Management Of Hiv Positive Pregnant Woman

MANAGEMENT OF HIV POSITIVE PREGNANT WOMAN

G VINOD PRABHU

EFFECT OF HIV ON PREGNANCY • • • • • • • •

Spontaneous abortion Ectopic pregnancy Genital and urinary tract infections Abruptio placenta Pre term labour Pre mature rupture of membranes Low birth weight, still birth Post partum infections

EFFECT OF PREGNANCY ON HIV • Earlier believed to accelerate the progress of infection. Prospective studies have not confirmed findings • Decrease in CD4 and CD8 cell count following pregnancy not statistically significant

MOTHER TO CHILD TRANSMISSION • Europe and USA - 15 - 25% • African and Asian - 25 - 40% • occurs in utero, during labour and delivery, post natally through breast feeding • 90% infection in children • reduced to 2% by anti-retroviral therapy

FACTORS AFFECTING TRANSMISSION Viral

Load, Genotype and Phenotype,Resistance

Maternal

Immunological, nutritional and clinical status Behavioural factors, Antiretroviral Treatment

Obstetrical

Prolonged rupture of membranes, Mode of Delivery, Intrapartum haemorrhage, Obstetrical procedure, Invasive foetal monitoring

Foetal

Prematurity, Genetic,Mutiple pregnancy

Infant

Breast feeding, Gastrointestinal factors Immature immune system

STRATEGIES FOR PREVENTION • • • • •

Termination of pregnancy Behavioural interventions Therapeutic interventions Obstetric interventions Modification of infant feeding practises

BEHAVIORAL INTERVENTIONS • Reduction in the frequency of unprotected sexual intercourse during pregnancy • reduction in the number of sexual partners during pregnancy • life style changes including avoidance of drug abuse and smoking in pregnancy

THERAPEUTIC INTERVENTIONS • Anti retro viral therapy: zidovudine alone or in combination long- or short- regimen • vitamin A and other micro nutrients • immuno therapy • treatment of STI

OBSTETRIC INTERVENTIONS • Avoidance of invasive tests • birth canal cleansing • caeserian section delivery

MODIFICATION OF FEEDING PRACTISES • Avoidance of breast feeding • early cessation of brest feeding • heat treatment of expressed breast milk

VOLUNTARY HIV TESTING AND COUNSELLING IN PREGNANCY • • • •

Testing of ante natal women pre test counselling post test counselling counsellimg about pregnancy related issues

TESTING OF ANTENATAL WOMEN • Routine testing without consent or counselling unacceptable practice and disadvantages may negate benefit • Benefits of voluntary testing-early counselling and treatment ,preventing transmission to child and sexual partners, decisions on continuation of pregnancy and future fertility. • Best predictors of return for counselling -counsellor skills and time spent for counselling. • ELISA and WESTERN BLOT

PRETEST&POSTTEST COUNSELLING • Essential elements of management of HIV in pregnancy • Pretest enables to make informed decisions • post test is an integral part of management of HIV positive persons and provides oppurtunity for risk reduction for HIV negative persons

MANAGEMENT OF HIV POSITIVE PREGNANT WOMAN • • • • • • • •

Antenatal care obstetrical management examination and investigations medical treatment during pregnancy antiretroviral therapy care during labour and delivery post partum care care of neonate

ANTENATAL CARE • Asymptomatic and no major obstetrical problems • no need in increase in number of antenatal visits • counselling and support-integral part of management • advice on possible risks of unprotected intercourse

OBSTETRIC MANAGEMENT • Invasive diagnostic procedures, such as chorion villus sampling,amniocentesis orcordocentesis should be avoided • external cephalic version of a breech fetus can cause potential maternal- fetal circulation leaks

EXAMINATION AND INVESTIGATIONS • Full physical examination at first visit • signs of HIV related infections - TB, oral/vaginal thrush, lymphadenopathy • shingles - herpes zoster • co existent STD’s • weight monitoring, HB estimation, T cell investigation • viral load estimation - for prognosis

MEDICAL TREATMENT DURING PREGNANCY • Pregnancy not a CI for ARTbetter avoided in the first trimester • VIT A supplementation • anti malarials in highly endemic areas • prophylaxis of opportunistic infections - TB, PCP, other dermatological conditions

ANTI RETROVIRAL THERAPY • Long course zidovudine treatment AFTER 14 WKS - ORAL DURING LABOUR - IV NEONATES - FOR 6 WKS

• Short course zidovudine treatment 300 mg oral twice daily from 36 wks to onset of labour 300 mg every 3 hrs from onset to delivery • combination therapy with lamivudine

CARE DURING LABOUR AND DELIVERY • Avoid prolonged rupture of membranes • avoid routine episiotomy • forceps preferred to vacuum delivery, if assisted • increasing evidence that caeserian section prevents transmission

POST PARTUM CARE • Require private facilities to lessen the social stigma associated with not breast feeding • observe signs of infection - UTI, chest, episiotomy and caeserian section wound infections • instructions on perineal care • full discussion on care of babies and risks and benefits of infant feeding choices

CARE OF NEONATES • • • • •

Handle babies with gloved hands HB monitoring - anemia with zidovudine Hepatic transaminases elevation infant feeding - mother’s choice potential modifications include complete avoidance of breast feeding, early cessation, pasteurisation of breast milk, avoid feeding in the presence of breast abscesses or cracked nipples

REFERENCE • HIV in Pregnancy - A Review by WHO and JOINT UNITED NATIONS PROGRAMME on HIV/STD

THANK YOU