1. HIV and other infectious diseases
affecting pregnancy
DR NAZIMAH IDRIS
Obstetrician & Gynecologist
Hospital Alor Setar

2. •
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HIV
URINARY TRACT INFECTIONS
HEPATITIS B
GROUP B STREPTOCOCCUS

3. HIV
• Magnitud of problem
• Vertical transmissions
• How does HIV and pregnancy affect each
other
• Our role in managing HIV infected
pregnancies

5. AIDS IN MALAYSIA- A BRIEF
HISTORY
18th April 1985
AIDS Task Force was established
22nd May 1985
AIDS gazetted as notifiable disease.
April 1986
Screening of blood/blood products
Dec. 1986
First documented case of AIDS

6. May 1988
AIDS - Plan of Action published
HIV & AIDS - Info. for Health Professionals
8th Sept. 1988
Prevention & Control of Communicable
Disease Act ( Act 342 ) was gazetted.
HIV (all forms) requires notification
1989
HIV Screening of inmates in
Correctional Institutions

7. 1992
- Ministerial level committee on AIDS was
established.
- Reorganization of AIDS Task Force
Formation of 2 advisory committee
i. National Technical Committee
( Chairman: DG)
a. Patient’s Management sub-com.
b. Prevention & Control sub-com.
ii. National Coordinating Committee
(Chairman: Secretary General, MOH)

8. Sept. 1993
AIDS/STD Section was created within the
Disease Control Division of Public Health
- To Coordinate National AIDS Programme
1993
Malaysian AIDS Council (MAC) was
established - initiated by Ministry of
Health
Jan 1994
Guideline for the Clinical Management of
HIV Infection in Adults

9. 15 Mac 1994
- Non-Nominal Notification of STDs & AIDS
- New Notification Form was introduced
April/May 1994
HIV Sentinel Surveillance among AN
mothers / STD cases / TB Cases
April 1995
AIDS Series 1-6 was published

10. TABURAN KES HIV/AIDS
MALAYSIA, 1986 -1998
JUMLAH HIV : 28, 541
4500
JUMLAH AIDS : 2, 354
NUMBER OF HIV INFECTION
4000
1000
900
800
3500
700
3000
600
2500
500
2000
400
1500
300
1000
200
500
100
0
HIV
AIDS
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
0
0
3
1
2
0
9
2
200
2
778
18
1794 2512 2507 3393 4198 4597 3924 4624
60
73
71
105 233 347 568 875
YEAR
0
NUMBER OF AIDS CASES
5000

11. Taburan Kumulatif Kes HIV/AIDS & Kematian
1989-1998 Negeri Kedah Mengikut Faktor Risiko
(N=1725)
Ibu-Bayi
1%
P/Darah
0%
T/Tahu
3% Homo/Bi
3%
S/Dadah
82%
Hetero
11%

12. Case 1
• 28 year-old G1P0, rapid screening positive,
confirmed with Western Blot
• Infection acquired from husband, IVDU,
passed away
• Seen at 18W, started AZT 300 mg bd
• CD4 count: 448
• Now at 32W, mum and fetus doing well

13. Case 2
• 35 y/o G5P4 diagnosed HIV positive
through antenatal screening
• Infected through husband, former IVDU
• Both went into depression, needed
psychiatric care
• Started treatment
• Delivered vaginally at term
• Status of baby pending

14. Magnitude of problem
•
•
•
•
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No. of people living with HIV/AIDS : 33.5m
95% in developing countries
16.4m women with HIV
16.3m people have died so far since beginning of
epidemic
11m children orphaned
800 000 children infected with HIV yearly
90% of children get it from their mother
(UNIAIDS/WHO Report on global HIV/AIDS
epidemic, June 2001)

15. Prevalence of HIV in antenatal
mothers
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•
•
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Nigeria : 2.4%
London : 0.19%
Where are we?
0.03%(Japaraj et al, 1999)

16. Rates of vertical
transmission
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•
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Europe : 20%
USA : 30%
Africa : 40%
Malaysia : ?
Can occur at any time during pregnancy,
60-75% during intrapartum, esp. with
prolonged rupture of membrane, use of
scalp electrodes, forceps, chorioamnionitis.

17. Rates of vertical transmission
with treatment
• PACTG 076 (1994) : AZT reduces vertical
transmission rate from 25.5% to 8.3%
• Perinatal HIV Group (1999) : AZT + LSCS
reduces it further to 2%
• McGowan (1999), Cooper ER (2000) :
HAART causes more complete and durable
viral suppression – reduces vertical
transmission to 2%

18. How does HIV and pregnancy
affect each other?
• Pregnancy and HIV do not adversely affect
each other, but…

19. • Advanced HIV disease in
developing countries was
associated with higher rates of
adverse pregnancy outcomes,
fetal mortality was mainly
related to fetal HIV infection
• In developed countries, no
such phenomena observed
(BJOG, 1998)

20. • Pregnancy has not been demonstrated to
adversely impact the course of HIV
infection
• No rise in viral load or drop in CD4 count
• Lymphocyte count may decrease

21. Managing HIV infected
pregnancy
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•
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Confirm the diagnosis
Counseling of couple
Decision to terminate?
Starting treatment
Monitoring maternal and fetal wellbeing
Labour and delivery
After birth

