HIV + pregnancy Flashcards
What is the prevalence of women living with HIV and giving birth in the UK?
2%
Prior to antenatal screening for HIV and ART in pregnancy what was the rate of vertical transmission?
25%
What is the current rate of vertical transmission of HIV if the mother is on ART and undetectable?
VERY low
0.1%
What is the currently stable number of perinatal HIV infections occurring in the UK?
30-40 per year
Does genital HSV increase the risk of vertical transmission of HIV?
No studies have confirmed
one study showed reduced HIV replication in genital tract when aciclovir added - unclear if clinical relevance
What is the recommendation for women who are pregnant and have previously had genital HSV?
offer
ACICLOVIR 400mg three times daily
from week 32
What scenarios are associated with increased vertical transmission of HIV?
chorioamnionitis
prolonged rupture of membranes (PROM)
premature birth
What organism or condition is implicated in chorioamnionitis?
Ureasplasma urealyticum
ie BV
When should a pregnant WLW HIV be screened for STI including BV?
early in pregnancy
&
28 weeks
What is the recommendation for a women who is pregnant and due ROUTINE cervical smear?
DEFER to 3 months post partum
When should colposcopy take place for a women who is pregnant and has ABNORMAL cytology from cervical smear?
late FIRST or early SECOND trimester
When should colposcopy take place for a women who is pregnant and is HPV POSITIVE on cervical smear?
Defer until after pregnancy
When should colposcopy take place for a women who is pregnant and has had recent treated or untreated CIN?
can be deferred until after pregnancy
however
follow up should be seen
What is the recommendation for a women who is pregnant and requires FOLLOW UP COLPOSCOPY following treatment for CIN2 or 3?
Do not delay
When should CD4 count be measured in women who are pregnant with HIV?
BASELINE & DELIVERY or as per ART start
When should VL be measured in women who are pregnant with HIV?
2-4 weeks after ART start
every TRIMESTER
36 weeks
DELIVERY
In women presenting late pregnant and new diagnosis of HIV what is the potential benefit of a VL 2 weeks after ART start?
more rapid assessment of ADHERENCE
When should LFTs be performed in women who are pregnant with HIV?
with all ROUTINE bloods
What can deranged LFTs be a sign of in women who are pregnant with HIV?
ART toxicity obstetric cholestasis pre-eclampsia HELLP acute fatty liver
If a women who is pregnant with HIV is not undetectable on ART what are the principles of management?
check ADHERENCE RESISTANCE test consider therapeutic DRUG MONITORING OPTIMISE best regimen consider INTENSIFICATION
Which ART readily crosses the placenta?
TENOFOVIR DF
RALTEGRAVIR
NEVIRAPINE
Which is the only ART licensed in pregnancy?
Zidovudine
If a women is on effective ART and becomes pregnant, what is the general recommendation?
Remain on current ART
If a women is on ART and becomes pregnant which regimens should consider switch or change in dosing schedule?
pharmokinetics: COBICISTAT boosted ART RAL daily dosing neural tube defect: DOLUTEGRAVIR if 1st trimester ???
What is the recommended NRTI backbone in pregnancy?
TDF/FTC
or
ABC/3TC
What is the recommended 3rd ART in pregnancy?
EFAVIRENZ
or
ATAZANAVIR/ritonavir
Which ART combination demonstrated increased risk of neonatal death and premature deliver in PROMISE trial?
TDF/FTC
+
LOPINAVIR/ritonavir
Why is the ART combination TDF/FTC + LOPINAVIR/ritonavir not recommended?
increased risk of
neonatal DEATH
&
PREMATURITY
What are alternative 3rd ART in pregnancy other than efavirenz or atazanavir?
Darunavir/ritonavir
Raltegravir BD
Rilpivirine
Dolutegravir (after 6 weeks)
If a pregnant women on ART has intermittent drug exposure due to hyperemesis gravidarum, what is the recommendation?
Stop ART until hyperemesis controlled
When should ART be started in pregnant women who are elite controllers of HIV?
