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DipHIV > HIV + pregnancy > Flashcards

HIV + pregnancy Flashcards

1
Q

What is the prevalence of women living with HIV and giving birth in the UK?

A

2%

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2
Q

Prior to antenatal screening for HIV and ART in pregnancy what was the rate of vertical transmission?

A

25%

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3
Q

What is the current rate of vertical transmission of HIV if the mother is on ART and undetectable?

A

VERY low

0.1%

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4
Q

What is the currently stable number of perinatal HIV infections occurring in the UK?

A

30-40 per year

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5
Q

Does genital HSV increase the risk of vertical transmission of HIV?

A

No studies have confirmed

one study showed reduced HIV replication in genital tract when aciclovir added - unclear if clinical relevance

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6
Q

What is the recommendation for women who are pregnant and have previously had genital HSV?

A

offer
ACICLOVIR 400mg three times daily
from week 32

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7
Q

What scenarios are associated with increased vertical transmission of HIV?

A

chorioamnionitis
prolonged rupture of membranes (PROM)
premature birth

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8
Q

What organism or condition is implicated in chorioamnionitis?

A

Ureasplasma urealyticum

ie BV

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9
Q

When should a pregnant WLW HIV be screened for STI including BV?

A

early in pregnancy
&
28 weeks

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10
Q

What is the recommendation for a women who is pregnant and due ROUTINE cervical smear?

A

DEFER to 3 months post partum

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11
Q

When should colposcopy take place for a women who is pregnant and has ABNORMAL cytology from cervical smear?

A

late FIRST or early SECOND trimester

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12
Q

When should colposcopy take place for a women who is pregnant and is HPV POSITIVE on cervical smear?

A

Defer until after pregnancy

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13
Q

When should colposcopy take place for a women who is pregnant and has had recent treated or untreated CIN?

A

can be deferred until after pregnancy
however
follow up should be seen

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14
Q

What is the recommendation for a women who is pregnant and requires FOLLOW UP COLPOSCOPY following treatment for CIN2 or 3?

A

Do not delay

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15
Q

When should CD4 count be measured in women who are pregnant with HIV?

A 
BASELINE
&
DELIVERY
or
as per ART start
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16
Q

When should VL be measured in women who are pregnant with HIV?

A

2-4 weeks after ART start
every TRIMESTER
36 weeks
DELIVERY

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17
Q

In women presenting late pregnant and new diagnosis of HIV what is the potential benefit of a VL 2 weeks after ART start?

A

more rapid assessment of ADHERENCE

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18
Q

When should LFTs be performed in women who are pregnant with HIV?

A

with all ROUTINE bloods

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19
Q

What can deranged LFTs be a sign of in women who are pregnant with HIV?

A 
ART toxicity
obstetric cholestasis
pre-eclampsia
HELLP
acute fatty liver
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20
Q

If a women who is pregnant with HIV is not undetectable on ART what are the principles of management?

A 
check ADHERENCE
RESISTANCE test
consider therapeutic DRUG MONITORING
OPTIMISE best regimen
consider INTENSIFICATION
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21
Q

Which ART readily crosses the placenta?

A

TENOFOVIR DF
RALTEGRAVIR
NEVIRAPINE

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22
Q

Which is the only ART licensed in pregnancy?

A

Zidovudine

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23
Q

If a women is on effective ART and becomes pregnant, what is the general recommendation?

A

Remain on current ART

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24
Q

If a women is on ART and becomes pregnant which regimens should consider switch or change in dosing schedule?

A 
pharmokinetics:
COBICISTAT boosted ART
RAL daily dosing
neural tube defect:
DOLUTEGRAVIR if 1st trimester ???
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25
Q

What is the recommended NRTI backbone in pregnancy?

A

TDF/FTC
or
ABC/3TC

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26
Q

What is the recommended 3rd ART in pregnancy?

A

EFAVIRENZ
or
ATAZANAVIR/ritonavir

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27
Q

Which ART combination demonstrated increased risk of neonatal death and premature deliver in PROMISE trial?

A

TDF/FTC
+
LOPINAVIR/ritonavir

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28
Q

Why is the ART combination TDF/FTC + LOPINAVIR/ritonavir not recommended?

A

increased risk of
neonatal DEATH
&
PREMATURITY

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29
Q

What are alternative 3rd ART in pregnancy other than efavirenz or atazanavir?

A

Darunavir/ritonavir
Raltegravir BD
Rilpivirine
Dolutegravir (after 6 weeks)

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30
Q

If a pregnant women on ART has intermittent drug exposure due to hyperemesis gravidarum, what is the recommendation?

A

Stop ART until hyperemesis controlled

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31
Q

When should ART be started in pregnant women who are elite controllers of HIV?

A

Start ART immediately, no delay

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32
Q

What dose of folic acid for women trying to conceive on dolutegravir?