22. Confirm the diagnosis
• Detect HIV antibody – Western Blot
• Detect Antigen – Viral culture, HIV DNA
PCR, p24 antigen assay, HIV RNA PCR

23. Counseling of couple
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By a knowledgeable staff
Private area
Maintain confidentiality
Issues:
Risk of disease to mother and fetus, risk of
infection to partner
• How to optimize management to get the best
outcome
• Social issues

24. Treatment
• Consider:
• Potential effects of the drug on the fetus and
newborn
• Adjustment in dosing and choice of drug in
view of pregnancy
• The effect of choice of drug on long-term
effect of disease i.e. resistance

25. Goals of treatment
• To preserve current and future health of
mother
• Prevent perinatal transmission
• Ensure health of fetus and neonate

26. The treatment
• National Consensus Guidelines on
Antiretroviral therapy: Three part regimen
of AZT
• Antepartum: AZT 200 mg tds at 14-34W
till delivery
• Intrapartum: IV AZT 2 mg/kg in first hour,
1 mg/kg until delivery. Substitute with oral
AZT 300 mg 3H if IV not available

27. Cont…
• Induction of labour : Begin AZT at time of
induction
• Elective LSCS : Begin AZT 4H before
surgery
• Postpartum : Baby: Syrup AZT 2mg/kg 6H,
begins 8-12H after birth, cont. for 6 weeks
• Postpartum : Mother : Reassess treatment.
To stop or start HAART.

28. Monitoring - Mother
• Clinical – general wellness(Karnofsky score),
opportunistic infection, drug side effects, drug
compliance
• CD4/CD8 cell count – 3 to 6mthly
• Viral load assays – first done after 2 mths Rx,
expect 2 log reduction (100 fold) by 2mths, rpt. 3
mthly or earlier
• Others: FBC, LFT, Renal fx, ESR, CK, serum
amylase

29. Monitoring - fetus
• As in others

30. Labour & Delivery
• Vaginal vs El. LSCS
• Vaginal – risk of transmission,
esp. with poor management
• Elective LSCS – able to
reduce transmission rate, but
increases risk to mother and
staff

31. Cont.
• To reduce transmission during vaginal
delivery:
• Start IV therapy
• Avoid prolonged exposure to maternal body
fluid – delay ARM, dry the baby after birth
• Avoid invasive procedure – fetal scalp
electrode, instrumentation, episiotomy

32. After delivery
• Baby – start Rx, no breastfeeding, Paeds
follow-up
• Mother – review treatment, physician
follow-up

34. Other infections
• Hepatitis B
• Urinary tract infections
• Group B Streptococcus

35. Hepatitis B
• Course of disease not affected by pregnancy
• Risk of transmission to fetus and health staff
• Fetal transmission : more if mother with acute
hepatitis in late pregnancy or carrier of HBVe
antigen
• Highly contagious, hazard of blood borne
transmission during attendance at delivery, 30x
more than HIV.

36. • 1 ml of blood from hepatitis B infected person
may contain up to 100 million infectious viral
particles as compared to HIV which ranges
from few hundred to about 10, 000
• Dried blood - HBV may remain viable for up to
1 week whereas the amount of HIV would have
been reduced up to 90 - 99%
• Get immunized!

37. Hepatitis B
• Screening
• Antenatal Mx

38. Screening
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Universal vs selective
At risk :
-at risk of HIV
-exposed to blood products, self or
partners
• -prison inmates, self or partners
• -acute or chronic liver dis., self or
partners

39. Pregnancy management
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Obstetrically, as in any other patients
Contact tracing
Counseling on risk to fetus
The baby: HBV immunoglobulin at
birth, concurrent immunization with
vaccine, repeat at 1st and 6th month of age

40. Urinary tract infections
• Significant risk factor for Low Birth Weight
infants and prematurity
• Pregnancy changes in urinary tract ->
urinary reflux -> UTI
• Asymptomatic bacteriuria : 5-9%, if
untreated, 15-45% develop acute cystitis
and pyelonephritis

41. Should we screen for
asymptomatic bacteriuria?
Universal screening
Vs
Selective screening
-hx of LBW babies
-hx of premature labour
-other at risk patients e.g.
diabetics

42. Group B Streptococcus
• Clinical significance: causes preterm delivery,
neonatal sepsis and neonatal death
• Can be found in up to 1/3rd of pregnant women
• 1/3rd infants colonized
• Of these, <1% develop early onset disease
• USA: 1600 cases, 80 deaths annually, leading
cause of infection-related death in newborns in
USA

43. Screening for GBS
• Method: Vaginal swabs, diagnostic kit using latex
particles coated with antibody
• Problems with detection:
• -only 10% of organisms are recovered from swabs
• -single swab is inadequate – cervical swabs
detects 30%, anorectal swab 80%
• -carriage is intermittent
• -need to swab more than once to increase isolation
rates

44. Cont.
• To prevent one case of early onset neonatal
GBS disease, 3000 women need to be
screened, 1000 treated.
• Screening at present not justified
• Future: screening to detect specific
antibodies against GBS antigens, vaccine to
induce antibody formation

45. THANK YOU