Hiv in pregnancy by zharif


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*I hope its help you all for preparation part 1 exam for MRCOG & MOG and your daily job.Good Luck May ALLAH bless our work and study,Good luck to all.dont forget to pray to ALLAH.if i wrong please correct me..process of learning..

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Hiv in pregnancy by zharif

  2. 2. HIV (HIV) Human immunodeficiency virus is a lentivirus (a member of the retrovirus family) 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. Group - Group VI (-ssRNA) Family - Retroviridae Genus - Lentivirus It is composed of two copies of positive single-stranded RNA.
  3. 3. STRUCTURE HIV HIV is different in structure from other retroviruses.
  4. 4. 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.
  5. 5. GUIDELINES FOR HIV IN PREGNANCY  RCOG –GREEN TOP NO 39 MANAGEMENT OF HIV IN PREGNANCY 2010  British HIV Association guidelines for the management of HIV infection in pregnant women 2012(NICE)
  6. 6. Guidelines  Objectives  to increase in the proportion of vaginal deliveries and a reduction in the number of emergency CS.  To reduce the risk of MTCT  Contents  Antenatal HIV management  Intrapartum HIV management  Postpartum HIV management  Neonatal HIV management
  7. 7. Antenatal management  Recommended to have screening for HIV infection in every pregnancy at their booking antenatal visit. - can prevent mother-to- child transmission and significantly improve their own health.  women who are HIV positive should be referred promptly for assessment and for their pregnancies to be management within a multidisciplinary team.  If a woman declines screening, her reasons should be explored sensitively to ensure that she has received accurate information on which to base her decision.  Involvement of a senior health professional should be considered. The decision to decline screening should be documented in the maternity notes and screening offered again at around 28 weeks
  8. 8. Multidisciplinary team HIV positive patients should be managed by a multidisciplinary team.  HIV physician  an Obstetrician  a Midwife  a Paediatrician  a Psychiatric team  support groups “Confidentiality is important.& an early assessment of their social circumstances.”
  9. 9. HIV test  Rapid HIV tests are recommended for women with unknown HIV status who present in labour and a reactive result should be acted on immediately  HIV screening test at 26 weeks of gestation or later, an urgent request should be made and the result issued by the laboratory with 24 hours.
  10. 10. ADVICE  Safer sex practice-use condom  Appropriate support  To screen others children and partners who unknown HIV status
  11. 11. 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
  12. 12. Invasive prenatal diagnosis  The risk of mother-to-child transmission with chorionic villus sampling or second-trimester amniocentesis hasn’t been estabilished.  If invasive prenatal diagnosis is contemplated, the advice of the fetal medicine specialist and HIV physician should be seeked and prophylaxis with HAART considered.  Invasive prenatal diagnostic testing should not be performed until after HIV status of the mother is known and should be ideally deferred until HIV VL has been adequately suppressed  Where possible, amniocentesis should be deferred until VL is <50 HIV RNA copies/mL
  13. 13. Recommended • All pregnant women who are HIV positive should be screened for syphilis, hepatitis B,C & other genital infection • When to do ? • This should be done as early as possible in pregnancy • repeated at around 28 weeks. • Bacterial vaginosis is associated with around a two-fold increased risk of preterm delivery & have been shown to stimulate HIV in vitro. • HIV positive taking HAART at the time of booking should be screened for gestational diabetes.
  14. 14. Antiretroviral therapy  Aims:  prevention of mother-to-child transmission  treatment of the mother to prevent maternal disease progression  The decision to start,modify or stop anti-retroviral therapy  should be undertaken by an HIV physician  in close liaison with other health professionals  obstetrician  paediatrician.
