A case based discussion

1. HIV IN PREGNENCY
A Case Based
Discussion
Dhammike Silva

3. BACKGROUND…
50%

4. BACKGROUND…
25%
• 1/3 Late
• CD4 count <
200 cells/ml
at the time of
diagnosis

5. BACKGROUND…
anti-retroviral drugs has transformed the management
since 1990s
restoration of immune function
increasing life expectancy
renders viral loads undetectable
reduces infectivity.

6. BACKGROUND…
2011
WHO
Mother to
child
1993 - 25.6%
2007- 2011-
0.57%

7. Viral load of >100,000 copies/ml - 40 %
1000 copies/ml - 1%
At undetectable VL (<50 copies/ml) - < 1%

8. TRANSMISSION TO
NEWBORN
Intact placenta acts as a very effective barrier
MTCT at the point of delivery is the commonest mode of
transmission
RISK FACT- high viral load at delivery, prolonged rupture of
membranes, prematurity, vaginal laceration, vaginal ulceration due to
herpes simplex infection or syphilitic ulcers, episiotomy, invasive fetal
monitoring and instrumental delivery
Post-partum exclusively due to breast feeding - up to 40% of

9. CASE HISTORY
25 yrs, P2 C0
MF 2.5 yrs
Husband- works at a saloon, denied extramarital affairs, 3 tattoos +
Index case- had an affair 5 yrs back with a three wheel driver, he was
diagnosed to have HIV + in 2016
P1 –
2 months following marriage, not aware about HIV status
12 wk of POA HIV AB done, report not available
T1 developed UTI & herpes zoster

10. CASE HISTORY
P1-
Premature delivery at 34/52, 1950 g
PBU for 11 days
Following 2/12 vaccination infant develop PUO
At SCBU THK, HIV AB became +
1/52 following diagnosis infant died due to severe pneumonia at Peradeniya
Hospital. (11/11/2015)
 Soon after mother and father both diagnosed HIV +
 2/12 following ( Jan 2016) mother started on ART

11. CASE HISTORY
 Monthly regular follow up & on ART
 five months following became pregnant while on ART
 LMP - 15/5/2016
 EDD – 22/2/2017
 antenatal and STl regular follow- December/Jan both viral count
undetectable
 at 38+5 admitted for EL/LSCS as decided
 EFW 2489 g, AFI & Doppler normal
 Anaesthetic & neonatology referrals arranged on admission

12. CASE MX - ANTENATAL
Started on ART ( Tenofovir, Emtricitabine, Efavirenz
since 2015)
No interruption
Even while fasting

13. ANTENATAL
STI screening yearly - The British HIV Association (BHIVA)
Twice during pregnancy – 1st & 3rd trimesters
chlamydia, syphilis, hepatitis, gonorrhoea and herpes
could potentially be transmitted
Test of cure should be performed following treatment for
any bacterial STI’s
Whooping cough vaccine and vitamin D should be offered
to women regardless of their HIV status.

14. ART
Viral load of less than 50 copies/ml (undetectable) and
who do not breast feed - 0.5% chance of transmitting the
virus
Should commence ART by 24 POG
Each week of ART reduces the odds of transmission by
8%
MTCT are lower in women who became pregnant on ART
Different types of ART used do not influence the rate of

15. ANTENATAL PROCEDURES
RR of HIV transmission of 1.9 with antenatal procedures
like
Amniocentesis
Cerclage
laser therapy
Amnioscopy
(The French Paediatric HIV Infection Study Group )
ART regimen including raltegravir (associated with rapid
viral load suppression) should be given along with single
dose of nevirapine 2-4 hours prior to the procedure

16. CASE MX - MOD
EL/LSCS at 38 POG
MDT – Con. Venereologist, Obstetrician, Anaesthetist,
Peadiatrcian
 Sister/ Nursing officer of Infection control unit, OT, ICU
 Spinal /Epidural not CI
 Antibiotic routine prophylaxis
 ARV without interruption on day of LSCS

17. Table
preparati
on

18. Protective
Kits

19. Waste
disposal

20. MOD
Historically a planned EL/ LSCS was the method of
choice for delivery
Effective control of viral load with ART more and
more women having vaginal deliveries.
Decision regarding MOD - after review of viral load at
36 weeks.
Planned vaginal delivery is recommended for
women on ART with an undetectable viral load in
the absence of obstetric complications (BHIVA guidelines)

21. MOD
MTCT rates of <0.5% in women with plasma viral
load <50 cp/ml taking ART, irrespective of MOD
(Published cohort data from the UK and other
European countries )
viral load is > 400 copies/ml at 36 weeks a planned
caesarean section is recommended regardless of the
ART agents

22. TOD
The timing of LSCS is a balance between …
Where the indication is to prevent MTCT, at 38-39 weeks
Women with an undetectable viral load and ROM at term - should
have immediate IOL
risks of
transient
tachypnoea
of the
newborn
labour
occurring
before the
scheduled
caesarean
section.

