OGCO-C2.3 Universal antenatal screening for HIV and HIV infection in pregnancy

Question 1

What is the antepartum Mx of HIV in pregnancy?

Answer 1

Aspects of care include monitoring of HIV viral load, CD4+ count+/- pneumocystic carinii prophylaxis, drug toxicities and contact tracing. Combination antiretroviral therapy (cART) should be started early during prengnacy. Those with HBV coinfection should recieve tenofovir based cART regimen

• Routine antenatal blood tests should be done
• Look out for oppurtunitistic infections
• STD screening at booking viist and consider repeat at 28 weeks of gestation
• Cervical smear if clinically indicated
• High dose 5mg folic acid should be given if patient is on cotrimoxazole
• Advise on condom use
• Inform paeds doctor on changes of drug regime
• ECV can be offered to women with plasma viral load <50 HIV RNA copies/mL

Question 2

What is the intrapartum Mx of HIV in pregnancy?

Answer 2

Combination antiretroviral therapy (cART) recommended regimen to prevent MTCT. Mode of delivery decided after review of plasma HIV viral load results at 36 weeks of gestation.

• Women with plasma viral load of <50HIV RNA copies/ml at 36 weeks and in the absence of obstretic complications, planned vaginal delivery should be supported. VBAC can be offered to women with a viral load <50HIV RNA copies/mL
• Women with a plasma viral load of 50-399 HIV RNA copies/mL at 36 weeks, elective C-section should be considered, taking into account the actual viral load, length of time on treatment, adherence issues, obstretic factors and the womens views
• For women with a plasma viral load of >400 HIV RNA copies/mL at 36 weeks, elective Caesarean section is recommended

Question 3

What is Mx of HIV pregnant women with PROM?

Answer 3

Delivery within 24 hours should be the aim

• If maternal HIV viral load is <50copiesmL, immediate induction or augmentation of labor is recommended in women who have PROM, with a low threshold for treatment of intrapartum pyrexia
• For women with SROM and a last measured plasma viral load of 50-399HIV RNA copies/mL, immediate CS recommended, but should taken into account the actual viral load, length of time on treatment, adherence issues, obstretic factors and womens views
• For women with SROM and maternal HIV viral load >400HIV RNA copies/mL, immediate CS is recommended

Artifical rupture of membranes should be avoided. Fetal blood sampling and fetal scalp electrode insertion should be avoided due to theoretical transmission risks. Instrumental delivery is not contraindicated.

Question 4

What is tx for untreated HIV women presenting in labor at term>

Answer 4

starting antiretroviral therapy early is more important than the route of delivery in preventing MTCT. All women should therefore be given:-
* One stat dose of Nevirapine 200 mg
* Oral Zidovudine 300 mg and Lamivudine 150 mg bd
* Raltegravir 400 mg bd
* Intravenous Zidovudine (IV bolus 2mg/kg, then 1mg/kg/hour till delivery) for the duration of labour

Neonatal prophylaxis should be commenced as soon as possible after birth, and at least within 4 hours. The regimen should be decided by the neonatal team. BCG vaccination should be withheld.

Question 5

What is Mx of postpartum management of HIV in pregnancy

Answer 5

• All women are recommended to continue cART postpartum.
• Breastfeeding is contraindicated
• Advise on contraception, annual cervical smear and mood assessment should be done at the postnatal clinic
• Long term follow-up with the HIV physician or at DH should be arranged/continued for maternal health

Question 6

What is flowchart for ugent HIV testing in antenatal or labor ward setting?

Answer 6