  15. 15.  All pregnant HIV positive women should be advised to take antiretroviral therapy:  a) For women who require HIV treatment for their own health, their prescribed HAART regimen should be continued throughout pregnancy and postpartum.  b) For women who do not require HIV treatment for their own health, HAART should be initiated between 20 and 28 weeks and discontinued at delivery.  c) For women who do not require HIV treatment for their own health, have a viral load less than 10 000 copies/ml and are prepared to be delivered by elective caesarean section, an acceptable alternative to HAART is zidovudine monotherapy initiated between 20 and 28 weeks, given orally twice daily, intravenously at delivery and discontinued immediately thereafter
  16. 16.  Timing  Antenatally  Intrapartum  Neonatal period(4-6 weeks)  Choice of antiretroviral therapy & Timing is decided by HIV physician.  Plasma viral load & CD4 counts regularly monitored.  Patients on antiretroviral therapy should be monitored for toxicity  full blood count  urea and electrolytes  liver function tests- Hepatoxicity  Lactate –(Lactic acidosis)  blood glucose-GDM
  17. 17.  In women who commence HAART in pregnancy a VL should be performed 2–4 weeks after commencing HAART, at least once every trimester, at 36 weeks and at delivery  presented with an opportunistic infection, initiation of HAART should not be delayed.  Treatment is indicated based on CD4 cell count only,  Treatment to the start of the second trimester is reasonable, particularly if the patient is experiencing nausea and/or vomiting of pregnancy
  18. 18. Type of ARV drug  Nucleoside reverse transcriptase inhibitors (NRTI) and nucleotide reverse transcriptase inhibitors (NtRTI)  deoxythymidine, zidovudine, stavudine, didanosine, zalcitabine, abacavir, lamivudine, emtricitabine, and tenofovir.[6]  Non-Nucleoside reverse transcriptase inhibitors (NNRTI)  nevirapine, delavirdine, efavirenz, and rilpivirine.[6]  Integrase inhibitors  Raltegravir &Elvitegravir.[3]  Protease inhibitors  Lopinavir, Indinavir,Nelfinavir, Amprenavir and Ritonavir. Maturation inhibitors
  19. 19. Nucleoside reverse transcriptase inhibitors (NRTI) and nucleotide reverse transcriptase inhibitors (NtRTI)  nucleoside and nucleotide analogues which inhibit reverse transcription. NRTIs are chain terminators such that once incorporated, work by preventing other nucleosides from also being incorporated because of the absence of a 3’ OH group. ; they both act as competitive substrate inhibitors  Zidovudine monotherapy can be used in women planning a CS who have a baseline VL <10 000 HIV RNAcopies/mL and CD4 cell count >350 cells/mL.  Emtricitabine is structurally similar to lamivudine but has a longer half-life
  20. 20. Non-Nucleoside reverse transcriptase inhibitors (NNRTI)  inhibit reverse transcriptase by binding to an allosteric site of the enzyme; NNRTIs act as non-competitive inhibitors of reverse transcriptase. NNRTIs affect the handling of substrate (nucleotides) by reverse transcriptase by binding near the active site and causing “molecular arthritis”  Efavirenz-earlier it contraindication in pregnancy  Report:{3 offspring of 20 the first trimester had significant abnormalities at birth: one had anencephaly and unilateral anophthalmia; the second microphthalmia; and the third a cleft palate}  On current evidence, that efavirenz can be used in pregnancy.
  21. 21. Integrase inhibitors  Inhibit the enzyme integrase, which is responsible for integration of viral DNA into the DNA of the infected cel
  22. 22. Protease inhibitors  block the viral protease enzyme necessary to produce mature virions upon budding from the host membrane. Particularly, these drugs prevent the cleavage of gag and gag/pol precursor proteins  Is are highly protein-bound and placental transfer in humans appears to be limited
  23. 23. HAART  regimens consist of three(3) drugs: 2 NRTIs + 1 PI/NNRTI/II  UK are now rarely prescribed zidovudine as part of HAART  zidovudine plus lamivudine, tenofovirplus emtricitabine or abacavir plus lamivudine are acceptable nucleoside backbones  the efficacy of HAART in pregnancy are based on a three/four-drug combination, including a zidovudine/lamivudine backbone  In the absence of specific contraindications, it is recommended that the third agent in HAART should be efavirenz or nevirapine (if the CD4 cell count is <250 cells/mL) or a boosted PI
  24. 24. Zidovudine Vs START Zidovudine START may allow the emergence of resistant virus maternal plasma viraemia is more likely to be suppressed to undetectable levels exposure of the mother and fetus to larger numbers of potentially toxic drugs
  25. 25.  No routine dose alterations are recommended for ARVs during pregnancy if used at adult licensed doses  third-trimester TDM if combining tenofovir and atazanavir  should have commenced ART by week 24 of pregnancy  combination of zidovudine, lamivudine and abacavir can be used if the baseline VL is <100 000 HIV RNA copies/mL plasma  If the VL is unknown or >100 000 copies/mL a three- or four-drug regimen that includes raltegravir is suggested