23. INTRAPARTUM CARE
There are theoretical reasons why a low traction
forceps may be preferred to a ventouse delivery (with
potential lower rates of fetal trauma)
- no data /evidence
Use of fetal scalp electrodes/fetal blood sampling ,
safe if viral load undetectable

24. LATE PRESENTERS…
If a woman presents after 28 weeks and is
subsequently found to be infected with HIV - should
start treatment without delay.
If a woman presents in labour & not on treatment,
should be given a stat dose of nevirapine ( rapidly
crosses the placenta , effective concentrations are
achieved within 2 hours and then maintained in the
neonate for up to 10 days)

25. CASE- MX OF NEWBORN
Clean the eyes with saline at delivery
Clamp cord as soon as possible
Cover umbilical cord with a swab- prevent blood
spurting
Avoid suction baby’s mouth & pharynx
Towel dry, bath as soon as possible, done at theatre

26. CASE- MX OF NEWBORN

27. NEONATAL POST EXPOSURE
PROPHYLAXIS
Antiretroviral treatment to the newborn is an example of
preexposure prophylaxis
should be decided before the delivery
The choice of the drugs given to the baby depends on the
mother’s antiretroviral drug history and known resistance
mutations
Monotherapy is usually sufficient, should be given for 4
weeks

28. CASE – NEONATAL PEP
Syrup nevirapine started daily
Dosing according to BW
As soon as possible, 1st dose given at theatre
Once daily for 6 weeks

29. NEONATAL POST EXPOSURE
PROPHYLAXIS
2 situations where triple combination (i.e. ART) neonatal
PEP is advised:
mother is found to be HIV positive after delivery (whereby treatment needs
given within 72 hours),
when there is detectable maternal viraemia at birth.
In addition Pneumocystis pneumonia (PCP) prophylaxis
should be started at 4 weeks-
all HIV infected infants
infants with an initial positive HIV DNA/RNA test
infants whose mothers viral load at 36 weeks or delivery is >1000 copies/ml

30. BREAST FEEDING
Women who breast feed may transmit HIV
There may be wide variations between plasma and
breast milk viral load
Risk high if–
viral load in plasma and breast milk is high,
premature delivery
breastfeeding is prolonged
nipples are cracked

31. BREAST FEEDING
Current standard of care in the UK is to avoid
breastfeeding in HIV positive mothers
Mixed feeding is thought to double the risk of HIV
transmission secondary to inflammation of gut

32. CASE MX- BREAST FEEDING
Mother agreed on exclusive formula feeding
Educated in maintaining sterility in preparation
Cabergoline to mother
Messures to prevent mastitis & breast abscess formation
Mother is provided separate container to discard breast milk
Should discard as clinical waste

33. CASE- NEWBORN TESTING
2 cc blood, EDTA bottle
Within 24 hours
Sent for RNA PCR
Sample send to reference laboratory, national STD/AIDS
control programme, Colombo

34. TESTING OF INFANTS
All infants born to HIV positive mothers should be tested
for HIV
HIV DNA PCR (or HIV RNA testing however this may
require more blood volume to test) should be performed
during the first 48 hours
2 weeks post infant prophylaxis (6 weeks of age)
2 months post infant prophylaxis (12 weeks of age)

35. TESTING OF INFANTS
HIV antibody testing for seroreversion (loss of maternal
antibodies) should be performed at age 18 months.
Diagnosis of in utero transmission can be made by the
identification of proviral DNA through amniocentesis or from
the cord blood/newborns blood sample at birth

36. IMUNIZATION…
BCG vaccination delayed, until HIV status ascertain at 8
weeks
At age of 2,4,6 months- hexavalent which include IPV is
preferred
Other schedule as routine

37. ETHICS…

38. THANK YOU ……..