HIV AND PREGNANCYHIV AND PREGNANCY

By Dr.Dharmesh G Patel (M.D.Obs & Gyn.)

HISTORY

AIDS(Acquired Immunodeficiency Syndrome) was first found in male homosexual in 1981 in USA

In India,first HIV infection was reported in 1986 from prostitute in Chennai.India has the largest HIV population in the world compared to any single nation.

States with high prevalence of India include Tamilnadu,Maharashtra,Karnataka,Andhra Pradesh & Manipur.

MODES OF TRANSMISSION

Sexual contact with an infected partner.Most common mode of transmission

Blood born- Infected blood & blood products

Parenteral Transmission- Sharing infected needles

Occupational exposure- By needle stick injury or contamination with patient’s blood or body fluids.Perinatal Transmission- From the infected mother to the fetus or newborn.

HIV Screening during Pregnancy

Why:-

ART reducing the perinatal transmission

How :-

All the antenatal patients should undergo HIV testing

It cannot be made compulsary

It should not be done for any patient without prior counselling and consent

Advantages of HIV screeingAdvantages of HIV screeing

Patient can choose the option of MTP.Patient can choose the option of MTP. Planned optimal care if continuation of pregnancy.Planned optimal care if continuation of pregnancy. Implementation of strategies to reduce risk of fetal Implementation of strategies to reduce risk of fetal

transmission.transmission. Future planning can be done by couples.Future planning can be done by couples.

Disadvantages of HIV screeningDisadvantages of HIV screening

Psychological trauma- reduced by counselling.Psychological trauma- reduced by counselling. Risk of social isolation.Risk of social isolation. Risk of marital disharmony.Risk of marital disharmony.

Effects of HIV on pregnancyEffects of HIV on pregnancy

Spontaneous abortion Spontaneous abortion Preterm labour and preterm babiesPreterm labour and preterm babies IUGRIUGR Perinatal mortalityPerinatal mortality

Incidence of perinatal transmission :-

15 to 35%

Transmission of HIV-2 is less frequent(1-4%) than for HIV-1(14-35%)

Perinatal TransmissionAntepartum transmission :- across the placenta

Intraparturm transmission :- during delivery as mentioned below

• direct contact with maternal blood &vaginal secretions while passing through the birth canal.•Ascending infection from the vagina or cervix to the fetal membranes & amniotic fluid•Absorption in fetal neonatal digestive tract,•Maternal fetal microtranfusion during uterine coutractions in labour,

Postpartum transmission :- through breast feeding

10-50%

40-80%

10-20%

Risk factors of transmissionRisk factors of transmission

High viral loadHigh viral load Low CD4 countLow CD4 count Placental abruptionPlacental abruption Vit. A deficiencyVit. A deficiency Invasive fetal monitoringInvasive fetal monitoring Vaginal delivaryVaginal delivary Maternal P24 antigenemiaMaternal P24 antigenemia Other STDs presenceOther STDs presence Preterm delivaryPreterm delivary Advanced maternal ageAdvanced maternal age Memberanes ruptured >4 hrsMemberanes ruptured >4 hrs Breast feedingBreast feeding

Management of HIV in pregnancyAntepartum :-

• Most patients will be asymptomatic.• Patient requires obsteric care + HIV care. Consult HIV specialist.• MTP option is offered.• Nutritional supplement including micronutrients.• Routine antenatal investigation + Baseline CBC, LFT,RFT.• Investigations of STDs, TB, Toxoplasmosis, Cytomegalovirus.• CD4 count & vital load in each trimester. If CD4 count < 200, prophylactic

Antibiotics are indicated.• Counsel against unprotected coitus.• USG- Routine + Fetal well being assessment.• Avoid invasive procedures.

Anti Retroviral Therapy(ART)Anti Retroviral Therapy(ART)

1. ACTG 076 regimen:-(AIDS Clinical Trial Group)

Zidovudine(AZT)

Reduction of transmission:- 25.5% to 8.3%

2. CDC Thai regimen :-

Zidovudine(AZT)

Reduction of transmission:- 50%

3.HIV NET 012 regimen:-

Nevirapine

Reduction of transmission:- 47%

4. PETRA study:-Zidovudine(AZT) + Lamuvidine(3TC)

Reduction of transmission :- 69%

ACTG 076 regimenACTG 076 regimen

Antepartum : oral AZT 100 mg 5times a day starting anytime from 14-34 wks & continued till delivery.

