptured membranes is
recommended for:
– women taking HAART who have a plasma viral load greater than 50 copies/ml
– women taking ZDV monotherapy as an alternative to HAART
– women with HIV and hepatitis C virus coinfection.
Single dose NVP for the mother is not necessary. Giving intrapartum Nevirapine to the mother may select for resistance to NNRTIs and limit future ARV options.
In a meta-analysis of studies conducted before the advent of HAART, rupture of membranes for more
than 4 hours is associated with a doubling of the risk of HIV transmission. These studies also demonstrated
a 2% incremental increase in transmission risk for every hour of ruptured membranes up to 24 hours.
Whether scar rupture in HIV infected women is associated with an increased risk of transmission
from prolonged fetal exposure to maternal blood is unknown but, in women taking HAART with a
plasma viral load of less than 50 copies/ml, this risk is likely to be very low indeed.
