Background

HIV is managed during pregnancy by a Multi-Disciplinary Team including an obstetrician, a paediatrician, a HIV specialist and a specialist midwife. Care involves regular checkups to monitor the disease as well as offer support for pregnant woman. The benefit of this is:

 

  • It helps to ensure women have a better understanding of the disease
  • It encourages treatment compliance and attendance in follow-up clinics.

 

    Antenatal Care

    Guidelines recommend that HIV positive pregnant women should have appointments every month with more regular follow up in cases where the woman has complications or is extremely immunocompromised.

     

    Psychosocial help and support is offered to all women who are either known HIV positive or newly diagnosed with the disease. This is an important part of the care given to these women and should not be overlooked.

     

    Regular monitoring of the disease i.e. CD4 counts, plasma viral load levels (mentioned later in this article) and drug toxicity, is dependent on the HIV specialist’s decision and varies between each patient. 

     

    HIV positive women are offered additional screening tests on top of the routine antenatal appointments and Ultrasound scans that all pregnant women have. This is summarised below:

    Anti-Retroviral Therapy (ART)

     

    There are three groups of drugs currently used in the UK for HIV treatment:

     

     

    1.  Nucleoside Reverse Transcriptase Inhibitors (NRTIs)

     

    2.  Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)

     

    3.  Protease Inhibitors (PIs).

     

     

    Highly Active Anti-Retroviral Therapy (HAART) generally involves a combination of these drugs with NRTIs being prescribed with either one NNRTI or PI.

     

    All HIV women are advised to take HAART during their pregnancy. The following advice is dependent on the patients circumstances:

     

    • Women who require HAART to protect their health are advised to take it continuously throughout their pregnancy and after delivery.

     

    • Women who do not require HAART are advised to take it between 20 and 28 weeks in order to protect their health. They can discontinue the treatment after delivery.

     

    • Zidovudine (NRTI) monotherapy treatment can be given between 20 and 28 weeks to protect the health of women who do not require HIV treatment and are prepared to have a C-section. This includes women who have a plasma viral load of <10,000 copies/ml.

     

    NRTIs and Nevirapine (NNRTI's) are usually well tolerated during pregnancy with minimal side effects. The ideal treatment should result in undetectable viral loads.

     

    Mother-to-Child Transmission

    HIV screening and antiretroviral therapies (ART) help to decrease the risk of mother-to-child transmission (MTCT).

     

    The biggest risk factor for MTCT in the UK is unidentified HIV in pregnancy. With a known diagnosis of HIV, then management by a team of specialist healthcare workers can reduced the risk of MTCT to less than 1%. The risk of transmission is approximately 15-35% if no treatment or interventions are carried out during the pregnancy.

     

    The main determinants of HIV transmission are dependent upon maternal and obstetric factors. Maternal issues include the mother’s plasma viral load and CD4 count. Maternal viral load is the single most  important factor which strongly predicts MTCT.

     

    A high plasma viral load and a low CD4 count both suggest a greater risk for MTCT. However, there is no evidence of a minimal viral load whereby the risk of transmission can be completely excluded. If a woman has a very low CD4 count she may be given prophylactic treatment for Pneumocystis jiroveci (previously called pneumocystis carinii) to prevent further infection.

    Delivery

    MTCT primarily occurs during labour due to a number of reasons:

     

    • Micro transfusions during contractions
    • Ascending infection after rupture of membranes
    • Direct contact of baby with the mother's genital tract secretions

     

    The decision on mode of delivery should be made by 36 weeks gestation. If a caesarean section is to occur, it should be planned for 38-39 weeks gestation in order to avoid membrane rupture and labour.

    Post-Natal Care

    Post-natal care involves a specific protocol for managment. This includes: 

     

    • ART for the baby: Zidovudine is the drug of choice. It is administered immediately after birth and can be stopped after 4-6 weeks if the mother has been on ART during her pregnancy.

     

    • Neonatal Infection Screen: PCR amplification to detect any infections which may have been contracted through placental antibody transmission. The screening test is carried out 4 times: at birth, 3 weeks, 6 weeks and six months.

     

    • Post-natal Observation: There is an increased maternal morbidity rate after delivery and so it is not recommended for women to be discharged immediately.  Infection precautions should be carried out and patients should ideally be placed in a side room for confidentiality reasons.
    •  HIV test: Carried out 1 day, 1 month and 3 months after birth. HIV-antibody test is the definitive test performed at 18 months. A negative result excludes infection.

       

      • Routine Immunisation:Advised except BCG vaccine which can only be administered after the baby is confirmed to be HIV negative.

       

      • Feeding: Due to the risk of MTCT, in developed countries formula feeding is highly recommended and should be the exclusive form of feeding. Oral Cabergoline should be given immediately to suppress lactation.

       

      • Follow-Up: Women who do not need to continue ART can stop their medication after consulting with an HIV specialist. It is also important to arrange a follow-up to provide support including advice on contraception methods which are not contraindicated with ART.

      References

       

      Lyall E.G., Blott M., de Ruiter A., Hawkins D., Mercey D., Mitchzla Z., et al. (2001) Guidelines for the management of HIV infection in pregnant women and the prevention of mother-to-child transmission. HIV Med, 2,pp.314-31.

      Mercey D., de Ruiter A. (2008) Human immunodeficiency virus in pregnancy. Obstetrics, Gynaecology and Reproductive Medicine, 19(3), pp. 75-79.

      National Library of Guidelines: guideline no.39, April 2004, Management of HIV in pregnancy, Royal College of Obstetricians and Gynaecologists, pp 1-12.

      Newell M.L., Dunn D.T., Peckham C.S., Semprini A.E., Pardi G. (1996)Vertical transmission of HIV-1: maternal immune status and obstetric factors. The European Collaborative Study. AIDS, 10, pp.1675-1681.

      Newell M.L. (2006) Current issues in the prevention of mother-to-child transmission of HIV-1 infection. Transactions of the Royal Society of Tropical Medicine and Hygiene, 100, pp.1-5.

      Penn Z., Dixit A. (2006) Human immunodeficiency virus infection in pregnancy. Current Obstetrics and Gynaecology, 16, pp.191-198.

      Sagara Y. (1992) Management of pregnancy of HIV infected woman. Early Human Development, 29, pp.231-232.

      Thorne C., Newell M. (2005) HIV, hepatitis and pregnancy. Women’s Health Medicine, 2(2), pp.40-43.

      Advertisement

      Fastbleep © 2019.