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Published on : Aug 11, 2023 | Views : 1862 | Downloads : 0

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Dr Ahmad Zharif Bin Hussein O&G Specialist HSIJB FB page: drzharif Youtube channel: drzharifhussein HIV in Pregnancy
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contents Understanding HIV in pregnancy: 1.HIV → pregnancy 2.Pregnancy → HIV PMTCT ART drug in pregnancy Pre-pregnancy care Antenatal care Intrapartum care Postpartum care O&G Tutorial by DrZharifHussein
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Introduction WHO AIM ≤ 50 case for livebirth peryear in every country Rate < 5% baby among Breastfeeding HIV mother & < 2% bayi Nonbreastfeeding HIV mother 2011-2015,Malaysia show reducing newcase from 11.7 to 0.39 for 100,000 livebirth. 2011- WHO campaign “no Child born with HIV” O&G Tutorial by DrZharifHussein
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Understanding HIV in pregnancy O&G Tutorial by DrZharifHussein
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HIV → pregnancy Maternal Miscarriage Risk of chorioamnitis & BV. Poor nutritional status. Risk of GDM (ARV) Risk of Pre-eclampsia Fetus Risk of preterm labour. risk of FGR (IUGR) MTCT risk. ARV drug risk (teratogenic). O&G Tutorial by DrZharifHussein
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Pregnancy → HIV NO adverse effect on HIV progression/survival. Not compliance to ARV drug : Nausea & vomiting (1st trimester) Anxious teratogenicity effect Ref: Pundir, J., & Coomarasamy, A. (2016). Human immunodeficiency virus. In Obstetrics: Evidence-based Algorithms (pp. 48-53). Cambridge: Cambridge University Press. doi:10.1017/CBO9781107338876.013 O&G Tutorial by DrZharifHussein
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MTCT O&G Tutorial by DrZharifHussein
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MTCT (Mother to Child Transmission) Ref: Pundir, J., & Coomarasamy, A. (2016). Human immunodeficiency virus. In Obstetrics: Evidence-based Algorithms (pp. 48-53). Cambridge: Cambridge University Press. doi:10.1017/CBO9781107338876.013 O&G Tutorial by DrZharifHussein
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Obstetric factors associated with transmission are: * Mode of delivery. * Duration of membrane rupture. * Delivery before 32 weeks of gestation. * Presence of other STI(Hep B,C & syphillis). * Chorioamnionitis. • Breastfeeding doubles the risk from 14 to 28%. Principal risk factors for transmission: * High plasma viraemia at delivery. * Short duration of HAART / not on HAART. * Delivery at <32 weeks of gestation. Ref: Pundir, J., & Coomarasamy, A. (2016). Human immunodeficiency virus. In Obstetrics: Evidence-based Algorithms (pp. 48-53). Cambridge: Cambridge University Press. doi:10.1017/CBO9781107338876.013 Obstetric factors O&G Tutorial by DrZharifHussein
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Neonatal factors Duration of breastfeeding (more longer more risk) Mixed feeding,Non-exclusive BF Condition of the breasts-ulcer/lesion Condition of the baby’s mouth(lesion in mouth) Pre-maturity, low birth weight O&G Tutorial by DrZharifHussein
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ARV in pregnancy O&G Tutorial by DrZharifHussein
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when to intiate in newly diagnosed/ naive ART pregnant women? O&G Tutorial by DrZharifHussein
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ART counselling First line HAART offers the best opportunity for effective viral suppression and immune recovery. It also improves mortality • To educate patient about the expected clinical, immunological and virological response • To ensure that patient knows the correct dosage and management of potential adverse effects • To develop an individualized medication schedule (Link to patient’s daily social activities and lifestyle) • To plan follow up sessions and provide contact details if urgent consultation is required due to adverse effects • To discuss the possible occurrence of IRIS after starting HAART O&G Tutorial by DrZharifHussein
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O&G Tutorial by DrZharifHussein
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O&G Tutorial by DrZharifHussein
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O&G Tutorial by DrZharifHussein
