HIV IN PREGNANCY

Perinatal Transmission of HIV:
  • Vertical transmission
  • Transplacental transmission
  • Vertical transmission is more in cases with preterm birth and with prolonged membrane rupture.
  • Risks of vertical transmission are directly related to the maternal viral load and inversely related to the maternal immune status.
  • Maternal antiretroviral therapy reduces the risk of vertical transmission.
  • Pregnancy has got no effect on HIV progression. Increased incidence of abortion, prematurity, IUGR and perinatal mortality in HIV-seropositive mothers still remains inconclusive. Maternal mortality and morbidity are not increased. 
Management:
Perinatal care:

  • Voluntary serologic testing for HIV
  • In seropositive cases, tests for other STDs
  • Counselling about the risk of HIV transmission
  • Progression of disease assessed by the CD4+ count and viral (HIV RNA) load
  • Antiretroviral therapy: Triple chemotherapy is prefferred as a first line defence and to be started any time between 14 and 34 weeks and then continued throughout pregnancy, labors and postpartum period.
Intrapartum care:
  • Zidovudine given IV infusion starting at the onset of labor (vaginal delivery) or 4 hrs before Cesarian Section (CS). Loading dose 2 mg/kg/hr and maintenance dose 1 mg/kg/hr until cord is clamped.
  • Elective CS reduces the risk of vertical transmission by about 50%. Cord should be clamped.
  • Elective CS reduces the risk of vertical transmission by about 50%. Cord shoud be clamped as early as possible and the baby should be bathed immediately.
  • Avoid procedures that result in break in the skin or mucous membrane of the infants. Amniotomy, attachment of scalp eletrode and determination of scalp blood pH should be avoided. Caps, masks, gowns and double gloves should be worn. Protective eyewear (goggles) should be used.
  • Blunt-tipped needle should be used and appropriate sterilization of instruments and linens should be done.
  • Post-exposure prophylaxis with triple therapy for 4 weeks reduces the risk of seroconversion by more than 80%.
Guidelines for Management of HIV in Pregnancy is as Follows:
  • If maternal HIV RNA level is more than 1000 copies/mL, the combination antiretroviral therapy is indicated.
  • For women with no treatment prior to labor, intrapartum prophylaxis is appropriate with zidovudine, zidovudine with lamivudine, zidovudine with nevirapine, or nevirapine alone. LSCS is recommended for HIV-infected women whose HIV-1 RNA load exceeds 1000 copies/mL.
  • There is no need to omit ergometrine and it can be given safely to HIV-positive mother.
  • Breastfeeding should be avoided.
HIV can be transmitted in pregnancy:
  • During delivery (most common)
  • In utero
  • During breastfeeding
Highest risk is associated with:
  • High maternal viral load
  • Low CD4 T-cell count Chorioamnionitis
  • Vitamin A deficiency
Lower risk is associated with:
  • LSCS
  • Antiretroviral prophylaxis (Zidovudine)
  • Avoiding breastfeeding
  • Vitamin A prophylaxis
  • Intrapartum nevirapine
  • Nevirapine administered as a single dose each to the mother and child within 72 hrs after birth is used to prevent vertical transmission of human immunodeficiency virus (HIV) under the prevention of parent-to­child transmission (PPTCT) of HIV program. 
  • Nevirapine is a non-nucleoside reverse transcriptase inhibitor (NNRTI) antiretroviral drug. It noncompetitively inhibits the reverse transcriptase enzyme and slows down HIV replication. It has been used as a part of highly active antiretroviral therapy (HAART) for long, and recently employed singly for prevention of vertical transmission of HIV. The efficacy of single-dose nevirapine in preventing vertical transmission of HIV has been proved beyond doubt.
  • Single-dose nevirapine (SDNVP) given to mothers at labor onset and to their newborns has been shown to be effective in reducing mother-to-child transmission (MTCT) of HIV by nearly half.
  • Order HIV lab investigation
  • Start Zidovudine or IV Zidovudine plus Nevirapine
  • Nevirapine at onset of labor 200 mg single dose given
  • Maximum vertical transmission (2/3rd) occurs at delivery
MATERNAL AND FETAL-NEONATAL INFECTION
  • Mother-to-child transmission accounts for most pediatric HIV infections.
  • Transplacental transmission can occur early, and the virus has been identified in specimens from elective abortion.
  • In most cases, the virus is transmitted peripartum, and 15 to 40 percent of neonates born to non breast feeding, untreated, HIV-infected mothers are infected
  • 20 percent of transmission occurs before 36 weeks, 50 percent in the days before delivery, and 30 percent intrapartum.
  • Transmission rates for breast feeding may be as high as 30 to 40 percent.
  • Exclusively top feeding is recommended in HIV-infected child
  • Vertical transmission is more common in preterm births, especially those associated with prolonged membrane rupture.
  • Concurrent syphilis infection is common and is also associated with vertical perinatal HIV transmission
  • Infection with Isospora belli is very common that may cause diahorrea 
  • There is evidence that placental inflammation and chorioamnionitis may increase HIV-1 transmission by 3 percent.
Exam Question
  • Pregnant lady with AIDS complains of diahorrea and stool examination shows acid fast positive cysts. She has infection with Isospora belli
  • Exclusively top feeding is recommended in HIV-infected child

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