Human immunodeficiency virus (HIV) Type I and Type II with more than 40 million people affected worldwide. Two million women pregnant yearly.
Pregnancy does not have a major adverse effect on HIV progression in asymptomatic woman (advanced disease may deteriorate).
Mother to child transmission in the absence of any treatment setting varies in non-breast feeding woman from 15-40% and it is higher in patients with HIV symptoms, low antenatal CD4-T lymphocyte counts and specially high viral loads. The risk of transmission with maternal virus load less than 500 copies/ml is very low.
Women diagnosed HIV positive during pregnancy should be informed that interventions (such as anti-retroviral therapy given antenatal and intrapartum and to the neonate for the first 4-6 weeks of life, cesarean section and avoidance of breastfeeding) can reduce the risk of mother-to-child HIV transmission from 25-30% to less than 2%.
Prophylaxis of pneumocystis carinii pneumonia (PCP) is usually administered when the CD4 T-lympocytes count is below 20-0 x 106/l. Women taking anti-retroviral drugs should be monitored for drug toxicities (full blood count, urea and electrolytes, liver function tests, lactate and blood glucose) and should have a detailed ultrasound scan to detect fetal anomalies
Whether periconceptual folate is effective in reducing the risk of neural tribe defects in those taking folate antagonists such as co-trimoxazole is unknown.
Presentation with symptoms or signs of pre-eclampsia, cholestasis or other signs of liver dysfunction during pregnancy may indicate drug toxicity and early liaison with HIV physicians should be sought.
Other anti-retroviral drug toxicities include gastrointestinal disturbances, hepatotoxicity, rashes, glucose intolerance and diabetes.
All pregnant women who are HIV should be screened for genital infections during pregnancy. This should be done as early as possible in pregnancy and repeated at around 28 weeks.
In women not requiring treatment for their own health anti-retroviral therapy is usually commenced between 28 and 32 weeks of gestation.
Treatment
All pregnant women who are HIV positive should be offered
anti-retroviral therapy to prevent mother-to-child transmission.
17 anti-retroviral drugs are currently licensed for the treatment of HIV infection but Zidovudine is the only anti-retroviral drug specifically indicated for use in pregnancy and is the only anti-retroviral drug available for intravenous administration.
Potent combinations of three or more anti-retroviral drugs, known as HAART, have now become the standard of care for HIV positive individuals requiring anti-retroviral therapy for their own health. HAART is indicated usually for those with CD4 T-lymphocyte count of 200-350 x 106/l). Optimum treatment of the mother will result in full suppression of plasma viraemia to undetectable levels (less than 50 copies/ml by current assays).
The women usually have a low plasma viral load less than 10,000-20,000 copies/ml) and a well-preserved CD4 T-lymphocyte count (greater than 350 x 106/l).
Two therapeutic options for women who do not yet require HIV treatment for their own health.
One option is simplified single-agent Zidovudine regimen, given orally twice daily antenatally, intravenously intrapartum and discontinued immediately after delivery.
An alternative option is a short-term anti-retroviral therapy (START) regimen, where HAART is taken for the duration of the pregnancy and discontinued shortly after delivery provided that the maternal vital load is undetectable.
Women with advanced HIV should be treated with a HAART regimen. The start of treatment should be deferred until after the first trimester, if possible, and should be continued after delivery.
These women are likely to have symptomatic HIV infection, a failing or low CD-4 T-lymphocyte count (less than 350 x 106/l) and/or a high viral load (greater than 10,000-20,000 copies/ml).
Women who conceive while taking HAART should continue their HAART regimen if it is effectively suppressing plasma viraemia. For women whose regimen is not suppressing viraemia, a change in therapy after the first trimester may be indicated.
Women who present with HIV late in pregnancy or during labor, such that a formal immunological and virological
assessment is not possible should be treated with HAART, to include Zidovudine. Zidovudine should be administered intravenously intrapartum and the HAART regimen should be continued intrapartum and postpartum until the results of the CD4 T-lymphocyte count and plasma viral load are known.
Cesarean section should be advised and the woman received prophylactic antibiotic. With very low viral load some suggest vaginal delivery, but other suggest cesarean section if labor not expected 4-6 hours after rupture of membranes. Before delivery or during labor, Retrovir (Zidovudine) 2 mg/kg/IV in one hour continue with 1 mg/kg/IV until delivery. Start 4 hours before cesarean section and until umbilical clamped. Child Handle with gloves and washed from maternal blood. The child is handed to the pediatrician and should receive Zedovudine. Blood test -- for HIV infection to be taken on the second day (not umbilical cord blood because of contamination) then 3 weeks, 6 weeks, 6 months. The definitive test is a negative HIV antibody test at 18 months of age. Pre-pregnancy management: No transmission in woman inseminated with washed sperm. References: (1) Nelson Pierce. Management of HIV in Pregnancy. Royal College of Obstetricians and Gynecologists. Guideline No. 39. April 2004. (2) Management of HIV in pregnancy. Royal College of Obstetricians and Gynecologists. Guideline No. 39. April 2004.
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