  26. 26. HBV infection  All HBV/HIV coinfected women should receive HAART containing tenofovir with emtricitabine or lamivudine unless contraindicated  Combining lamivudine/emtricitabine with tenofovir may also reduce the risk of breakthrough HBV viraemia  CD4 cell count is <500 cells/mL, HAART should be continued postpartum  CD4 cell count is >500 cells/mL and there is no other indication to treat HBV, consideration should be given to continuing anti-HBV treatment postpartum with HAART incorporating tenofovir and emtricitabine  If a decision is taken to discontinue therapy,careful monitoring of liver function is imperative, there is HBV viraemia and evidence of liver inflammationor fibrosis, HAART containing tenofovir and emtricitabine should be continued
  27. 27.  In the absence of obstetric complications, normal vaginal delivery can be recommended if the mother has fully suppressed HIV VL on HAART  Neonatal immunization with or without HBIG should commence within 24 h of delivery
  28. 28. HCV  On diagnosis of new HCV infection, confirmation of HCV viraemia with quantitative VL and genotype,assessment of hepatic inflammation and function and concomitant liver disease should be performed.  LFTs should be repeated at 2 weeks after commencingHAART to detect evidence of hepatotoxicity  Coinfected mothers with HCV should not be treated for HCV with pegylated interferon with or without ribavirin and all women who discover they are pregnant while receiving treatment should discontinue both pegylated interferon and ribavirin immediately.  HCV antiviral therapy is contraindicated in pregnant women due to possible teratogenicity  In all non-immune HCV coinfected women after the first trimester, vaccination against HBV is recommended
  29. 29. Failure to suppress  Treatment of HAART during pregnancy has not achieved a plasma VL of <50 copies/mL at 36 weeks the following interventions are recommended: • Review adherence and concomitant medication. • Perform resistance test if appropriate. • Consider TDM. • Optimize to best regimen. • Consider intensification.  these interventions should be undertaken as soon as possible
  30. 30. Intrapartum management  Mode of delivery  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 VL >400 HIV RNA copies/mL regardless of ART  Vaginal delivery can be offered to women taking HAART with plasma viral loads of less than 50 copies/ml.  Elective caesarean section for obstetric indications or maternal request should be delayed till 39-40 completed weeks of gestation in women with plasma viral loads of less than 50 copies/ml, to reduce the risk of transient tachypnoea of the newborn. “A plan regarding mode of delivery should be made at around 36 weeks following detailed discussion with the mother”
  31. 31. LSCS  A zidovudine infusion  should be started four hours before beginning the caesarean section  Should continue until the umbilical cord has been clamped.  A maternal sample for plasma viral load and CD 4 should be taken at delivery.  The cord should be clamped as early as possible after delivery and the baby should be bathed immediately after the birth.  a technique of ‘bloodless’ caesarean section may further reduce the risk of mother-tochild transmission.  opening the uterus with a staple gun,which simultaneously cuts and giveshaemostasis.
  32. 32.  This should be sheduled at 38 weeks to reduce the risk of spontaneus labour or membrane rupture.  Contamination of the baby with maternal blood should be avoided  Secure the bleeding points  Cord clamped as soon as possible  Not to rupture membrane till fetal head out  Drainage should be used and they should be used to closed suction system  Universal precautions :gloves, aprons & face protection should be employed.
  33. 33. VBAC  VBAC should be offered to women with a VL <50 HIV RNA copies/Ml
  34. 34. In Labour  planned vaginal delivery should have their membranes left intact for as long as possible (ARM if have indication)  Use of fetal scalp electrodes and fetal blood sampling should be avoided.  Women should continue their HAART regimen throughout labour .  If an intravenous infusion of zidovudine is required it should be commenced at the onset of labour and continued until the umbilical cord has been clamped.  A maternal sample for plasma viral load should be taken at delivery.  The cord should be clamped as early as possible after delivery and the baby should be bathed immediately after the birth.
  35. 35. Vaginal delivery  Forceps preferred to Vacuum  Remove maternal blood stain with alcohol wipe prior to Vitamin K injection  Universal precautions :gloves, aprons & face protection should be employed.  Amniotomy and possible use of oxytocin may be considered for augmentation of labour.
  36. 36. Preterm delivery  Initial assessment  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  a single dose of oral nevirapine (200 mg) given at least 2 hours before delivery,  a double dose of oral tenofovir (600 mg) and intravenous ZDV.
  37. 37. SROM in HIV  SROM-spontaneus rupture of Membranes  ruptured membranes for more than four hours , associated with double the risk of HIV transmission.  These studies also demonstrated a 2% incremental increase in transmission risk for every hour of rupturedmembranes up to 24 hours.  The relevance of these studies for women taking HAART who have undetectable viral loads is uncertain.  delivery should be expedited.  should be given to startingintravenous broad-spectrum antibiotics.
