Pregnancy Flashcards
When should patient be assessed for antenatal and postnatal depression?
Booking, 4-6 weeks postpartum, 3-4 months postpartum
As per NICE guidance
When should CD4 be checked?
If already on ARVs - one at baseline, one at delivery
If commencing ARVs - as per routine initiation with repeat at delivery
If commencing ARVs in pregnancy when should VL be checked?
2-4 weeks after commencing
Once every trimester
At 36 weeks
At delivery
What other blood tests are needed regularly for women commencing ARV in pregnancy?
LFTs should be done with each routine blood test
How to manage women commenced on ARV in pregnancy with VL that is not suppressing
Review adherence and concomitant meds Perform resistance test if appropriate Consider TDM Optimise to best regimen Consider intensification
Which ARVs should be altered during pregnancy?
Switch off any non standard regime (eg PI monotherapy)
Discuss risks of NTD with DTG with patient trying to conceive
Raltegravir should be 400mg BD (not 1200mg OD)
DRV/c, ELV/c - lower pharmacokinetics in pregnancy
Modify to include agents that cross placenta
Folic acid requirements for pregnant WLWH
5mg OD to 12/40 if on Dolutegravir
Any other ARV - 400ug OD as per normal guidelines
When to commence ARVs in pregnancy
Includes elite controllers
All women encouraged to start and take lifelong
VL <30,000 - ASAP in second trimester
VL 30,000-100,000 - at start of second trimester
VL > 100,000 and/or CD4 <200 - first trimester
All should be started by 24/40
What to prescribe women starting ARVs in pregnancy
Truvada or Kivexa as backbone
EFV and ATV/r have best safety data in pregnancy as 3rd agent
RPV, RAL BD, DRV/r BD alternative options
DTG only after 6 weeks gestation which must be confirmed
TAF may be prescribed after first trimester
When would you use AZT monotherapy in pregnancy?
NOT recommended
Only to be used in women declining ARVs with VL <10,000 who are willing to have c section
When is INSTI based regime recommended for new starters during pregnancy
High baseline VL >100,000 where cART is failing to suppress the virus
How should a woman presenting after 28 weeks be managed?
Start ARVs without delay
If VL >100,000 or unknown start 3 or 4 drug regime containing either BD Raltegravir 400mg or DTG 50mg OD
How to manage an untreated woman presenting in labour at term
Stat dose 200mg NVP
Commence zidovudine 300mg, lamivudine 150mg BD, Raltegravir 400mg BD
IV zidovudine for duration of labour
If delivery is not imminent consider CS
Why is nevirapine given to untreated women presenting in labour?
Rapidly crosses placenta
Within 2 hours achieves then maintains effective concentrations in neonate for up to 10 days
Dosing IV zidovudine in labour
Load with 2mg/kg for 1 hr.
Then 1mg/kg until cord clamped.
Decreases transmission from 7.5% to 2.9%
Where should pregnant PLWH be reported to for data collection and how
NSHPC online
Notification and outcome forms
Forms available for children born to these women also and breastfeeding for surveillance
Which infants should be reported to NSHPC
All, regardless of infection status
NSHPC data
89% pregnancies since 2015 have been in women diagnosed preconception
76% since 2015 conceived on ARVs
Vertical transmission rate 200-2016 2.1% - 0.28%
No evidence of increased congenital abnormalities with exposure to RAL and ELV
What percentage of women LWH have depressive symptoms
30% ASTRA study
Prevalence of pregnancy related domestic values in PLWH
14%
Always ask about DV
STIs in pregnancy
Studies from Kenya show reduced HIV RNA shedding in cervix mucosa after treatment of cervicitis
Untreated STI doubles risk of spontaneous preterm birth in PWLWH
BV and maternal fever associated with increased risk of HIV transmission (as chorioamnionitis) - study of abx for this showed no benefit in reducing vertical transmitting
STI screening
Including BV - at disclosure of pregnancy and repeat at 28 weeks
In context of full suppression unclear whether increased transmission risk
Sexual transmission risk increased with concomitant STI if detectable
Drugs that are not as effective in pregnancy
Elvitegravir
Cobicistat
Darunavir
All trough levels too low to allow complete suppression/avoid resistance
HSV management in pregnancy
No conclusive evidence that treating decreases risk of vertical HIV transmission
As per BASHH/RCOG for aciclovir 400mg TDS from 32/40 to delivery
Cervical cytology in pregnancy
As per national guidance for all women
If due - defer until 3/12 postpartum
If previous normal colposcopy should still have repeat during pregnancy if due
Unless a clinical contraindication women referred for colp can have it in 1st and 2nd trimester
Can truvada plus kaletra be used in pregnancy?
PROMISE study - RCT - showed increased risk of neonatal death and prematurity with tdf/FTC + lpv/r (lpv/r given at higher than standard dose though)
Use of efavirenz in pregnancy
Lots of evidence for use of EFV - safe.
