Maternal Medicine - HIV and Hepatitis Flashcards
How many women a year in the UK are pregnant and HIV positive?
1200
If a woman declines screening at booking when should she be re-tested according to the BHIVA guideline?
Further test offered with specialist
If still declines for point of care test when in labour
What is the rate of mother to child transmission of HIV in the UK?
<0.25
13-30% if unaware of status
When should treatment to reduce MCT start?
Third trimester or 16/40 if VL >30,000
When should treatment start for the woman’s health?
If CD4<= 350 or she has an AIDS defining illness
If VL >100,000 regardless of CD4 count
When should infection prophylaxis be given?
If CD4 <250
What other precautions should be taken if a new diagnosis is made in pregnancy?
Screen previous children
Screen previous partners
Full STI screen including herpes (esp in Africans)
Smear test
What advice can be given if VL is <50?
Can have vaginal birth but need to consider VL trajectory and review therapy if borderline
When should a C/S be offered (ie VL)?
If VL is 50-399 consider C/S +/- repeat of VL depending on trajectory
If VL is >400 offer elective CS at 38-39 weeks
What happens to the risk of MCT following SROM?
Increases by 2% the original risk for every hour following SROM
What advice do BHIVA give re: VL and term SROM?
VL < 50 - augment immediately
VL >1000 - for C/S immediately
VL 50-999 consider C/S depending on clinical picture (ie obstetric hx etc)
When should IV zidovudine be given?
If untreated HIV and in labour
If VL >1000 or unknown
Consider if on monotherapy and having el c/s
What is the guidance for SROM < and > 34/40?
If >34/40 for augmentation with GBS cover
If <34/40 for steroids and conservative management while optimising VL
What is the guidance if mum’s partner has new diagnosis of HIV and she is negative at booking?
Screen for seroconversion in each trimester and near to delivery
Advise barrier methods
Test baby - if negative no follow up
What is the advice for breastfeeding in UK?
Advise not to
If insists on feeding needs to do so exclusively (flora in gut changed by formula - increases transmission from BF)
Carry on ART with monthly VL
Test baby monthly after 10/7 PEP
How many have hepatitis B in the UK?
1 in 1000
What is the risk of transfer of Hepatitis B to the untreated infant?
60-85%
How many infected infants with become chronic carriers of Hep B?
90-95%
What is the risk of chronic liver disease in neonatal hepatitis and how many will die secondary to chronicth disease/hepatocellular Ca?
40%
25% risk death
What is the transmission rate in HBeAg positive mother without intervention?
70-90%
What is the transmission rate in HBeAg negative monther?
10%
When should immunoglobulins (HBIG) be given to baby?
If mum has active infection or if baby <=1.5kg
When should mum be treated with tenofovir or lamivudine and when?
If advancing maternal disease or high VL
Given in third trimester (28/40)
What is the HBV vaccine schedule for baby?
5 vaccines 24 hours 1 month 2 months 12 months Preschool
How long should babies have postnatal HIV prophylaxis for if mum was on cART antenatally following NVD?
4/52
By when should all pregnant women with HIV be commenced on cART?
24/40 even if not reqired for own health
If VL >30,000 start at 13/40
>100,000 may need earlier
Which HIV drugs are used in pregnancy?
Zidovudine, lamivudine
Alternatively:
Tenofovir + emtricitabine
Abacavir + lamivudine
In combination with protease inhibitor
When is zidovudine monotherapy used in pregnancy?
Planned C/S and
VL<10,000 and
CD4 >350
Also: elite controllers - CD4 >350, VL <50 untreated
What ART should be used if HIV diagnosed after 28/40?
And in labour?
Raltegravir - drops VL quickly
In labour - nevirapine single dose
Zidovudine + lamivudine + raltegavir
IV zidovudine
+tenofovir if prem
How long should neonatal PEP be?
4/52
Start within 4 hours of being born (ideally immediately)
If VL undetectable at 36/40 or had an elCS on zidovudine monotherapy - baby can have the same monotherapy
Otherwise trriple drug combination
May need PCP prophylaxis
When should ART be continued postpartum?
- Hx of AIDS defining illness or CD4 <350
- If commenced with CD4 350-500 and co-infected hep
- Can consider all women with CD4 350-500
What is the recommended mode of delivery when VL >=400?
Elective Caesarean Section
How often should the neonate be tested for HIV? (ie not breast fed)
First 48 hours then prior to discharge
6/52
3/12
18/12 for seroconversion
If breast fed - also once monthly and as above
What are the vertical transmission rates of Hep B with no intervention?
90% when HepB e-antigen positive
10% of surface antigen positive, e antigen-negative mother
>90% neoneates infected will become chronic carriers
By how much does vaccination and Ig administration in highly infectious mothers reduce vertical transmssion?
90%
What is the neonatal vaccine schedule for hep B?
Birth 1 month 2 months 6 months 1 year - yest serlogy Preschool booster 3 yrs 4 months