  38. 38. PPROM in HIV  PPROM-preterm prelabour rupture of membranes  If there is preterm rupture of membranes, with or without labour, the risk of HIV transmission should be set against the risk of preterm delivery.  Preterm infants are more likely to be infected with HIV.  To the use of short-term steroids to promote fetal lung maturation.  Oral erythromycin -accordance with national guidelines and consideration should be given to starting intravenous broad-spectrum antibiotics.  Evidence of chorioamnionitis and fetal distress are indications for prompt delivery.  Less 34/52 – multidiscipline team involvement and obstetric indication for decision time of delivery  After 34/52- delivery expedited
  39. 39. ECV  ECV can be performed in women with HIV ECV should be offered to women with a VL <50 copies/mL and breech presentation at >36 + 0 weeks in the absence of obstetric contraindications
  40. 40. Induction  previously been avoided as there were concerns about the duration of ruptured membranes and risk of MTCT but recent evidence would appear to be reassuring on this point
  41. 41. Late diagnose & unknown HIV status  Rapid multidisciplinary team assessment and HAART should be commenced ASAP  vaginal delivery if she commences HAART and achieves a viral load of less than 50 copies/ml by 36 weeks.  elective caesarean section at 38/52 -If the viral load is greater than 50 copies/ml at 36 weeks  Diagnosed during labour, urgent advice should be sought from the HIV physicians regarding optimum HAART; delivery should be by caesarean section and, wherepossible, should be timed with respect to anti- retroviral administration.  HAART regimen(intravenous ZDV and oral nevirapine (an anti-retroviral with rapid placental transfer and of proven benefit in reducing transmission)  delivery should be timed to be at least 2 hours after administration of nevirapine
  42. 42.  An untreated woman presenting in labour at term should be given a stat dose of nevirapine 200 mg and commence fixed-dose zidovudine with lamivudine and raltegravir.  It is suggested that intravenous zidovudine be infused for the duration of labour and delivery.
  43. 43. Postpartum management  women with HIV advised not to breast feed  Neonate infections.  PCR is done as maternal antibodies cross the placenta  Typically, tests are carried out at birth, then at three weeks, six weeks and six months.  definitive test is the HIV antibody test: a negative result at 18 months of age confirms that the child is uninfected.  should receive guidance about contraception in the immediate postpartum period.
  44. 44. Management of the neonate  All infants born to women who are HIV positive should be treated with anti-retroviral therapy from birth.  Usually treatment is discontinued after four to six weeks  Zidovudine monotherapy is recommended if maternal VL is <50 HIV RNA copies/mL at 36 weeks’ gestation or thereafter before delivery (or mother delivered by CS while on zidovudine monotherapy).
  45. 45.  There are two situations where triple combination ART for neonates is advised: (i) Post-delivery infant-only prophylaxis: mother found to be HIV positive after delivery, which is only effective if given within 48–72 h of birth  (ii) Detectable maternal viraemia (>50 HIV RNA copies/mL) at delivery, mother may be on HAART or not: • delivery before complete viral suppression is achieved (e.g. starting HAART late or delivery premature); • viral rebound with or without resistance, with or without poor adherence; • unplanned delivery ( e.g. premature delivery before starting ART or late presentation when maternal HIV parameters may be unknown).  Infants <72 h old, born to untreated HIV-positive mothers
  46. 46. Recommendation for for HIV-infected mother in labor who had no prior therapy 1. Single dose Nevirapine during labor and a single dose to the neonate at age 48h. 2. Intrapartum AZT, the 6 weeks of AZT to the neonate.(2mg/kg 4 times daily) 3. The two dose Nevirapine combined with the intrapartum and 6 weeks AZT regimen.
  47. 47.  IN case of maternal HIV antiretroviral resistance: AZT is still recommended to the infant, plus other medications based on maternal HIV resistance pattern.
  48. 48. Neonatal care  HIV DNA PCR (or HIV RNA testing) should be performed on the following occasions:  _ During the first 48 h and before hospital discharge.  _ 2 weeks post infant prophylaxis (6 weeks of age).  _ 2 months post infant prophylaxis (12 weeks of age).  _ On other occasions if additional risk (e.g.breastfeeding).  HIV antibody testing for seroreversion should be checked at age 18 months.
  49. 49. PCP  PCP prophylaxis, with co-trimoxazole, should be initiated from age 4 weeks in: • All HIV-positive infants • In infants with an initial positive HIV DNA/RNA test result (and continued until HIV infection has been excluded). • Infants whose mother’s VL at 36 weeks’ gestational age or at delivery is >1000 HIV RNA copies/mL despite HAART or unknown (and continued until HIV infection has been excluded).
  50. 50. 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. Women testing immunoglobulin G negative for these infections should be considered for immunisation postpartum, depending on their CD4 count
  51. 51. Continuation of ARV  ARV therapy should be continued in all pregnant women who commenced HAART with a history of an AIDS-defining illness or with a CD4 cell count <350 cells/mL  ART should be continued in all women who commenced HAART for PMTCT with a CD4 cell count of between 350 and 500 cells/mL during pregnancy who are coinfected with HBV or HCV  ART should be discontinued in all women who commenced HAART for PMTCT with a CD4 cell count >500 cells/mL unless there is discordance with her partner or co-morbidity
  52. 52. Prepregnancy management  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 in accordance with national guidelines. For women taking cotrimoxazole, higher dose folate (5 mg) should be administered.  All women who are HIV positive are recommended to have yearly cervical cytology.
  53. 53. THANK YOU