However - EFV no longer preferred regime for starting in general
Could use in pregnancy then switch postpartum
Can dolutegravir be used in pregnancy?
Only recommended after 6 weeks (confirmed) until further data available
5mg folic acid OD
How to intensify if not suppressing or baseline >100,000
Use INSTI - RAL or DTG
Median time to suppress 7 days (compared for 35 in non INSTI arm of study)
Tsepamo study
DTG and NTD
Comparable rates of NTD as in those with non-dtg regimes
Risk of NTD with DTG
2 per 1000 births vs 1 per 1000 births with other types of ARV
If woman accepts this risk can continue DTG - no need to switch of past 6 weeks by the time we are made aware
Needs incr dosed folic acid
Same scans as normal population
Darunavir in pregnancy
If already suppressed on OD darunavir pre pregnancy continue and monitor
If initiating - BD
How should HIV2 be managed in pregnancy?
Transmission less common than with HIV1
Recommend case discussion with HIV2 expert
Truvada, darunavir, ritonavir would be recommended
Baby pep - discuss with expert - zidovudine monotherapy or triple therapy incl ral
Affect of HBV coinfection on pregnancy
Negligible effect on pregnancy
However the HIV infection increases HBV disease progression
Tests when diagnosing new HBV infection in pregnancy
HBV DNA quantification, e antigen status, hep A, C and D screening, non invasive liver tests (eg for haemochromatosis, AIH)
LFT repeat 2 and 4 weeks after starting ART (risk iris and hepatotoxicity) then regular monitoring
Liver biopsy and fibroscan contraindicated
Use blood fibrosis markers eg fib4index
Management of HBV conifection in pregnancy
If not already on ARVs - start tenofovir based regime immediately - ideally with FTC rather than 3TC
Close monitor LFT
Acute hep B possible if already on 3TC but less likely to occur if patient on TDF
Risk from high HBV DNA - acute hepatitis, increased transmission risk - likely to be mitigated by patient likely to already be on TDF with 3TC or FTC
For those already on ART for HIV plus Hep B pre pregnancy should regime be changed when discover are pregnant??
TDF FTC and 3TC - should not change if virally suppressed as benefit outweighs risk to foetus
Entecavir - in general should only be used with full ARV regime, avoid in pregnancy as has carcinogenic potential
TAF safe after first trimester (IMPAACT 2010)
When should hepatitis A vaccine be given in non-immune HIV/HBV coinfected pregnant women?
After first trimester at 0 and 6 months as per normal schedule
Additional dose at 1m if CD4 <300
Postpartum management HBV/HIV coinfection
Do not stop ARVs - high risk of acute HBV flare
Delivery recommendation for HIV/HBV Coinfected woman
If VL suppressed can have NVD regardless of HBV VL
Neonatal immunisation - HBV/HIV coinfected mother
HBV vaccine
Plus HBIG if
- maternal HBV DNA >10
- and/or eAg pls
- or anti-HBe negative/unknown
Aim HBV DNA <200,000 at birth - lowers transmission risk
Management of HCV coinfection in pregnancy
Increased transmission compared to non HIV infected, hep c infected women - therefore ARVs reduce vertical transmission
Higher transmission risk if higher viraemia
Investigations for new HCV coinfection in pregnancy
RNA, genotype, subtype Liver function Autoimmune liver ?haemachromatosis Hep a, hep b Ultrasound if suspect advanced liver disease
Biopsy and fibroscan contraindicated in pregnancy
HCV/HIV monitoring in pregnancy
LFTs 2 and 4 weeks after starting ARVs
Regular monitoring of RNA - not for treatment during pregnancy
Hep A and B vaccines if needed
HCV treatment in women of childbearing age
Not during pregnancy
Stop if becomes pregnant
Avoid pregnancy during treatment and for 6 months after stopping if ribavarin - if either mum OR dad taking
Need 2 forms of reliable contraception
Prioritised for DAA therapy so can stop as soon as possible in order to become pregnant sooner
Delivery for women with HCV/HIV coinfection
Irrespective of HCV VL if HIV well controlled on ARVs can be recommended for normal vaginal delivery
Antenatal screening
As per normal guidelines
BHCG can be increased with PI and NNRTI cART increasing false positives for Downs and increase number of invasive tests offered
Invasive tests should be deferred until VL <50 but if not commence Raltegravir and also stat dose NVP 2-4hrs before procedure
ECV
Can be offered if VL <50
Decision about delivery
Made at 36/40
<50 - normal vaginal delivery
40-400 - pre labour Cs should be considered
> 400 pre labour CS recommended
Monitoring in labour
Amniotomy, fetal scalp electrodes, instrumental delivery, episiotomy all ok if suppressed on ARVs
Evidence reassuring regarding inductions
VBAC
Can be offered if VL <50
When to schedule CS
If for high VL needs to be 38-39/40 to avoid onset labour
If only for obstetric complications >39/40
This is to balance against risk of transient tachypnoea of newborn
Management of SROM
Expedite - should deliver within 24hrs if VL <50
Cs or deliver within 24h if 50-400
CS within 24hrs if >400
SROM 34-37 weeks
Will need GBS prophylaxis as well as deliver within 24hrs
SROM <34/40
IM steroids and oral erythromycin
Optimise hiv control
MDT discussion of timing and mode of delivery
Induction recommended to reduce risk of developing chorioamnionitid
Load with ARVs as preterm neonate may not be able to swallow
When is IV zidovudine used?