A

5mg daily

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33
Q

Timing of ART start - pregnant woman - VL <30 000?

A

asap SECOND trimester

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34
Q

Timing of ART start - pregnant woman - VL 30 000 - 100 000?

A

EARLY SECOND trimester

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35
Q

Timing of ART start - pregnant woman - VL >100 000?

A

FIRST trimester

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36
Q

Timing of ART start - pregnant woman - CD4 <200?

A

FIRST trimester, regardless of VL

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37
Q

By what gestation should all pregnant woman have started ART?

A

24 weeks

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38
Q

What is the median length of ART treatment associated with no vertical transmission in women starting ART in pregnancy?

A

16 weeks

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39
Q

Starting ART after what gestation is associated with increased risk of VL TRANSMISSION?

A

30 weeks

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40
Q

Starting ART after what gestation is associated with REDUCED likelihood of VL SUPPRESSION?

A

20 weeks

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41
Q

How does a history of previous premature delivery alter ART start timing in a pregnant woman?

A

Start ART earlier and independent of viral load

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42
Q

What dosing schedule should be considered if using darunavir/ritonavir in pregnancy?

A

TWICE daily

600mg/100mg

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43
Q

When can TAF be considered as ART in pregnancy?

A

after first trimester

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44
Q

What is the preferred PI in pregnancy?

A

ATAZANAVIR

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45
Q

What is the definition of late presentation with HIV in pregnancy?

A

28 weeks gestation onwards

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46
Q

What ART class must be included if a pregnant women with HIV presents >28 weeks?

A

INTEGRASE inhibitor

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47
Q

Pregnant women presenting in labour with HIV and not on ART - how many steps to IMMEDIATE management AT TERM?

A

FOUR steps

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48
Q

Pregnant women presenting in labour with HIV and not on ART - step 1?

A

NEVIRAPINE 200mg STAT

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49
Q

Pregnant women presenting in labour with HIV and not on ART - step 2?

A

ORAL ZIDOVUDINE 300mg
+
LAMIVUDINE 150mg TWICE daily

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50
Q

Pregnant women presenting in labour with HIV and not on ART - step 3?

A

RALTEGRAVIR 400mg TWICE daily

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51
Q

Pregnant women presenting in labour with HIV and not on ART - step 4?

A

For duration of labour:
IV ZIDOVUDINE 2mg/kg LOAD over 1 hour
then
IV zidovudine 1mg/kg until cord clamped

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52
Q

Pregnant women presenting in labour with HIV and not on ART - how long is IV ZIDOVUDINE?

A

Duration of LABOUR

until cord CLAMPED

53
Q

Pregnant women presenting in labour with HIV and not on ART - what is the BENEFIT of oral nevirapine STAT?

A

rapid crossing of placenta

effective concentrations in neonate

54
Q

How LONG does effective nevirapine concentrations last in the neonate following maternal stat dose?

A

up to TEN days

55
Q

How QUICKLY can effective nevirapine concentrations be achieved in neonate following maternal stat dose?

A

within TWO hours

56
Q

Pregnant women presenting in labour with HIV and not on ART - recommended mode of delivery?

A

C-section

57
Q

Pregnant women presenting in labour with HIV and not on ART - what additional ART should be given if preterm labour?

A

TENOFOVIR DF DOUBLE dose

58
Q

What is the benefit of double dose tenofovir in pregnant woman with HIV presenting in PRETERM labour and not on ART?

A

rapidly crosses placenta
preloads neonate
useful if oral route for PEP in neonate delayed

59
Q

BHIVA guidance - risk of neural tube defect in pregnancy on DOLUTEGRAVIR?

A

DTG 2 per 1000 births

nonDTG 1 per 1000 births

60
Q

At what gestation does the neural tube close?

A

within 6 weeks

61
Q

Are additional anomaly scans recommended for pregnant women exposed to dolutegravir in first trimester?

A

No

As per national guidance only

62
Q

What physiological changes occur in pregnancy?

A 
INCREASED
- gastrointestinal pH
- gut transit time
- body water and fat
- cardiac output, ventilation, liver and renal blood flow
DECREASE
- plasma protein concentration
CHANGE
- to metabolic enzyme pathway in liver ie CYP450
63
Q

What change to nevirapine in pregnancy should be considered?

A

switch 400mg MR to

200mg BD

64
Q

In what scenarios is darunavir/ritonavir recommended to be given twice daily in pregnancy?

A
  • starting ART in pregnancy
  • known PI resistance
  • HIV 2
65
Q

What is the risk of vertical transmission for HIV2 vs HIV1?

A

less common than HIV1

0-4%

66
Q

What is the recommended ART regimen in pregnancy and HIV2?