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ARV Drug (Nucleoside or nucleotide reverse transcriptase inhibitors (NRTI) ) Zidovudine (AZT) Lamivudine (3TC) Tenofovir disoproxil fumarate (TDF) Emtricitabine (FTC) *risk of congenital malformation(about 2.8%). O&G Tutorial by DrZharifHussein
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Non-nucleoside reverse transcriptase inhibitors (NNRTI) Nevirapine (NVP) Efavirenz (EFV ) safe-no teratogenicity O&G Tutorial by DrZharifHussein
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Protease Inhibitors (PI) Lopinavir / ritonavir (LPV/r) Integrase Inhibitors Raltegravir (RAL) Dolutegravir (after 6 weeks’ gestation)-risk of NTD O&G Tutorial by DrZharifHussein
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January 2018, the APR report for infants exposed to antiretrovirals includes the following. • Abacavir, atazanavir, lamivudine, emtricitabine, lopinavir, nevirapine, ritonavir, tenofovir DF and zidovudine: there are now more than 200 prospective reports of first-trimester exposure with no signal of increased risk, and a greater than two-fold higher rate than in the general population has been excluded. • Darunavir, efavirenz, indinavir, raltegravir and rilpivirine have been shown to have congenital malformation rates within the expected range, and a congenital malformation rate greater than 1.5-fold higher than in the general population has been excluded. • For newer agents (cobicistat, dolutegravir, elvitegravir and tenofovir alafenamide) and a number of less commonly prescribed older compounds (saquinavir, fosamprenavir, enfuvirtide, tipranavir, maraviroc and etravirine) there have been insufficient reported outcomes of first-trimester exposure to exclude such risk. Ref: British HIV Association guidelines for the management of HIV in pregnancy and postpartum 2018 (2019 second interim update) O&G Tutorial by DrZharifHussein
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Regime ART in pregnant women ART used during pregnancy must consist of 2 NRTIs plus either a NNRTI or a boosted PI or an integrase strand transfer inhibitors O&G Tutorial by DrZharifHussein
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Raltegravir in late presenting HIV mother? O&G Tutorial by DrZharifHussein
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Intrapartum Zidovudine O&G Tutorial by DrZharifHussein
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Adherence to ART ART adherence is the key to successful HIV treatment ART adherence is the key to successful HIV treatment. Current data shows that to maintain successful viral suppression, 95% or more adherences to ART is required. Specific group at risk of poor adherence includes: • Poor family support • Intravenous drug users • Adolescence and • Pregnant mothers • Underlying psychiatric illness O&G Tutorial by DrZharifHussein
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Pre-pregnancy O&G Tutorial by DrZharifHussein
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Serodiscordant couples • The risk of transmission for each act of sexual intercourse is 0.001% – 0.03%. This risk is significantly reduced, if the male partner has a viral load of <50 copies/ml and is taking HAART. The risk can be further reduced by limiting exposure to the fertile period of the cycle and ensuring that all genital infections have been treated. • Couples who are serodiscordant choosing to have intercourse should use condoms as it is associated with an 80% reduction in transmission. O&G Tutorial by DrZharifHussein
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Serodiscordant couples References 1. Cohen MS, Chen YQ, McCauley M, et al. and the HPTN 052 Study Team. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365:493–505. 2. Dunkle KL et al. New heterosexually transmitted HIV infections in married or cohabiting couples in urban Zambia and Rwanda: an analysis of survey and clinical data. The Lancet, 2008, 371(9631):2183–2191. 2.British HIV Association guidelines for the management of HIV in pregnancy and postpartum 2018 (2019 second interim update). 3.Malaysian Consensus Guidelines on Antiretroviral Therapy 2017 • Assisted conception with either donor insemination or sperm washing is significantly safer than timed unprotected intercourse. • Sperm washing is simple and is significantly safer than timed unprotected intercourse, with no case of seroconversion in either female partner or child born in over 3000 cycles of sperm washing combined with IUI, IVF or ICSI reported in the literature. O&G Tutorial by DrZharifHussein
