Management of HIV in Pregnancy and postpartum

• Preferentially targets CD4 cells
  Transmission through
  ○ sexual intercourse
  ○ intravenous drug use
  ○ transfusion of blood or blood products
  ○ mother to child during pregnancy and breastfeeding
  •
• Pregnancy does not adversely affect HIV progression or survival
• HAART (Highly Active Anti-Retroviral Therapy) in pregnancy may be at increased risk of GDM, PET, and PTD
• cART and HAART can be used interchangebly

Those with CD4 lymphocyte counts < 200 × 106/l are at
risk of opportunistic infections; provide prophylaxis against Pneumocystis carinii
pneumonia (PCP) – cotrimoxazole is the firstline agent

Cotrimoxazole (Given for
Pneumocystis Carinii), a folate antagonist, raises the possibility of neural tube defects

MTCT rates

Majority of In-Utero transmissions occur in the 3rd trimester.

Interventions to prevent Mother-to-child transmission

1. Antiretroviral therapy – Single most important management
2. Appropriate management of delivery (LSCS)
3. Avoidance of breastfeeding.
4. Treatment of newborn – control of disease

Obstetric management

Ultrasound screening for fetal anomaly should be offered to all pregnant women between 18+0 and 20+6 weeks’ gestation.

The combined screening test for fetal aneuploidies and non-invasive prenatal testing (NIPT) for those who screen as high risk is recommended as this has the best sensitivity and specificity and will minimise the number of women who may need invasive testing.

All women should be offered screening for trisomies 13, 18 and 21.

The most effective screening is with the combined test at 11+0 to 13+6 weeks’ gestation.

This includes maternal age, nuchal translucency, β-human chorionic gonadotrophin (βHCG) and pregnancy-associated plasma protein A (PAPP-A). In the general population this has a detection rate of 92.6% with a false-positive rate of 5.2%

Invasive prenatal diagnostic testing should not be performed until after the HIV status of the woman is known, and should ideally be deferred until HIV viral load has been adequately suppressed to <50 HIV RNA copies/mL.

If not on Combination antiretroviral therapy cART and the invasive diagnostic test procedure cannot be delayed until viral suppression is achieved, it is recommended that women should commence cART to include raltegravir and be given a single dose of nevirapine 2–4 hours prior to the procedure.

External cephalic version (ECV) can be offered to women with plasma viral load <50 HIV RNA copies/mL.

Mode of delivery

For women with a plasma viral load of

<50 HIV RNA copies/mL at 36 weeks, and in the absence of obstetric contraindications, planned vaginal delivery should be supported.

50–399 HIV RNA copies/mL at 36 weeks, pre-labour CS (PLCS) should be considered, taking into account the actual viral load, the trajectory of the viral load, length of time on treatment, adherence issues, obstetric factors and the woman’s views.

≥400 HIV RNA copies/mL at 36 weeks,

PLCS is recommended.

In women for whom a vaginal delivery has been planned and labour has commenced, obstetric management should follow the same guidelines as for the HIV-negative population, apart from duration of ruptured membranes

Vaginal birth after CS (VBAC) can be offered to women with a viral load <50 HIV RNA copies/mL.

Where the indication for CS is the prevention of vertical transmission, CS should be undertaken at between 38 and 39 weeks’ gestation.

Where PLCS is undertaken only for obstetric indications and plasma viral load is <50 HIV RNA copies/mL, the usual obstetric considerations apply and the CS will usually be performed after 39 weeks’ gestation.

Management of SROM

In all cases of term pre-labour SROM, delivery within 24 hours should be the aim.

If maternal HIV viral load is

<50 HIV RNA copies/mL, immediate induction or augmentation of labour is recommended in women who have pre-labour SROM, with a low threshold for treatment of intrapartum pyrexia.

should aim for delivery within 24 hours of SROM.

50–399 HIV RNA copies/mL, immediate CS is recommended, but should take into account the actual viral load, the trajectory of the viral load, length of time on treatment, adherence issues, obstetric factors and the woman’s views.

≥400 HIV RNA copies/mL, immediate CS is recommended.

The management of preterm SROM at ≥34 weeks is the same as that of term SROM, except that women at 34–37 weeks’ gestation will require group B streptococcus prophylaxis in line with national guidelines.

When preterm SROM occurs at <34 weeks:

• Intramuscular steroids should be administered in accordance with national guidelines;

• Where HIV viral load is not controlled, this should be optimised;

• There should be multidisciplinary discussion about the timing and mode of delivery.

Use of intrapartum intravenous infusion of zidovudine

Intrapartum intravenous zidovudine infusion is recommended in the following circumstances:

For women with a viral load >1000 HIV RNA copies/mL plasma who present in labour or with SROM or who are admitted for PLCS.

For untreated women presenting in labour or with SROM in whom the current viral load is not known.

The use of intrapartum intravenous zidovudine infusion can be considered in women on cART with a plasma HIV viral load <1000 HIV RNA copies/mL.

Place of birth

All women living with HIV are recommended to give birth in a facility that has direct access to paediatric care (i.e. a co-located birth centre or obstetric unit).

Water birth

There is scant safety evidence to support water births in women living with HIV

however, women who choose a water birth should be supported to achieve this where the viral load is <50 HIV RNA copies/mL.

SLCOG

Management of HIV positive pregnant women in the STD clinic

There are two possibilities;

• A pregnant woman may be identified as having HIV infection during routine antenatal screening and referred to the STD clinic by the MOH or VOG for further management.

• A woman already diagnosed as living with HIV and under care services from STD clinic can become pregnant.

All pregnant women with HIV should have an individualized, regularly updated plan of care which summarizes mutually agreed obstetric and HIV management plan.

Check whether the woman has already attended for antenatal care and encourage regular attendance at antenatal visits.

Ask about health of other children and encourage checking HIV status of other children.

Counselling

The following areas need to be covered in counseling.

1. ART and adherence to treatment
2. Choice of infant feeding
3. Partner disclosure/screening
4. HIV testing of other children
5. 100% Condom use to prevent acquiring other STIs, entry of other strains of HIV and onward transmission to a negative partner
6. Postpartum family planning

Neonatal Management

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