A

TDF/FTC
+
DARUNAVIR/ritonavir TWICE daily

67
Q

For viral hepatitis infection in pregnancy, what assessment of fibrosis can take place?

A

Blood based fibrosis score (ie Fib4)

fibroscan or biopsy contraindicated

68
Q

In HIV+viral hepatitis co-infection, when should LFTs be checked following ART start?

A

TWO & FOUR weeks

69
Q

In HIV+viral hepatitis co-infection, why should LFTs be checked 2 & 4 weeks after ART start?

A
  • ART hepatotoxicity

- hepatitis flare due to IRIS

70
Q

What anti-HBV agents can be used in pregnancy?

A 
TDF
emtricitabine
lamivudine
(TAF - after 1st trimester)
TELBIVUDINE
71
Q

Which popular antiHBV agent cannot be used in pregnancy?

A

ENTECAVIR

72
Q

Why is ENTECAVIR not recommended in pregnancy?

A

CARCINOGENIC potential

73
Q

What are the benefits of emtricitabine vs lamivudine?

A

longer INTRACELLULAR half life

resistance less rapid

74
Q

Which ART should be avoided in HIV+viral hepatitis co-infection?

A

Nevirapine
Zidovudine
Didanosine
Stavudine

75
Q

Viral hepatitis + HIV in pregnancy - when is hepatitis A vaccination recommended?

A

after first trimester

0 and 6 months

76
Q

Viral hepatitis + HIV in pregnancy - in what scenario is a THIRD dose of hepatitis A vaccine recommended?

A

CD4 <300

0, 1 & 6 months

77
Q

Postpartum viral hepatitis flares - what factor is a predictor of risk of flare?

A

eAg positive

78
Q

Viral hepatitis + HIV in pregnancy - what is the recommended mode of delivery?

A

Dependent on HIV VL

- can be vaginal irrespective of HBV viral load

79
Q

What FOUR situations does the neonate require Hepatitis B immunoglobulin?

A

maternal HBV DNA >10^6
eAg positive
eAntibody negative
eAntibody status unknown

80
Q

Within what time period should hepatitis B immunoglobulin be given to the neonate post party, if indicated?

A

24 hours

81
Q

What HBV DNA viral load seems to result in reduced vertical transmission?

A

<200 000

82
Q

What THREE things reduce risk for HBV vertical transmission?

A

DNA <200 000
Neonatal HBIG (if eAg +ve, eAb -ve or unknown, high DNA)
Neonatal HBV vaccine

83
Q

What is the rate of Hepatitis C vertical transmission?

A

5%

84
Q

What impact does hepatitis C + HIV co-infection have on the risk of vertical transmission of either?

A

Increased risk of vertical transmission

85
Q

If a person is treated for PEG interferon for viral hepatitis, the function of which gland should be monitored?

A

THYROID

86
Q

How long should pregnancy/conception be avoided following RIBAVARIN treatment?

A

SIX months for both MEN and WOMEN

87
Q

If a women with hepatitis C is planning pregnancy, what action should be taken?

A

PRIORITISE for DAA treatment

88
Q

What is the hepatitis B vaccine schedule recommended in women with either HIV or HCV and pregnant?

A

Accelerated course
0, 1 and 4 months
after first trimester

89
Q

When does HCV vertical transmission most likely take place?

A

IN UTERO

90
Q

What antenatal screening is recommended for pregnant women with HIV?

A 
as per national guidelines
Trisomy 13, 18, 21 screening
11-14 weeks
US for foetal anomaly
18-21 weeks
91
Q

What impact can HIV have on the tests used for screening for trisomy?

A

increased BHCG
BHCG is associated with Downs
therefore HIV can result in false-positive trisomy screen

92
Q

At what stage can amniocentesis be considered in pregnant women living with HIV?

A

viral load <50

93
Q

Pregnant women + HIV, not on ART, needs amniocentesis urgently - what ART do you start?

A

3 or 4 drug regimen including RALTEGRAVIR
+
NEVIRAPINE 2-4 hours BEFORE procedure

94
Q

When can external cephalic version (for breech position) be offered to women with HIV?

A

VL undetectable

from 36 weeks

95
Q

At what gestation must the viral load be <50 to allow vaginal delivery?

A

36 weeks

96
Q

If viral load is between 50 and 399 at 36 weeks gestation what is the recommendation for delivery?

A

Pre-labour C-section

consider actual viral load, trajectory, length of ART, women’s views and obstetric factors

97
Q

If viral load is between >400 at 36 weeks gestation what is the recommendation for delivery?

A

Pre-labour C-section

98
Q

What is the increased risk of vertical transmission with every increase in 1 log^10?

A

2.4 fold increase

99
Q

When should pre-labour C-section be scheduled for in pregnant women with HIV?

