5. BACKGROUND…
anti-retroviral drugs has transformed the management
since 1990s
restoration of immune function
increasing life expectancy
renders viral loads undetectable
reduces infectivity.
8. TRANSMISSION TO
NEWBORN
Intact placenta acts as a very effective barrier
MTCT at the point of delivery is the commonest mode of
transmission
RISK FACT- high viral load at delivery, prolonged rupture of
membranes, prematurity, vaginal laceration, vaginal ulceration due to
herpes simplex infection or syphilitic ulcers, episiotomy, invasive fetal
monitoring and instrumental delivery
Post-partum exclusively due to breast feeding - up to 40% of
9. CASE HISTORY
25 yrs, P2 C0
MF 2.5 yrs
Husband- works at a saloon, denied extramarital affairs, 3 tattoos +
Index case- had an affair 5 yrs back with a three wheel driver, he was
diagnosed to have HIV + in 2016
P1 –
2 months following marriage, not aware about HIV status
12 wk of POA HIV AB done, report not available
T1 developed UTI & herpes zoster
10. CASE HISTORY
P1-
Premature delivery at 34/52, 1950 g
PBU for 11 days
Following 2/12 vaccination infant develop PUO
At SCBU THK, HIV AB became +
1/52 following diagnosis infant died due to severe pneumonia at Peradeniya
Hospital. (11/11/2015)
Soon after mother and father both diagnosed HIV +
2/12 following ( Jan 2016) mother started on ART
11. CASE HISTORY
Monthly regular follow up & on ART
five months following became pregnant while on ART
LMP - 15/5/2016
EDD – 22/2/2017
antenatal and STl regular follow- December/Jan both viral count
undetectable
at 38+5 admitted for EL/LSCS as decided
EFW 2489 g, AFI & Doppler normal
Anaesthetic & neonatology referrals arranged on admission
12. CASE MX - ANTENATAL
Started on ART ( Tenofovir, Emtricitabine, Efavirenz
since 2015)
No interruption
Even while fasting
13. ANTENATAL
STI screening yearly - The British HIV Association (BHIVA)
Twice during pregnancy – 1st & 3rd trimesters
chlamydia, syphilis, hepatitis, gonorrhoea and herpes
could potentially be transmitted
Test of cure should be performed following treatment for
any bacterial STI’s
Whooping cough vaccine and vitamin D should be offered
to women regardless of their HIV status.
14. ART
Viral load of less than 50 copies/ml (undetectable) and
who do not breast feed - 0.5% chance of transmitting the
virus
Should commence ART by 24 POG
Each week of ART reduces the odds of transmission by
8%
MTCT are lower in women who became pregnant on ART
Different types of ART used do not influence the rate of
15. ANTENATAL PROCEDURES
RR of HIV transmission of 1.9 with antenatal procedures
like
Amniocentesis
Cerclage
laser therapy
Amnioscopy
(The French Paediatric HIV Infection Study Group )
ART regimen including raltegravir (associated with rapid
viral load suppression) should be given along with single
dose of nevirapine 2-4 hours prior to the procedure
16. CASE MX - MOD
EL/LSCS at 38 POG
MDT – Con. Venereologist, Obstetrician, Anaesthetist,
Peadiatrcian
Sister/ Nursing officer of Infection control unit, OT, ICU
Spinal /Epidural not CI
Antibiotic routine prophylaxis
ARV without interruption on day of LSCS
20. MOD
Historically a planned EL/ LSCS was the method of
choice for delivery
Effective control of viral load with ART more and
more women having vaginal deliveries.
Decision regarding MOD - after review of viral load at
36 weeks.
Planned vaginal delivery is recommended for
women on ART with an undetectable viral load in
the absence of obstetric complications (BHIVA guidelines)
21. MOD
MTCT rates of <0.5% in women with plasma viral
load <50 cp/ml taking ART, irrespective of MOD
(Published cohort data from the UK and other
European countries )
viral load is > 400 copies/ml at 36 weeks a planned
caesarean section is recommended regardless of the
ART agents
22. TOD
The timing of LSCS is a balance between …
Where the indication is to prevent MTCT, at 38-39 weeks
Women with an undetectable viral load and ROM at term - should
have immediate IOL
risks of
transient
tachypnoea
of the
newborn
labour
occurring
before the
scheduled
caesarean
section.
