HIV in Pregnancy Flashcards
How much vertical transmission of HIV is lowered by treatment ?
Without treatment 👉25 - 40 %
HAART + Avoid breastfeeding 👉 1%
cART+undetectable viral load👉0.5%
how long does it take for HIV antibodies test & HIV P24 antigen test to be detectable after infection?
HIV antibodies test 👉 may take up to 3 months
HIV P24 antigen 👉 within 1 month of infection
What is the role of rapid HIV tests in screening pregnant women?
Women of unknown status who present in labour( takes 20 minutes)
What is the incidence of depression in women with HIV?
30 - 50 %
When should assessment of depression be undertaken in women with HIV ?
At booking
4 - 6 weeks postpartum
3 - 4 months postpartum
How to asses depression in women with HIV?
Whooley questions
When to break confidentiality with women diagnosed with HIV ?
In order to inform a sexual partner
If appears to want to delay telling
What is the incidence of STD in women with HIV ? When to screen?
0- 4 %
Screening is recommended if the pregnant woman newly diagnosed with HIV
Screening is suggested if she is living with HIV
What are the baseline investigations required in pregnant women who are newly diagnosed with HIV ?
No additional baseline investigations required ( as performed in general antenatal clinic )
In pregnant women commencing cART in pregnancy what are the additional baseline investigations required ?
LFTs : performed as routine initiation of cART & then with each routine blood test
Why to monitor LFTs in pregnant women commencing cART ?
Hepatotoxicity may occur as a result of the initiation of cART
Or development of obstetric complications ( HELLP - obstetric cholestasis - preeclampsia - acute fatty liver)
In women conceiving on cART when to measure CD4 count ?
Baseline
At delivery
In women who commence cART in pregnancy , when CD4 count should be performed?
At initiation of treatment
At delivery
In women who commence cART in pregnancy, when should HIV viral load be performed?
2 - 4 weeks of starting treatment
Each trimester
36 week
At delivery
When to do HIV resistance testing?
Prior to initiation of treatment
Except: late presenting women
( > 28w)
If they choose to stop cART further HIV resistance testing should be done
What medications from cART that has possible adverse fetal outcomes? How to manage?
DOLUTEGRAVIR
Possible neural tube defects
if she is trying to conceive or in the first trimester 5 mg of folic acid
If she isn’t on that drug 👉400mcg
What are the Elite controllers?
People with HIV who maintain an undetectable viral load and high CD4 counts without treatment
How long a pregnant woman with HIV will be on medications?
Lifelong including elite controllers
When to start cART in women with HIV positive in pregnancy?
First trimester: if
Viral load > 100,000 or
CD4 < 200
At the start of 2nd trimester: if
Viral load 30,000 - 100,000
2nd trimester: if
Viral load < 30,000
🚩 all women should have started cART by 24w of pregnancy
What is the management in pregnant women with HIV positive who present > 28w or in labour and not on treatment?
Commence cART immediately
& IV zidovudine during labour
What are the investigations that should be done in a pregnant woman with HIV &new HBV infection ?
LFTs
HBV DNA quantitative
Antigen e
HAV + HCV + HDV screening
How to manage HAV non immune pregnant woman with HIV+ & HBV ?
Vaccination after 1st trimester
as per normal schedule
( 0 - 6 months)
If CD4 < 300 👉 ( 0 - 1 - 6 months)
What is the mode of delivery recommended if the woman has fully suppressed HIV viral load on cART & HBV infection?
Vaginal birth irrespective of HBV viral load
Among HCV medications , which drug is contraindicated in pregnancy?
Ribavirin ( directly acting antiviral DAA)
If the woman is trying to conceive or discovers she is pregnant should discontinue the drug
What vaccinations are recommended in women with both HIV & HCV?
1- HBV after the 1st trimester if non immune
2- HAV after the 1st trimester if non immune ( 0 - 6 months) Unless CD4<300 👉( 0 - 1 - 6 months)
Updated:
What is the recommended mode of birth in women receiving effective cART for HIV with HCV infection?
Vaginal birth irrespective of HCV viral load
What are the best fetal screening modalities in HIV+ pregnant women?
🚩PAPP-A & NT : not altered by HIV infection or ART ( combined)
🚩NIPT
📌 triple test is altered by :
- increased ßhcg & á- fetoprotein
Lower unconjucated oesteriol
In women with HIV
- reduction in ßhcg in women on ART
If invasive prenatal testing is indicated in HIV+ women, when to perform?
On cART 👉 deffer until viral load
< 50 RNA copies
Not on cART 👉 commence cART
At 36w of gestation; how to determin the mode of delivery in HIV+ women?
