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HIV

The document discusses the implications of HIV in pregnancy, including transmission risks, management options, and treatment protocols for HIV-positive pregnant women. It highlights the importance of maternal well-being and prevention of vertical transmission, noting significant decreases in perinatal transmission rates since 2000. Additionally, it outlines antenatal testing strategies, antiretroviral therapy recommendations, and considerations for delivery and breastfeeding.

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10 views27 pages

HIV

The document discusses the implications of HIV in pregnancy, including transmission risks, management options, and treatment protocols for HIV-positive pregnant women. It highlights the importance of maternal well-being and prevention of vertical transmission, noting significant decreases in perinatal transmission rates since 2000. Additionally, it outlines antenatal testing strategies, antiretroviral therapy recommendations, and considerations for delivery and breastfeeding.

Uploaded by

kulshresthapoorvi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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HIV in Pregnancy and Childbirth

Dr. Anju Huria,


Professor & Head,
Deptt. of Obstetrics & Gynaecology,
Government Medical College & Hospital,
Chandigarh.
- AIDS first described in 1981

- Causative agent in RNA retro virus

HIV – 1

HIV – 2

Most cases worldwide due to HIV -1


Transmission

Sexual contract

Blood or blood – contaminated products

Vertical to fetus / baby from mother

- Intra uterine : 20% before 36 weeks, 50% 36 wks – to delivery


- During delivery : 30%
- Breast feeding : 30 – 40%

Risk of vertical transmission correlates with viral RNA levels


but not absolutely
Aims for pregnant HIV +ve women

- Maternal well being

- Prevention of vertical transmission


Perinatal transmission rates decreased

From 20 – 30% (1981 – 2000)

To 1 – 2% (2000 onwards)

www.WHO.int/hiv/topics/arv

In USA

100,000 women are infected – 6000 deliveries annually

19 million globally
GMCH Data

Total antenatal HIV +ve

2007 3963 11

2008 4052 05

2009 2920 09
Pregnancy

HIV testing - Universal testing and right of refusal

- Test with Enzyme Immuno Assay (EIA)

- Confirm with Western Blot if EIA is repeatedly reactive

Indeterminate W.B.

Repeat + test sexual partner


Effect of Pregnancy on HIV

No effect on HIV disease progression

No difference in CD4+ Lymphocytes


or

HIV RNA trajectory

or

Clinical AIDS rate with one / multiple pregnancies


Effect of HIV on pregnancy

In developing countries, studies have shown increase in


incidence of preterm birth

- Low birth weight

- IUGR

- Still births

- and Infant deaths

And risk was inversely proportional to CD4+ lymphocyte count.

Zidovudine monotherapy also associated with increased risk of


preterm birth and LBW babies.
Management Options

Ideal:
- Prepregnancy testing and counselling
- If positive and requiring therapy in non-pregnant state
- (CD4+ count < 350 cells / µl
HIV RNA level > 55000 copies /ml)
Should get therapy without Efavirenz. Pregnancy to be
delayed till HIV RNA levels undetectable .
Single factor most strongly related to perinatal transmission
is HIV RNA levels.
Maternal

It patient already HIV + diagnosed with criteria for ART (Anti-

retroviral therapy)

- CD4 count ≤ 350 µl

- HIV RNA 55000 copies / ml

ART (HAART) started / continued in 1st trimester with

pregnancy – safe drugs

Discontinue Efavirenz (teratogenic)


Antenatal Testing

In USA

- Opt out strategy for testing

- In India

- Opt in

If rate is ≥ in 1000 pregnancies, or patient is high-risk for HIV


HIV testing is to be repeated in 3rd trimester.
High risk for HIV

- Injection drug use

- Multiple sexual partners

- Suspected / known HIV + sexual partner

- Any other STD in patient


Antenatal Testing

- By ELISA

- Confirmation by Western Blot (in USA)

- Three tests (ELISA) in India


Antenatal / Prenatal

- If HIV + status found at pregnancy

- Counselling

- MTP is offered

- CD4+ lymphocyte testing and HIV RNA is done

- Baseline RFT & LFT

- Hb, TLC, DLC

- If criteria for treatment start therapy in 1st trimester


Antiretroviral Therapy

For Antiretroviral naive patients : (with CD4 < 350 & RNA

≥ 55000)

- 200 mg Lopinavir, 50 mg Ritonavir combination :

Ritomax forte 2 Cap. BD

Or

- Nelfinavir (250 mg tabs) 750 mg tds)

Plus

- Zidovudine Lamivudine combination


300 mg 150 mg
For all other pregnant women

Start in 2nd trimester

Zidovudine + Lamivudine 1 Tab. BD


300 mg 150 mg

Duovir (Rs. 205 for 10)

Combivir (Rs. 820 for 10)


This regime should contain Zidovudine

I/V zidovudine should be given during labour

If HIV RNA level < 1000 copies / ml then monotherapy with


Zidovudine can be given.

Do not chose Nevirapine if CD4+ count >250 as risk of


hepatotoxicity is very high.
Surveillance for

- Symptoms of nausea, vomiting, muscle cramps


- New symptoms every 2 – 4 weeks
- LFT and electrolytes every 2 – 4 weeks at beginning of
therapy (1 – 2 months)
- Then every month in 3rd trimester
- CD4+ lymphocyte count every 3 months during pregnancy
- HIV RNA levels every 4 weeks after starting therapy till
undetectable and then every 3 months (at least 1 log fall
after 4 – 8 weeks of starting therapy)
- GCT at 24 – 28 weeks as scheduled.
If patient first seen in Labour

- Rapid HIV test so that peripartum prophylaxis can be given

- Confirm later – W.B. or ELISA


Intrapartum

If detected only during labour

- Nevirapine 2 tabs to mother before delivery

- Nevirapine Syrup 2 mg / kg to baby after 48 hrs of birth

If patient already on Zidovudine & Lamivudine

I/V Zidovudine 2 mg / kg in one hour I / V

Then 1 mg / kg / hr infusion till delivery

Neonate : 2 mg / kg 6 hrly x 6 wks start 8 – 12 hrs after birth


Avoid during pregnancy and labour

- Amniocentesis

- Scalp electrode for fetal monitoring

- Early ARM

- Scalp blood testing


C.S. : C.S. reduces transmission (0.43 adjusted
odds ratio)

If done before labour and rupture of membranes


(ROM)

Transmission in C.S. = 1.8%

Vaginal delivery = 10.5%


Indications for LSCS

- If viral load unknown or

- > 1000 copies / ml at 36 wks gestation

- If she has not taken anti HIV medication during her


pregnancy

- Not had any prenatal care till 36 wks

- Should be done before rupture of membrane


Breast feeding

- Increases risk of transmission by 15 – 20%

- WHO recommendation for USA – avoid

- For developing countries

Encourage breast feeding if hygienic top feeding not feasible

- Should have exclusive breast feeding or exclusive top


feeds
Contraceptive options

- Barrier contraception

- IUCD if without severe immune compromise and low risk of


sexually transmitted infection.

- Hormonal contraception can be used sp depot provera


ART drugs reduce blood levels of estrogens so CoC pills
may not be effective and may cause break-through
bleeding

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