A

if VL >50
- 38-39 weeks
if VL <50 and C-section for obstetric reason
- 39 weeks

100
Q

When should maternal corticosteroid be considered for pregnant women undergoing pre-labour C-section?

A

if C-section planned before 39 weeks

101
Q

Following term spontaneous rupture of membranes in a woman with HIV, when should delivery complete by?

A

within 24 hours

102
Q

What is the management of intrapartum pyrexia following SROM in woman with HIV?

A

low threshold for antibiotics

chorioamnionitis associated with vertical transmission

103
Q

SROM at 34-37 weeks gestation + HIV - what is the management?

A

Delivery by 24 hours

Group B streptococcus prophylaxis

104
Q

SROM at <34 weeks gestation + HIV - what is the management?

A

Intramuscular steroids
+/- erythomycin
Discuss delivery with MDT

105
Q

When is IV zidovudine recommended intrapartum?

A

VL >1000
Untreated woman
VL unknown
Consider if VL 50-1000

106
Q

In what type of birth centre should women with HIV deliver?

A

with onsite paediatric care for neonatal PEP

107
Q

Within what time period must PEP be administered to neonate following delivery?

A

within 4 hours

108
Q

Neonatal PEP - VERY LOW RISK - criteria?

A
  • ART >10 weeks
  • TWO viral load <50 FOUR weeks apart
  • viral load <50 on or after 36 weeks
109
Q

Neonatal PEP - LOW RISK - criteria?

A 
- less than 10 weeks ART
or
- less than TWO undetectable viral loads
and
- viral load <50 on or after 36 weeks
110
Q

Neonatal PEP - HIGH RISK - criteria?

A
  • viral load expected or known >50
111
Q

Neonatal PEP - LOW RISK - treatment?

A
  • oral zidovudine FOUR weeks
112
Q

Neonatal PEP - VERY LOW RISK - treatment?

A
  • oral zidovudine TWO weeks
113
Q

Neonatal PEP - HIGH RISK - treatment?

A
  • oral nevirapine TWO weeks

- oral zidovudine & lamivudine FOUR weeks

114
Q

Neonatal PEP for HIV2 - HIGH RISK - treatment?

A

Seek advice, nevirapine NOT effective

  • oral RALTEGRAVIR
  • oral zidovudine & lamivudine
115
Q

What situation might indicate infant PEP out with the neonatal period?

A

significant HIV exposure

eg. detectable viral load + breastfeeding

116
Q

What dose of ZIDOVUDINE is given as neonate PEP?

A

Based on gestation and weight

2mg - 4mg/kg TWO to THREE times daily

117
Q

What dose of LAMIVUDINE is given as neonate PEP?

A

2mg/Kg TWICE daily

118
Q

What dose of NEVIRAPINE is given as neonate PEP?

A

2mg/Kg daily for 1 week then 4mg/kg daily
or
4mg/Kg daily (if mother has had 3 days NVP before delivery)

119
Q

When is PCP prophylaxis for infant indicate?

A

From 4 weeks

If HIV PCR +ve

120
Q

Neonate vaccination + exposed to HIV - recommendation?

A

Follow national vaccine schedule if low or very low risk of vertical transmission

121
Q

What SIX factors increase the risk of HIV transmission via breast milk?

A

1) DETECTABLE viral load
2) ADVANCED maternal DISEASE
3) Longer DURATION of breastfeeding
4) Breast and nipple INFLAMMATION
5) Infant MOUTH or GUT inflammation
6) mixed feeding

122
Q

What is the difference of HIV transmission via breast feeding for 6 and 12 months?

A

6 months 0.3%

12 months 0.6%

123
Q

BHIVA recommendation for breastfeeding?

A

High income country

  • FORMULA feed safest option
  • no transmission risk
124
Q

What is the benefit of CABERGOLINE for women post party?

A

Suppresses lactation

125
Q

What is the mechanism of action of CABERGOLINE?

A

Dopamine agonist

Suppresses prolactin release

126
Q

If a woman with HIV chooses to breastfeed - what is required?

A

1) Monthly VL - mother and baby
2) Exclusive breast feeding
3) Stop breastfeeding if breast inflammation or mother or infant GI upset

127
Q

If a woman with HIV chooses to breastfeed - how should weaning to solids be managed?

A

standard UK guidance

gradual introduction

128
Q

Infant HIV follow up - non-breast fed?

A 
HIV DNA (or RNA):
-48 hours
- 4-6weeks (2 weeks after PEP)
- 12 weeks (8 weeks after PEP)
HIGH RISK (additional)
- 2 weeks
then
HIV antibody
- 18 -24 months
129
Q

Infant HIV follow up - BREASTFED?

A 
HIV DNA (or RNA):
-48 hours
- 2 weeks
- monthly
then
4 & 8 weeks after stopping breast feeding
then
HIV antibody
- 18 -24 months

DipHIV (14 decks)

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