HIV in pregnancy Flashcards
If HIV positive what else to screen for
As routine: hepatitis B,
rubella (German measles) syphilis. STIs
Also for hepatitis C, varicella zoster (chickenpox), measles and toxoplasmosis.
What immunizations should be given to someone with HIV in pregnancy
dTap - generally wait until 28 weeks but risk benefit can give in T1 Hepatitis B (if you are not immune) and pneumococcus, Influenza
Varicella and MMR post preg if not immune
Antenatal management
- how to monitoring fetal wellbeing + other pregnancy management (GDM)
MDT approach
peer support
assessment for depression
NIPT is best as will minimise the people who need invasive testing
Invasive testing should be deferred until HIV status in known and viral load less then 50
Increased risk of GDM - test early - 24-28 weeks
Fundal height monitoring and if slows then growth scans
ECV is ok if viral load under 50
Intrapartum care
If ELLSCS
If NVD
If PROM - LSCS ASAP
If term - PROM - IOL ASAP
For IV Zidovudine once ROM
If PPROM must risk assess prolonged SRM and increasing ifection risk vs prematurity
How to monitor the disease ?
if already on ART - continue this - just a CD4 at baseline and delivery
If starting ART: follow starting protocols with CD4 at delivery
HIV viral load + LFTs at initiation of tx, 2-4 weeks after starting and at least every trimester, at 36 weeks and at delivery
If already on ART how does this change in pregnancy ?
If already on ART - continue
except:
- non standard regime (protease inhibitor monotherapy)
- it needs a drug that crosses the placenta
- drugs that have evidence of NTD include dolutegravir
- dosing change
- Regimen that has a lower pharmocokinetics in pregnancy eg darunavir or elvitegravir with cobicistat
Postnatal care
Breast feeding increases transmission by 50%
Recommend formula feeding
Assessment for postnatal depression at 3-6 weeks and at 3-4 months post partum
Intrapartum care
If ELLSCS
If NVD
IV zidovudine if viral load over 1000 or unknown viral load (in labour, SRM or pre LSCS) - can be considered if viral load 50-399
If PROM - LSCS ASAP
If term - PROM - IOL ASAP
For IV Zidovudine once ROM
- delivery should be achieved within 24 hours
If PPROM must risk assess
If 34-37 weeks advice same as above, GBS prophylaxis and delivery within 24 horus
under 34 weeks - IM steroids, control viral load, MDT discussion re timing of delivery
How to start ART?
When
what
First need to perform resistance testing and wait for results expect in late dx (after 28 weeks)
If they have had time off ART - resistance tx needs to be repeated
Definitely by 24 weeks
T1 if viral load >100,000 or CD4 under 200
Early T2 if 30-100 000 load
T2 ASAP if less then 30,000
British HIV guidelines
Start
tenofivir DR or abacavir with emtricitabine or lamivudine (nucleoside backbone)
The third agent should be efavirenz or atazanavir - most safety data
Postnatal care
Breast feeding increases transmission by 50%
Recommend formula feeding
Assessment for postnatal depression at 3-6 weeks and at 3-4 months post partum
Recommend ongoing ART post delivery
Neonatal management
Very low risk:
ART in mum over 10 weeks, 2 viral loads less then 50 and at or after 36 weeks
2 weeks zidovudine monotherapy
Low risk
Maternal viral load less then 50 at 36 weeks or preterm
4 weeks zidovudine monotherapy
High Risk
Combination PEP if unknown or high viral loads - if resistance seek advice
PEP ASAP within 4 hours, ok if mum was known resistant,
Do not continue PEP beyond 4 weeks
Test for HIV day 2, on discharge, 6 weeks, 12 weeks - confirm at 18 months
Co trimox prophylaxis from 1 month if + tests
When would a woman be on zidovudine only
not recommended
only if declining viral load <10,000 and willing to have a LSCS
How to manage an untreated woman at term in labour
Stat nevirapine
commence zidovudine and lamivudine and raltegravir
Receive IV zidovudine for the duration of the labour
If PTL - consider doubling tenofovir
What other tests if + hep B
Hep e antigen
HBV Viral load
HBSAg
Ensure other hep viruses have been screen for - A, C, D
LFTs, coags,
USS
HIV on HAART + contraception
Cant use COCPs and POPs, implants as interact with HAARTS
Depo is metabolised completely in the liver so this is ok every 12 weeks
IUCD ok
