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:
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:
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:
NRTIs and Nevirapine (NNRTI's) are usually well tolerated during pregnancy with minimal side effects. The ideal treatment should result in undetectable viral loads.
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.
MTCT primarily occurs during labour due to a number of reasons:
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 involves a specific protocol for managment. This includes:
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.
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