Viral load < 50 👉 vaginal delivery
Or external cephalic version
Viral load 50 - 399 👉 CONSIDER
Pre labour CS 38 - 39 w
Viral load >400 👉 RECOMMENDED
PRCS 38 - 39 w
What is the management in HIV+ women with spontaneous rupture of membranes SROM ?
Delivery within 24h
If viral load < 50 👉 immediate induction of labour
If viral load 50 - 399 👉 immediate CS
if viral load > 400 👉 immediate CS
What is the management in women with HIV+ & preterm spontaneous rupture of membranes SROM( 34 - 37 w) ?
🔴 Delivery within 24h + GBS prophylaxis
If viral load <50 👉 immediate induction of labour +GBS prophylaxis
If viral load >50 👉 immediate CS + GBS prophylaxis
What is the management in women with HIV+ & preterm SROM < 34w?
1- IM steroids
2- optimization of viral load
3- MDT: to take the decision of the time & mode of the delivery.
When to double the dose of medication given to HIV+ women before giving birth?
Preterm delivery
When is intrapartum IV zidovudine in women with HIV+ recommended ?
🍀If viral load > 1000 & in labour or
SROM or PLCS
🍀untreated women presented in labour
CONSIDER IV zidovudine if viral load 50 - 1000 in labour
What is the place of birth recommended in HIV + women?
Has direct access to paediatric care
Co located birth center
Or obstetric unit
About neonatal care of HIV+ women
When to consider the neonate very low risk? How to manage?
1- women have been on cART > 10W
&2- two documented maternal viral load < 50 during pregnancy at least 4 weeks apart
&3- maternal viral load <50 at 36w or after
🎀 management: 2 weeks zidovudine monotherapy started within 4h
About neonatal care of HIV+ women
When to consider the neonate low risk? How to manage?
1- if criteria in ( very low risk) aren’t fulfilled + maternal viral load < 50 at 36w
2- the infant born prematurely & most recent maternal HIV viral load < 50
🎀 management: zidovudine for 4 w
Started within 4h
About neonatal care of HIV+ women
When to consider the neonate high risk? How to manage?
If maternal viral load > 50 on the day of birth
Or if viral load is unknown
🎀 management: cART ( 3 drugs) 4w
Started within 4h
About neonatal care of HIV+ women
When to give IV zidovudine to the neonate instead of orally?
Premature infants until enteral feeding is started
If the neonate is HIV+ , how to prevent pneumocystic pneumonia?
Co trimoxazole from 1 month of age
For neonates of HIV+ women how vaccinations should be given?
As per the national schedule
* Rotavirus vaccine: is NOT contraindicated unless the baby is HIV+ & severely immunosuppressed
* BCG should not be delayed if indicated in very low risk & low risk babies
What are the factors that increase the HIV transmission via breast milk when women are not on cART ?
1- detectable HIV viral load
2- advanced maternal HIV disease
3- longer duration of breastfeeding
4- infant mouth infection
5- nipples infection
6- mixed feeding: solid food given to infant less than 2 months
What is the breastfeeding advice for women with HIV ?
NO BREASTFEEDING
What is the criteria to breast feed in women with HIV ?
Small on going risk of transmission :
1- suppressed viral load ( during the last trimester of pregnancy)
2- good adherence history
3- monthly attendance to do HIV viral load for her & the baby during breastfeeding and 2 months after stopping breastfeeding
What is the maximum duration of breastfeeding in women with HIV allowed?
6 months
No solid food / no mastitis / no infant gastrointestinal symptoms/ no detectable viral load
When to perform HIV infection test in non breast feed infants ?
2 days
Prior to discharge
2 weeks IF HIGH RISK at delivery
6 weeks
12 weeks
In non breast feed infants of women with HIV when to check HIV antibodies?
*From the first sample from the baby
When the maternal antibodies status is not documented
* (22 - 24) months for seroconversion
* 18 months
In breastfed infants of women with HIV , when to test HIV antigen ( molecular diagnostics) ?
1- 2 days of age and prior to discharge
2- At 2 weeks
3- Monthly at the duration of breastfeeding
4- 4 w and 8w after cessation of breastfeeding
In breastfed infants of women with HIV , when to do antibodies testing?
1- First sample from the baby when the maternal antibodies status isn’t documented
2-( 22 - 24) months for seroversion
3- 8 weeks after cessation of breastfeeding
When women with HIV should be seen for postpartum follow up?
4 - 6 weeks postpartum by a member of MDT
Case :
Pregnant 13 w screened HIV+ & counseled to commence cART at 14w what to do now ?
Screen for STD
LFTs
CD4 counts