For women with VL> 1000 who present in labour, STOM or planned CS
Untreated women presenting in labour or SROM with unknown VL
CAN BE CONSIDERED if 50-1000 but oral will do
Where should women with HIV give birth?
A facility with direct access to paediatric care
Can WLWH have water birth?
Scant safety evidence
Can be supported if VL <50
Infant PEP
VERY LOW RISK
2 weeks zidovudine monotherapy even if maternal zidovudine resistance
IF
cART >10 weeks
VL <50 after 36 weeks
2x VL <50 at least 4 weeks apart in pregnancy
Infant PEP
LOW RISK
4 weeks zidovudine even if maternal zidovudine resistance
If not all criteria are fulfilled but VL <50 at 36 weeks
Or
If infant born <34 weeks but maternal VL <50
Infant PEP
HIGH RISK
4 weeks zidovudine/lamivudine/nevirapine (2 weeks NVP)
VL > 50, or unknown, or uncertainty about maternal adherence
If maternal resistance start anyway then seek guidance
When to start neonatal PEP
ASAP at least within 4 hours
Infant PEP dosage
Low/very low risk
> 34 weeks - 2 or 4 weeks of AZT oral 4mg/kg BD or IV 1.5mg/kg IV QDS over 60mins
30-34 weeks - oral 2mg/kg bd 2 weeks THEN 2mg/kg TDS for 2 weeks . if IV 1,5mg/kg bd until 34 weeks then 4 weeks 1.5mg/kg QDS for 4 weeks
Less than 30 weeks - 2mg/kg oral BD 4 weeks - if IV 1.5mg/kg for 4 weeks BD
Infant PEP doses
HIGH RISK
3TC 4mg/kg bd 4/52
NVP - if mother not on NVP 2mg/kg OD one week then 4mg/kg one week
If mother >3 days NVP - 4mg/kg OD for 2 weeks
AZT
>34/40 - oral 4mg/kg bd 4 weeks (iv 1.5mg/kg QDS 4/52)
30-34/40 - 2mg/kg bd 2 weeks then tds 2 weeks (if IV 1.5mg/kg bd to 34 weeks, then QDS for 4 more weeks)
<30/40 - oral 2mg/kg bd 4 weeks (1.5mg/kg bd 4 weeks)
Why is neonatal nevirapine only for 2 weeks
Long half life, risk of resistance if transmission has occurred and on nvp monotherapy
Infant PEP with maternal HIV2 infection
Low and very low risk as per hiv 1
Nevirapine not effective so give AZT, 3TC and RAL if high risk
Infant pep after 2/4 weeks
Shouldn’t be restarted or continued even in breastfeeding- reassess if significant exposure
PCP prophylaxis
If HIV PCR positive at any time start from 1 month old- stop if proven to be hiv negative
Infant immunisation
As per national schedule
Rotavirus unless confirmed to be infected and severely immunosuppressant
If low or very low risk give BCG at birth
PROMISE trial
Transmission rate 0.3% at 6 months, 0.6% at 12 months
Breastfeeding
Formula is recommended as no data to support U=U
If want to BF - can be supported if fully suppressed, good adherence, strong engagement with MDT.
exclusive BF whilst adhering to CART for first 6 months
Monthly clinic reviews and baby testing until 2 months after stopping BF
Testing for non breastfed infants
During first 48hrs and prior to discharge. A
At 6 weeks.
At 12 weeks.
At 2 weeks of high risk.
Antibody testing - if no maternal antibody documented should be tested at first sample from infant, 22-24 months for seroreversion
Testing for breastfed infants
Within 48hrs or predischarge
At 2 weeks
Monthly during breastfeeding
4 and 8 weeks after cessation of breastfeeding
Antibody testing - first sample from infant if maternal not documented, 22-24months or minimum 8 weeks after finishing breastfeeding if this is later
Management of infant HIV infection
Septrin from 4 weeks
Refer to a specialist centre
Feed back to obstetric team for investigation into avoidable factors in transmission
Postnatal care
Lifelong ARVs
Follow up at 4-6 weeks
Mental health assessment
Condoms until first review then discuss contraception
Smears can restart after 3 months
If new diagnosis in pregnancy - children and partner need testing
