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Pregnancy Flashcards

1
Q

When should patient be assessed for antenatal and postnatal depression?

A

Booking, 4-6 weeks postpartum, 3-4 months postpartum

As per NICE guidance

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2
Q

When should CD4 be checked?

A

If already on ARVs - one at baseline, one at delivery

If commencing ARVs - as per routine initiation with repeat at delivery

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3
Q

If commencing ARVs in pregnancy when should VL be checked?

A

2-4 weeks after commencing
Once every trimester
At 36 weeks
At delivery

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4
Q

What other blood tests are needed regularly for women commencing ARV in pregnancy?

A

LFTs should be done with each routine blood test

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5
Q

How to manage women commenced on ARV in pregnancy with VL that is not suppressing

A 
Review adherence and concomitant meds
Perform resistance test if appropriate
Consider TDM
Optimise to best regimen
Consider intensification
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6
Q

Which ARVs should be altered during pregnancy?

A

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

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7
Q

Folic acid requirements for pregnant WLWH

A

5mg OD to 12/40 if on Dolutegravir

Any other ARV - 400ug OD as per normal guidelines

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8
Q

When to commence ARVs in pregnancy

A

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

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9
Q

What to prescribe women starting ARVs in pregnancy

A

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

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10
Q

When would you use AZT monotherapy in pregnancy?

A

NOT recommended

Only to be used in women declining ARVs with VL <10,000 who are willing to have c section

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11
Q

When is INSTI based regime recommended for new starters during pregnancy

A

High baseline VL >100,000 where cART is failing to suppress the virus

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12
Q

How should a woman presenting after 28 weeks be managed?

A

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

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13
Q

How to manage an untreated woman presenting in labour at term

A

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

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14
Q

Why is nevirapine given to untreated women presenting in labour?

A

Rapidly crosses placenta

Within 2 hours achieves then maintains effective concentrations in neonate for up to 10 days

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15
Q

Dosing IV zidovudine in labour

A

Load with 2mg/kg for 1 hr.
Then 1mg/kg until cord clamped.

Decreases transmission from 7.5% to 2.9%

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16
Q

Where should pregnant PLWH be reported to for data collection and how

A

NSHPC online
Notification and outcome forms

Forms available for children born to these women also and breastfeeding for surveillance

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17
Q

Which infants should be reported to NSHPC

A

All, regardless of infection status

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18
Q

NSHPC data

A

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

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19
Q

What percentage of women LWH have depressive symptoms

A

30% ASTRA study

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20
Q

Prevalence of pregnancy related domestic values in PLWH

A

14%

Always ask about DV

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21
Q

STIs in pregnancy

A

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

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22
Q

STI screening

A

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

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23
Q

Drugs that are not as effective in pregnancy

A

Elvitegravir
Cobicistat
Darunavir

All trough levels too low to allow complete suppression/avoid resistance

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24
Q

HSV management in pregnancy

A

No conclusive evidence that treating decreases risk of vertical HIV transmission

As per BASHH/RCOG for aciclovir 400mg TDS from 32/40 to delivery

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25
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
26
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)
27
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
28
Can dolutegravir be used in pregnancy?
Only recommended after 6 weeks (confirmed) until further data available 5mg folic acid OD
29
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)
30
Tsepamo study
DTG and NTD | Comparable rates of NTD as in those with non-dtg regimes
31
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
32
Darunavir in pregnancy
If already suppressed on OD darunavir pre pregnancy continue and monitor If initiating - BD
33
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
34
Affect of HBV coinfection on pregnancy
Negligible effect on pregnancy However the HIV infection increases HBV disease progression
35
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
36
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
37
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)
38
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
39
Postpartum management HBV/HIV coinfection
Do not stop ARVs - high risk of acute HBV flare
40
Delivery recommendation for HIV/HBV Coinfected woman
If VL suppressed can have NVD regardless of HBV VL
41
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
42
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
43
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
44
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
45
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
46
Delivery for women with HCV/HIV coinfection
Irrespective of HCV VL if HIV well controlled on ARVs can be recommended for normal vaginal delivery
47
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
48
ECV
Can be offered if VL <50
49
Decision about delivery
Made at 36/40 <50 - normal vaginal delivery 40-400 - pre labour Cs should be considered > 400 pre labour CS recommended
50
Monitoring in labour
Amniotomy, fetal scalp electrodes, instrumental delivery, episiotomy all ok if suppressed on ARVs Evidence reassuring regarding inductions
51
VBAC
Can be offered if VL <50
52
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
53
Management of SROM
Expedite - should deliver within 24hrs if VL <50 Cs or deliver within 24h if 50-400 CS within 24hrs if >400
54
SROM 34-37 weeks
Will need GBS prophylaxis as well as deliver within 24hrs
55
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
56
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
57
Where should women with HIV give birth?
A facility with direct access to paediatric care
58
Can WLWH have water birth?
Scant safety evidence | Can be supported if VL <50
59
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
60
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
61
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
62
When to start neonatal PEP
ASAP at least within 4 hours
63
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
64
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)
65
Why is neonatal nevirapine only for 2 weeks
Long half life, risk of resistance if transmission has occurred and on nvp monotherapy
66
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
67
Infant pep after 2/4 weeks
Shouldn’t be restarted or continued even in breastfeeding- reassess if significant exposure
68
PCP prophylaxis
If HIV PCR positive at any time start from 1 month old- stop if proven to be hiv negative
69
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
70
PROMISE trial
Transmission rate 0.3% at 6 months, 0.6% at 12 months
71
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
72
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
73
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
74
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
75
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

DipHIV (7 decks)

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