Start ART immediately, no delay
What dose of folic acid for women trying to conceive on dolutegravir?
5mg daily
Timing of ART start - pregnant woman - VL <30 000?
asap SECOND trimester
Timing of ART start - pregnant woman - VL 30 000 - 100 000?
EARLY SECOND trimester
Timing of ART start - pregnant woman - VL >100 000?
FIRST trimester
Timing of ART start - pregnant woman - CD4 <200?
FIRST trimester, regardless of VL
By what gestation should all pregnant woman have started ART?
24 weeks
What is the median length of ART treatment associated with no vertical transmission in women starting ART in pregnancy?
16 weeks
Starting ART after what gestation is associated with increased risk of VL TRANSMISSION?
30 weeks
Starting ART after what gestation is associated with REDUCED likelihood of VL SUPPRESSION?
20 weeks
How does a history of previous premature delivery alter ART start timing in a pregnant woman?
Start ART earlier and independent of viral load
What dosing schedule should be considered if using darunavir/ritonavir in pregnancy?
TWICE daily
600mg/100mg
When can TAF be considered as ART in pregnancy?
after first trimester
What is the preferred PI in pregnancy?
ATAZANAVIR
What is the definition of late presentation with HIV in pregnancy?
28 weeks gestation onwards
What ART class must be included if a pregnant women with HIV presents >28 weeks?
INTEGRASE inhibitor
Pregnant women presenting in labour with HIV and not on ART - how many steps to IMMEDIATE management AT TERM?
FOUR steps
Pregnant women presenting in labour with HIV and not on ART - step 1?
NEVIRAPINE 200mg STAT
Pregnant women presenting in labour with HIV and not on ART - step 2?
ORAL ZIDOVUDINE 300mg
+
LAMIVUDINE 150mg TWICE daily
Pregnant women presenting in labour with HIV and not on ART - step 3?
RALTEGRAVIR 400mg TWICE daily
Pregnant women presenting in labour with HIV and not on ART - step 4?
For duration of labour:
IV ZIDOVUDINE 2mg/kg LOAD over 1 hour
then
IV zidovudine 1mg/kg until cord clamped
Pregnant women presenting in labour with HIV and not on ART - how long is IV ZIDOVUDINE?
Duration of LABOUR
until cord CLAMPED
Pregnant women presenting in labour with HIV and not on ART - what is the BENEFIT of oral nevirapine STAT?
rapid crossing of placenta
effective concentrations in neonate
How LONG does effective nevirapine concentrations last in the neonate following maternal stat dose?
up to TEN days
How QUICKLY can effective nevirapine concentrations be achieved in neonate following maternal stat dose?
within TWO hours
Pregnant women presenting in labour with HIV and not on ART - recommended mode of delivery?
C-section
Pregnant women presenting in labour with HIV and not on ART - what additional ART should be given if preterm labour?
TENOFOVIR DF DOUBLE dose
What is the benefit of double dose tenofovir in pregnant woman with HIV presenting in PRETERM labour and not on ART?
rapidly crosses placenta
preloads neonate
useful if oral route for PEP in neonate delayed
BHIVA guidance - risk of neural tube defect in pregnancy on DOLUTEGRAVIR?
DTG 2 per 1000 births
nonDTG 1 per 1000 births
At what gestation does the neural tube close?
within 6 weeks
Are additional anomaly scans recommended for pregnant women exposed to dolutegravir in first trimester?
No
As per national guidance only
What physiological changes occur in pregnancy?
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
What change to nevirapine in pregnancy should be considered?
switch 400mg MR to
200mg BD
In what scenarios is darunavir/ritonavir recommended to be given twice daily in pregnancy?
- starting ART in pregnancy
- known PI resistance
- HIV 2
What is the risk of vertical transmission for HIV2 vs HIV1?
less common than HIV1
0-4%
What is the recommended ART regimen in pregnancy and HIV2?