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HIV mother • To optimize health of mother and baby – advise to delay conception until: * HAART regimen is optimised and is effectively suppressing viraemia. * Any opportunistic infections are treated. • Folate supplementation – higher dose folate (5 mg) for women taking cotrimoxazole. • Yearly cervical cytology because of the association of HIV, immunosuppression, and cervical neoplasia. O&G Tutorial by DrZharifHussein
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Counselling prepregnancy ** MDT approach Counselling couple: 1.About antenatal,intrapartum and postpartum care. 2.Effective and appropriate contraceptive methods to reduce the likelihood of unplanned pregnancy. 3.Provide information on safe sex and encourage the elimination of alcohol, tobacco, and other drugs of abuse. 4.ARV drugs compliance,safety of drug,teratogenicity effect & regime. 5.provide information complication HIV towards pregnancy and pregnancy towards HIV. 6.Assess the pshycosocial issue. O&G Tutorial by DrZharifHussein Ref : 1. https://aidsinfo.nih.gov/contentfiles/glchunk/glchunk_152.pdf 2. https://www.bhiva.org/file/5bfd30be95deb/BHIVA-guidelines-for-the-management-of-HIV-in-pregnancy.pdf
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Antenatal O&G Tutorial by DrZharifHussein
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Antenatal care Ref: Garis Panduan Pencegahan Jangkitan HIV/Sifilis Dari Ibu-ke-Anak (Prevention of Mother-To-Child Transmission HIV/Syphilis) 2020 all pregnant women- screening 1.screening (RDT/EIA) reactive → confirmatory test. 2.screening (RDT/EIA) non reactive : Low risk mother- no need to repeat. High risk pregnant women if negative to screening (RDT/EIA) before 36 week O&G Tutorial by DrZharifHussein
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High-risk mother: Women whose past or present sexual partners were HIV infected, bisexual or injecting drug use Women seeking treatment for sexually transmitted infections (STI) Commercial sex worker Women with past or present history of injecting drug Women with history of blood transfusion before 1986 Unprotected vaginal or anal intercourse with more than one sex partner . Ref: Garis Panduan Pencegahan Jangkitan HIV/Sifilis Dari Ibu-ke-Anak (Prevention of Mother-To-Child Transmission HIV/Syphilis) 2020 O&G Tutorial by DrZharifHussein
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Antenatal care All infective screening MDT management (ID physician,FMS,Obstetrician,& paediatrician) Confidentiality safer sex practice-Condom Ix- MOGTT- on HAART Detail scan for fetal anomaly. Aneuploidy screening (recommended) invasive prenatal diagnostic- limited data safety. ECV → if VL less than 50 O&G Tutorial by DrZharifHussein
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Antenatal monitoring Monitor for drug toxicities – FBC, urea and electrolytes and liver function tests regularly. Pregnant women with advanced HIV are at increased risk of opportunistic infections, particularly PCP. • Adverse effects of HAART – gastrointestinal disturbances, skin rashes, and hepatotoxicity. • Presentation with symptoms suggestive of PET, cholestasis or other signs of liver dysfunction may indicate drug toxicity therefore seek early liaison with HIV physicians. O&G Tutorial by DrZharifHussein
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Newly diagnosed/HAART Naive counselling start HAART regardless of CD4 level diagnosed >> 28 week of gestation→ consider RAL(refer ID) Do viral load at 32-36 week → decide mode of delivery continue ART post delivery O&G Tutorial by DrZharifHussein
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Diagnosed in Labour/not on HAART LSCS is recommended IV AZT (2mg/kg for 1 hour followed by 1mg/kg/h) start 2 NRTI+ Raltegravir (RAL) or 2NRTI + EFV/NVP switch to 1st line regime post delivery O&G Tutorial by DrZharifHussein
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On HAART Stable on HAART (VL < 50 copies before pregnant) counselling continue HAART do viral load at 32-36 weeks Continue HAART post delivery O&G Tutorial by DrZharifHussein