Intrapartum : I/V AZT 2mg/kg. over 1 hour then 1 mg/kg/hour from onset of labour until delivery.

Postpartum : To the neonate, 2mg/kg birth weight every 6 hours for 6 weeks beginning 8-12 hours after birth.

CDC Thai regimen :

Antepartum : Oral AZT 300 mg twice daily starting at 36 wks gestation.

Intrapartum : Oral AZT 300 mg every 3 hourly from onset of labour till delivery.

HIV NET 012 regimen :

NVP 200 mg tablet at the onset of labour. NVP 2 mg/kg (single dose) to the newborn within 72 hours of birth.

PETRA study :

Post exposure prophylaxis with triple therapy for 4 weeks. AZT 200 mg tid + Lamivudin 150 mg bid + indinavir 800 mg tid.

Universal work precautionsUniversal work precautions

Wear double gloves, goggles, plastic apron, long gown, Wear double gloves, goggles, plastic apron, long gown, mask, cap & overshoes (gum boots).mask, cap & overshoes (gum boots).

Protection from blood & amniotic fluid splash.Protection from blood & amniotic fluid splash. Minimal use of needles & sutures.Minimal use of needles & sutures. If needle stick injury occurs, remove the gloves, let the If needle stick injury occurs, remove the gloves, let the

injury site bleed, wash it throughly with soap & water & injury site bleed, wash it throughly with soap & water & start Zidovudine prophylaxis 1 to 2 hours of injury as per start Zidovudine prophylaxis 1 to 2 hours of injury as per protocol.protocol.

Proper disinfevtion of gowns, gloves, masks, caps, goggles Proper disinfevtion of gowns, gloves, masks, caps, goggles & shoes. This is advised even if they are disposable. & shoes. This is advised even if they are disposable. Immediate immersing in bleaching powder solution is Immediate immersing in bleaching powder solution is recommended.recommended.

Eventhrough delivery may be allowed in the same labour Eventhrough delivery may be allowed in the same labour from proper disinfection of floor, labour table & mattresses from proper disinfection of floor, labour table & mattresses or rubber used, is also done.or rubber used, is also done.

Proper disposal of blood, placenta, cord & deadbody (SB) Proper disposal of blood, placenta, cord & deadbody (SB) by incineration.by incineration.

INTRAPARTUM MANAGEMENTINTRAPARTUM MANAGEMENT

Elective LSCS reduces perinatal transmission upto 50-80%.Elective LSCS reduces perinatal transmission upto 50-80%. When labour has started or membranes have ruptured When labour has started or membranes have ruptured

LSCS still debated.LSCS still debated. LSCS may increase the morbidity to immunocompromised LSCS may increase the morbidity to immunocompromised

mother.mother. During Delivery:- During Delivery:-

• to take precaution for personal safety,to prevent spread,to decrease perinatal transmission.• Avoid ARM• Avoid Vaginal tears• Avoid Instrumental delivery• Restrict Episiotomy• Avoid fetal scalp electrode/ fetal blood sampling

POSTPARTUM MANAGEMENTPOSTPARTUM MANAGEMENT

Wash newborn after birth,especially face.Wash newborn after birth,especially face. Mouth suction is avoided,no mouth to mouth breathingMouth suction is avoided,no mouth to mouth breathing Avoid hypothermiaAvoid hypothermia Anti Retroviral Therapy (ART)Anti Retroviral Therapy (ART) All vaccines are given to asymptomatic children.While only All vaccines are given to asymptomatic children.While only

inactivated vaccines are recommended for symptomatic inactivated vaccines are recommended for symptomatic childrenchildren

New born testingNew born testingELISA TEST false positive upto 18 months

Before that to consider newborn positive 2 tests must be positive from

HIV 1 culture,p-24 antigen,PCR

BREASTFEEDINGBREASTFEEDING

Risk of transmission :- 10 to20%

Developing countries there is more risk of neonatal death due to Infectious diarrhoea and dehydration in bottlefed babies.

Also apart from it other advantages of BF to mother and child

So, WHO recommened that breastfeeding to be given to the child born from mother who is HIV positive