TDF/FTC
+
DARUNAVIR/ritonavir TWICE daily
For viral hepatitis infection in pregnancy, what assessment of fibrosis can take place?
Blood based fibrosis score (ie Fib4)
fibroscan or biopsy contraindicated
In HIV+viral hepatitis co-infection, when should LFTs be checked following ART start?
TWO & FOUR weeks
In HIV+viral hepatitis co-infection, why should LFTs be checked 2 & 4 weeks after ART start?
- ART hepatotoxicity
- hepatitis flare due to IRIS
What anti-HBV agents can be used in pregnancy?
TDF emtricitabine lamivudine (TAF - after 1st trimester) TELBIVUDINE
Which popular antiHBV agent cannot be used in pregnancy?
ENTECAVIR
Why is ENTECAVIR not recommended in pregnancy?
CARCINOGENIC potential
What are the benefits of emtricitabine vs lamivudine?
longer INTRACELLULAR half life
resistance less rapid
Which ART should be avoided in HIV+viral hepatitis co-infection?
Nevirapine
Zidovudine
Didanosine
Stavudine
Viral hepatitis + HIV in pregnancy - when is hepatitis A vaccination recommended?
after first trimester
0 and 6 months
Viral hepatitis + HIV in pregnancy - in what scenario is a THIRD dose of hepatitis A vaccine recommended?
CD4 <300
0, 1 & 6 months
Postpartum viral hepatitis flares - what factor is a predictor of risk of flare?
eAg positive
Viral hepatitis + HIV in pregnancy - what is the recommended mode of delivery?
Dependent on HIV VL
- can be vaginal irrespective of HBV viral load
What FOUR situations does the neonate require Hepatitis B immunoglobulin?
maternal HBV DNA >10^6
eAg positive
eAntibody negative
eAntibody status unknown
Within what time period should hepatitis B immunoglobulin be given to the neonate post party, if indicated?
24 hours
What HBV DNA viral load seems to result in reduced vertical transmission?
<200 000
What THREE things reduce risk for HBV vertical transmission?
DNA <200 000
Neonatal HBIG (if eAg +ve, eAb -ve or unknown, high DNA)
Neonatal HBV vaccine
What is the rate of Hepatitis C vertical transmission?
5%
What impact does hepatitis C + HIV co-infection have on the risk of vertical transmission of either?
Increased risk of vertical transmission
If a person is treated for PEG interferon for viral hepatitis, the function of which gland should be monitored?
THYROID
How long should pregnancy/conception be avoided following RIBAVARIN treatment?
SIX months for both MEN and WOMEN
If a women with hepatitis C is planning pregnancy, what action should be taken?
PRIORITISE for DAA treatment
What is the hepatitis B vaccine schedule recommended in women with either HIV or HCV and pregnant?
Accelerated course
0, 1 and 4 months
after first trimester
When does HCV vertical transmission most likely take place?
IN UTERO
What antenatal screening is recommended for pregnant women with HIV?
as per national guidelines Trisomy 13, 18, 21 screening 11-14 weeks US for foetal anomaly 18-21 weeks
What impact can HIV have on the tests used for screening for trisomy?
increased BHCG
BHCG is associated with Downs
therefore HIV can result in false-positive trisomy screen
At what stage can amniocentesis be considered in pregnant women living with HIV?
viral load <50
Pregnant women + HIV, not on ART, needs amniocentesis urgently - what ART do you start?
3 or 4 drug regimen including RALTEGRAVIR
+
NEVIRAPINE 2-4 hours BEFORE procedure
When can external cephalic version (for breech position) be offered to women with HIV?
VL undetectable
from 36 weeks
At what gestation must the viral load be <50 to allow vaginal delivery?
36 weeks
If viral load is between 50 and 399 at 36 weeks gestation what is the recommendation for delivery?
Pre-labour C-section
consider actual viral load, trajectory, length of ART, women’s views and obstetric factors
If viral load is between >400 at 36 weeks gestation what is the recommendation for delivery?