23. INTRAPARTUM CARE
There are theoretical reasons why a low traction
forceps may be preferred to a ventouse delivery (with
potential lower rates of fetal trauma)
- no data /evidence
Use of fetal scalp electrodes/fetal blood sampling ,
safe if viral load undetectable
24. LATE PRESENTERS…
If a woman presents after 28 weeks and is
subsequently found to be infected with HIV - should
start treatment without delay.
If a woman presents in labour & not on treatment,
should be given a stat dose of nevirapine ( rapidly
crosses the placenta , effective concentrations are
achieved within 2 hours and then maintained in the
neonate for up to 10 days)
25. CASE- MX OF NEWBORN
Clean the eyes with saline at delivery
Clamp cord as soon as possible
Cover umbilical cord with a swab- prevent blood
spurting
Avoid suction baby’s mouth & pharynx
Towel dry, bath as soon as possible, done at theatre
27. NEONATAL POST EXPOSURE
PROPHYLAXIS
Antiretroviral treatment to the newborn is an example of
preexposure prophylaxis
should be decided before the delivery
The choice of the drugs given to the baby depends on the
mother’s antiretroviral drug history and known resistance
mutations
Monotherapy is usually sufficient, should be given for 4
weeks
28. CASE – NEONATAL PEP
Syrup nevirapine started daily
Dosing according to BW
As soon as possible, 1st dose given at theatre
Once daily for 6 weeks
29. NEONATAL POST EXPOSURE
PROPHYLAXIS
2 situations where triple combination (i.e. ART) neonatal
PEP is advised:
mother is found to be HIV positive after delivery (whereby treatment needs
given within 72 hours),
when there is detectable maternal viraemia at birth.
In addition Pneumocystis pneumonia (PCP) prophylaxis
should be started at 4 weeks-
all HIV infected infants
infants with an initial positive HIV DNA/RNA test
infants whose mothers viral load at 36 weeks or delivery is >1000 copies/ml
30. BREAST FEEDING
Women who breast feed may transmit HIV
There may be wide variations between plasma and
breast milk viral load
Risk high if–
viral load in plasma and breast milk is high,
premature delivery
breastfeeding is prolonged
nipples are cracked
31. BREAST FEEDING
Current standard of care in the UK is to avoid
breastfeeding in HIV positive mothers
Mixed feeding is thought to double the risk of HIV
transmission secondary to inflammation of gut
32. CASE MX- BREAST FEEDING
Mother agreed on exclusive formula feeding
Educated in maintaining sterility in preparation
Cabergoline to mother
Messures to prevent mastitis & breast abscess formation
Mother is provided separate container to discard breast milk
Should discard as clinical waste
33. CASE- NEWBORN TESTING
2 cc blood, EDTA bottle
Within 24 hours
Sent for RNA PCR
Sample send to reference laboratory, national STD/AIDS
control programme, Colombo
34. TESTING OF INFANTS
All infants born to HIV positive mothers should be tested
for HIV
HIV DNA PCR (or HIV RNA testing however this may
require more blood volume to test) should be performed
during the first 48 hours
2 weeks post infant prophylaxis (6 weeks of age)
2 months post infant prophylaxis (12 weeks of age)
35. TESTING OF INFANTS
HIV antibody testing for seroreversion (loss of maternal
antibodies) should be performed at age 18 months.
Diagnosis of in utero transmission can be made by the
identification of proviral DNA through amniocentesis or from
the cord blood/newborns blood sample at birth
36. IMUNIZATION…
BCG vaccination delayed, until HIV status ascertain at 8
weeks
At age of 2,4,6 months- hexavalent which include IPV is
preferred
Other schedule as routine