Management of HIV in Pregnancy
Management of HIV in Pregnancy. The learning objectives are first, to understand the requirement for antenatal, intrapartum, and postpartum intervention in the management of HIV positive pregnant women in a multidisciplinary setting. And secondly, to have comprehensive knowledge on the interventions available to reduce vertical transmission from mother to child at all stages of pregnancy. The incidence of HIV infection in Singapore has doubled over the past 10 years. Heterosexual transmission remains the most common route of acquiring this infection. According to statistics, women of the reproductive age are most at risk of becoming infected with HIV. This will in turn increase the risk of perinatal, or mother to child transmission.
The risk of mother to child transmission of HIV ranges from 20% to 40% without any intervention. From 1985 to 2011 And there were 31 recorded cases in Singapore. Testing for HIV in the antenatal period should be offered to all women, regardless of disciplines at risk for infection. In Singapore, initial screening tests for the presence of HIV antibodies in maternal blood.
If HIV antibodies are detected, the same blood sample is sent for confirmatory Western blot tests. If a woman is tested positive, there should be prompt referral to a joint care service, [INAUDIBLE] a consultant in high-risk obstetrics and an infectious disease physician. The initial booking visit assessment should include a thorough history and physical examination. The main objective is to assess for opportunistic infections and advanced HIV, which may compromise both maternal and fetal health. It is also important to identify any modifiable behavior-- such as concomitant illicit drug use, or continuing sexual intercourse with multiple partners-- so that relevant counseling may be performed. System specific clinical examination include fundoscopy, abdominal, neurological, and pelvic examination. Determining gestational age with dating scan is crucial, as early delivery may be necessary to reduce the risk of perinatal transmission.
Important screening tests specific to HIV in pregnancy include CD4 cell count-- which is the major determinant of the approach to antiretroviral therapy-- also a HIV viral load is required. This should be repeated every trimester to monitor the response therapy or to detect indications for therapy. Other screening tests that are important include hepatitis C-- due to the shared route of transmission and increased risk of vertical transmission with HIV co-infection-- a baseline titer of CMV and Toxoplasma would be useful as well. Other tests include mycobacterium tuberculosis, screening for sexually transmitted infections including syphilis, chlamydia, and gonorrhea.
A test for bacterial vaginosis is also recommended. Prophylaxis of opportunistic to infections, especially pneumocystis carinii pneumonia, is the same as in non-prime adults. The CD4 cell count of less than 200 cells per millimeters cubed is recommended. Pentamidine is the preferred drug in during the first trimester, due to its lack of systemic absorption and reduced risk of teratotoxicity.
In the second and third trimester, Bactrim or Dapsone is preferred. Regarding prenatal diagnosis, the risk of vertical transmission during CVS or amniocentesis is uncertain. If prenatal diagnosis it's contemplated, consult with a fetal maternal specialist. A HIV physician should be sought and prophylaxis with highly active antiretroviral therapy should be considered. Antiretroviral therapy can be implemented in a three-stage process during the antepartum, intrapartum, and postpartum period. In the antenatal period, all HIV positive women should be offered Anti-Retroviral Therapy, or ART, only after the first trimester to reduce the risk of a drug induced teratogenicity. A regiment of two nucleoside reverse transcriptase inhibitors and one protease inhibitor or non-nucleoside reverse transcriptase inhibitor, reduces the risk of vertical transmission to less than 1%.
The mode of delivery is based on the viral load measured during the 36 weeks of gestation, and also the choice of ART use in the antenatal period. In general, women on ART with a viral load of less than 50 copies per mL, may be offered a normal vaginal delivery. Women who should be recommended a Caesarean delivery include those who have a viral load greater than 50 copies per mL despite being on ART. Those who are on Zidovudine monotherapy, and those who have concomitant hepatitis C infection are also recommended to undergo elective Caesarean section. Other interventions that have been shown to reduce the risk of vertical transmission to the baby include avoidance of invasive fetal monitoring in labor, the use of intrapartum IV Zidovudine, and early cord camping after delivery. In the postpartum period, women should be advised not to breast feed and given supportive advice on formula feeding.
All neonates who are at high risk of transmission include those born to mothers with high viral load greater than 1,000 copies per mL despite ART, mothers whose diagnosis was made only after delivery, mothers who received only intrapartum ART, and those of known drug resistant HIV. In summary, HIV positive pregnant women should be managed with a multidisciplinary team with interventions aimed at reducing perinatal infection at three stages-- antenatally, during the intrapartum and postpartum period. The three proven interventions that can reduce mother to child transmission are an elective Caesarean section, three drug combination antiretroviral therapy, and abstinence from breastfeeding.
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