Pre-labour C-section
What is the increased risk of vertical transmission with every increase in 1 log^10?
2.4 fold increase
When should pre-labour C-section be scheduled for in pregnant women with HIV?
if VL >50
- 38-39 weeks
if VL <50 and C-section for obstetric reason
- 39 weeks
When should maternal corticosteroid be considered for pregnant women undergoing pre-labour C-section?
if C-section planned before 39 weeks
Following term spontaneous rupture of membranes in a woman with HIV, when should delivery complete by?
within 24 hours
What is the management of intrapartum pyrexia following SROM in woman with HIV?
low threshold for antibiotics
chorioamnionitis associated with vertical transmission
SROM at 34-37 weeks gestation + HIV - what is the management?
Delivery by 24 hours
Group B streptococcus prophylaxis
SROM at <34 weeks gestation + HIV - what is the management?
Intramuscular steroids
+/- erythomycin
Discuss delivery with MDT
When is IV zidovudine recommended intrapartum?
VL >1000
Untreated woman
VL unknown
Consider if VL 50-1000
In what type of birth centre should women with HIV deliver?
with onsite paediatric care for neonatal PEP
Within what time period must PEP be administered to neonate following delivery?
within 4 hours
Neonatal PEP - VERY LOW RISK - criteria?
- ART >10 weeks
- TWO viral load <50 FOUR weeks apart
- viral load <50 on or after 36 weeks
Neonatal PEP - LOW RISK - criteria?
- less than 10 weeks ART or - less than TWO undetectable viral loads and - viral load <50 on or after 36 weeks
Neonatal PEP - HIGH RISK - criteria?
- viral load expected or known >50
Neonatal PEP - LOW RISK - treatment?
- oral zidovudine FOUR weeks
Neonatal PEP - VERY LOW RISK - treatment?
- oral zidovudine TWO weeks
Neonatal PEP - HIGH RISK - treatment?
- oral nevirapine TWO weeks
- oral zidovudine & lamivudine FOUR weeks
Neonatal PEP for HIV2 - HIGH RISK - treatment?
Seek advice, nevirapine NOT effective
- oral RALTEGRAVIR
- oral zidovudine & lamivudine
What situation might indicate infant PEP out with the neonatal period?
significant HIV exposure
eg. detectable viral load + breastfeeding
What dose of ZIDOVUDINE is given as neonate PEP?
Based on gestation and weight
2mg - 4mg/kg TWO to THREE times daily
What dose of LAMIVUDINE is given as neonate PEP?
2mg/Kg TWICE daily
What dose of NEVIRAPINE is given as neonate PEP?
2mg/Kg daily for 1 week then 4mg/kg daily
or
4mg/Kg daily (if mother has had 3 days NVP before delivery)
When is PCP prophylaxis for infant indicate?
From 4 weeks
If HIV PCR +ve
Neonate vaccination + exposed to HIV - recommendation?
Follow national vaccine schedule if low or very low risk of vertical transmission
What SIX factors increase the risk of HIV transmission via breast milk?
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
What is the difference of HIV transmission via breast feeding for 6 and 12 months?
6 months 0.3%
12 months 0.6%
BHIVA recommendation for breastfeeding?
High income country
- FORMULA feed safest option
- no transmission risk
What is the benefit of CABERGOLINE for women post party?
Suppresses lactation
What is the mechanism of action of CABERGOLINE?
Dopamine agonist
Suppresses prolactin release
If a woman with HIV chooses to breastfeed - what is required?
1) Monthly VL - mother and baby
2) Exclusive breast feeding
3) Stop breastfeeding if breast inflammation or mother or infant GI upset
If a woman with HIV chooses to breastfeed - how should weaning to solids be managed?
standard UK guidance
gradual introduction
Infant HIV follow up - non-breast fed?
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
Infant HIV follow up - BREASTFED?
HIV DNA (or RNA): -48 hours - 2 weeks - monthly then 4 & 8 weeks after stopping breast feeding then HIV antibody - 18 -24 months