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Failing HAART (VL> 1000 copies after treatment iniated for 3 months) -Refer ID physician -Alert ID paediatrician -Resistance testing if available -LSCS at 38 weeks - during delivery- intrapartum AZT -Cont HAART post delivery O&G Tutorial by DrZharifHussein
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Intrapartum Mode of delivery depend on viral load at 32-36 weeks. ELLSCS : between 38 and 39 weeks’ gestation O&G Tutorial by DrZharifHussein
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Intrapartum Intravenous Zidovudine Infusion Intrapartum IV Zidovudine (AZT) infusion (2 mg/kg for the 1st hour followed by 1 mg/kg/h subsequently) is recommended for women with a viral load of >1000 copies/mL who present in labour or with ruptured membranes or who are admitted for planned PLCS. Current evidence suggests that intrapartum IV AZT has no additional benefit in prevention of vertical transmission in pregnant women on ART with viral load ≤1000 copies/mL during late pregnancy and near delivery . Ref : Consensus MALAYSIA /HIVGuideline_2017 O&G Tutorial by DrZharifHussein
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SVD (VL < 50) continue HAART No invasive procedure ARM if indicated Augmentation of labour (pitocin & ARM)-Safe Instrumental delivery-if indicated only (low cavity forcep preferable to ventous) Avoid mid-cavity and rotational instrumental deliveries. Ref: Pundir, J., & Coomarasamy, A. (2016). Human immunodeficiency virus. In Obstetrics: Evidence-based Algorithms (pp. 48-53). Cambridge: Cambridge University Press. doi:10.1017/CBO9781107338876.013 O&G Tutorial by DrZharifHussein
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LSCS Time : 38-39 weeks Early cord clamping. Keep surgical field as haemostatic as possible and take care to avoid rupturing the membranes until the head is delivered through the surgical incision. Peripartum antibiotics in accordance with national guidelines. If IV ZDV is indicated, start the infusion 4 hours before beginning the CS and continue until the umbilical cord is clamped. Take a maternal sample for plasma viral load and CD4 lymphocyte count at delivery. Ref: Pundir, J., & Coomarasamy, A. (2016). Human immunodeficiency virus. In Obstetrics: Evidence-based Algorithms (pp. 48-53). Cambridge: Cambridge University Press. doi:10.1017/CBO9781107338876.013 O&G Tutorial by DrZharifHussein
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PROM Mode of delivery must consider of the maternal viral load, duration of ROM and the expected time of delivery. After ROM, there is an increased risk of perinatal HIV transmission of 2% per hour . Chorioamnionitis → associated with perinatal transmission of HIV. Delivery should be expedited for women with PROM at term, either with induction of labour or Caesarean section. There should be a low threshold to start antibiotics if signs suggestive of chorioamnionitis are present. Ref : Consensus MALAYSIA /HIVGuideline_2017 O&G Tutorial by DrZharifHussein
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PPROM When premature rupture of membrane (PPROM) occurs at < 34 weeks, intramuscular steroids should be administered in accordance to national guidelines. There should be multidisciplinary discussion between Obstetrician, Paediatrician and ID Physician about the timing and mode of delivery after PPROM. Ref : Consensus MALAYSIA /HIVGuideline_2017 O&G Tutorial by DrZharifHussein
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Postpartum O&G Tutorial by DrZharifHussein
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Breastfeeding Breast-Feeding Breast-feeding is not recommended as it is associated with risk of transmission up to 14%. Replacement feeding (AFASS). For women on ART, compliance must be stressed if they insist on breast-feeding their baby. Ref : Consensus MALAYSIA /HIVGuideline_2017 O&G Tutorial by DrZharifHussein
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AFASS Acceptable Perceive no barrier to replacement feeding Feasible Has adequate time,knowlege,skills and resources to prepare replacement food Affordable Able to pay for the cost of purchasing/producing, preparing replacement feed Sustainable Available in continuous and uninterrupted supply Safe Correctly and hygenically prepared ,stored and fed to baby O&G Tutorial by DrZharifHussein
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Thank You Fbpages: Drzharif , Youtube channel :drzharifhussein.