Pmtct

OVERVIEW OF PREVENTION OF MOTHER TO CHILD TRANSMISSION (PMTCT) IN UNIVERSITY OF PORT HARCOURT TEACHING HOSPITAL. GOAL OF PMTCT To generate information for the formulation of national policy and a

comprehensive PMTCT intervention in Nigeria.

To critically appraise and reduce MTCT of HIV in Nigeria. Identification and Support of HIV infected pregnant women

and their families – access to care. Anti retroviral therapy strategy to reduce maternal viral load and

subsequent reduction in the fetus.

Modification of obstetric practices. Modification of breast feeding practices

. Continuity of care for infected women and their families, proper

follow up for infant.

FACTS ON MTCT 10-30% During Pregnancy, 1.3 Million Children living with HIV/AIDS worldwide. -40-60% Delivery -15-20% Breastfeeding Generally MTCT rates are 15-20% in developed countries (BMS) and 39-45% in developing countries (Mixed Feeding Transmission rates globally in absence of ARV 14 – 40% with ARV 2-15%

PREVENTION STRATEGIES Obstetric Factors  Duration of membrane rupture >4 hours related to doubling risk of MTCT.  Elective caesarean section in meta-analysis and randomized trial associated with 50% reduction in MTCT (French study).  Beckermann’s group in California in 2002 queried the place of routine use of Elective Caesarean Section since risk of MTCT was reduced in women on anti-retroviral therapy with undetectable viral load in 80 patient with vaginal delivery only 3 had MTCT.  Chorioamnionitis – is associated with increase risk in some studies (Zaire, PACTG 185, Ariel Project)

Obstetric Factors Contd.  Increased HIV in cervico-vaginal secretion during pregnancy.  Thus increase Transmission in Labour.  Genital Tract infection  Obstetric Haemorrhage.  Intrapartum  Invasive Obstetric Procedure  Chorionic Villous Biopsies  Fetal Scalp Electrodes  Instrumental Deliveries of which forceps is at a lower risk than

vacuum.  Episiotomy and vaginal tears.

FETAL FACTORS      

Prematurity Multiple pregnancies especially in Twin I in Vaginal Delivery Fetal nutrition Fetal immune status Genetic factors such as maternal and infant HLA Human Leucocytes antigen Concordance Low birth weight

INFANT FACTORS Breastfeeding; Accounts for 15-40% Ver. Trans. Rate in absence of ARV. As against 18% for formula feed babies Mixed feeding Breast abscess Mastitis Active nipple disease Paediatric thrush

ANC: CARE Health Education VCT – Pre Test, Post test Rapid test; Abbot determine, Unigold, Immunocomb (confirmatory) Full Blood Count. LAB; CD4 count, Hepatitis B and C Avoid invasive diagnostic procedures Watch for Tell Tale Signs –TB Family/Nutritional Support. Treat Malaria/ARV/Opportunistic infection Fe/FA supplement Family Planning

CARE IN LABOUR & DELIVERY Avoid ARM / PROM / FETAL SCALP PROCEDURES. Universal Precaution is applied Avoid Routine Episiotomy Forceps Preferable to Vacuum Elective C/S at 38 weeks- Beneficial Prophylactic antibiotics

POST PARTUM CARE  No Separate Nursing Facilities  Avoid Stigma  Watch for infection  Care of perineum  Safe handling of Lochia, Sanitary Material

CARE OF NEONATES Handle babies with gloves until secretions and Blood are washed off. Infant feeding decision breast feeding approximately doubles the risk of HIV from 15 to 30% but avoidance of breastfeeding significantly reduces rates of infection (Kreiss) 1997. Mixed feeding is strongly discouraged. Expressing and heat treating of breast milk (62.5C for 5 minutes) Pretorian Regime. Breast Milk from another woman (Such as HIV negative wet nursing or banked milk). Syrup Nevirapine 2mg/kg start dose within 72 hours of birth. Children born to HIV positive women should be followed up on regular basis.

ANTI RETROVIRAL TREATMENT REGIMEN IN PREGNANCY AND LABOUR ARV NEVIRAPINE (PMTCT)

ANTENATAL NIL

LAMUVIDINE 150mg b.d ZIDOVUDINE 300mg b.d NEVIRAPINE 200mg b.d

From 14 weeks

INTRAPARTUM I dose of 200mg orally at onset of labour

POSTPARTUM 1 dose of 2mg/kg within 72 hours of birth.

1 dose of 2mg/kg within 72 hours of birth.

IMMUNIZATION BCG & OPV 0 – at birth DPT

– 6 weeks, 10 weeks, 14 weeks

OPV 1,2 and 3.

– 6 week, 10 weeks, 14 weeks

Measles

- 9 months to 15 months

Hepatitis B Vaccine - At birth, 6 weeks and 6 months Yellow fever, cerebrospinal-meningitis

- 1 year

ALL LIVE VACCINES SHOULD BE AVOIDED AS MUCH AS POSSIBLE Opportunistic infections - Co-trimoxazole.

CONCLUSION PMTCT is an affordable and sustainable intervention that will drastically reduce new HIV infections in the general population and at the same time prolong and improve the quality of life for those women already infected.