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21 - Maternal Infections > HIV in Pregnancy > Flashcards

HIV in Pregnancy Flashcards

1
Q

How much vertical transmission of HIV is lowered by treatment ?

A

Without treatment 👉25 - 40 %
HAART + Avoid breastfeeding 👉 1%
cART+undetectable viral load👉0.5%

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2
Q

how long does it take for HIV antibodies test & HIV P24 antigen test to be detectable after infection?

A

HIV antibodies test 👉 may take up to 3 months
HIV P24 antigen 👉 within 1 month of infection

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3
Q

What is the role of rapid HIV tests in screening pregnant women?

A

Women of unknown status who present in labour( takes 20 minutes)

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4
Q

What is the incidence of depression in women with HIV?

A

30 - 50 %

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5
Q

When should assessment of depression be undertaken in women with HIV ?

A

At booking
4 - 6 weeks postpartum
3 - 4 months postpartum

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6
Q

How to asses depression in women with HIV?

A

Whooley questions

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7
Q

When to break confidentiality with women diagnosed with HIV ?

A

In order to inform a sexual partner
If appears to want to delay telling

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8
Q

What is the incidence of STD in women with HIV ? When to screen?

A

0- 4 %
Screening is recommended if the pregnant woman newly diagnosed with HIV
Screening is suggested if she is living with HIV

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9
Q

What are the baseline investigations required in pregnant women who are newly diagnosed with HIV ?

A

No additional baseline investigations required ( as performed in general antenatal clinic )

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10
Q

In pregnant women commencing cART in pregnancy what are the additional baseline investigations required ?

A

LFTs : performed as routine initiation of cART & then with each routine blood test

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11
Q

Why to monitor LFTs in pregnant women commencing cART ?

A

Hepatotoxicity may occur as a result of the initiation of cART
Or development of obstetric complications ( HELLP - obstetric cholestasis - preeclampsia - acute fatty liver)

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12
Q

In women conceiving on cART when to measure CD4 count ?

A

Baseline
At delivery

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13
Q

In women who commence cART in pregnancy , when CD4 count should be performed?

A

At initiation of treatment
At delivery

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14
Q

In women who commence cART in pregnancy, when should HIV viral load be performed?

A

2 - 4 weeks of starting treatment
Each trimester
36 week
At delivery

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15
Q

When to do HIV resistance testing?

A

Prior to initiation of treatment
Except: late presenting women
( > 28w)
If they choose to stop cART further HIV resistance testing should be done

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16
Q

What medications from cART that has possible adverse fetal outcomes? How to manage?

A

DOLUTEGRAVIR
Possible neural tube defects
if she is trying to conceive or in the first trimester 5 mg of folic acid
If she isn’t on that drug 👉400mcg

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17
Q

What are the Elite controllers?

A

People with HIV who maintain an undetectable viral load and high CD4 counts without treatment

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18
Q

How long a pregnant woman with HIV will be on medications?

A

Lifelong including elite controllers

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19
Q

When to start cART in women with HIV positive in pregnancy?

A

First trimester: if
Viral load > 100,000 or
CD4 < 200
At the start of 2nd trimester: if
Viral load 30,000 - 100,000
2nd trimester: if
Viral load < 30,000
🚩 all women should have started cART by 24w of pregnancy

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20
Q

What is the management in pregnant women with HIV positive who present > 28w or in labour and not on treatment?

A

Commence cART immediately
& IV zidovudine during labour

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21
Q

What are the investigations that should be done in a pregnant woman with HIV &new HBV infection ?

A

LFTs
HBV DNA quantitative
Antigen e
HAV + HCV + HDV screening

22
Q

How to manage HAV non immune pregnant woman with HIV+ & HBV ?

A

Vaccination after 1st trimester
as per normal schedule
( 0 - 6 months)
If CD4 < 300 👉 ( 0 - 1 - 6 months)

23
Q

What is the mode of delivery recommended if the woman has fully suppressed HIV viral load on cART & HBV infection?

A

Vaginal birth irrespective of HBV viral load

24
Q

Among HCV medications , which drug is contraindicated in pregnancy?

A

Ribavirin ( directly acting antiviral DAA)
If the woman is trying to conceive or discovers she is pregnant should discontinue the drug

25
Q

What vaccinations are recommended in women with both HIV & HCV?

A

1- HBV after the 1st trimester if non immune
2- HAV after the 1st trimester if non immune ( 0 - 6 months) Unless CD4<300 👉( 0 - 1 - 6 months)

26
Q

Updated:
What is the recommended mode of birth in women receiving effective cART for HIV with HCV infection?

A

Vaginal birth irrespective of HCV viral load

27
Q

What are the best fetal screening modalities in HIV+ pregnant women?

A

🚩PAPP-A & NT : not altered by HIV infection or ART ( combined)
🚩NIPT
📌 triple test is altered by :
- increased ßhcg & á- fetoprotein
Lower unconjucated oesteriol
In women with HIV
- reduction in ßhcg in women on ART

28
Q

If invasive prenatal testing is indicated in HIV+ women, when to perform?

A

On cART 👉 deffer until viral load
< 50 RNA copies
Not on cART 👉 commence cART

29
Q

At 36w of gestation; how to determin the mode of delivery in HIV+ women?

A

Viral load < 50 👉 vaginal delivery
Or external cephalic version
Viral load 50 - 399 👉 CONSIDER
Pre labour CS 38 - 39 w
Viral load >400 👉 RECOMMENDED
PRCS 38 - 39 w

30
Q

What is the management in HIV+ women with spontaneous rupture of membranes SROM ?

A

Delivery within 24h
If viral load < 50 👉 immediate induction of labour
If viral load 50 - 399 👉 immediate CS
if viral load > 400 👉 immediate CS

31
Q

What is the management in women with HIV+ & preterm spontaneous rupture of membranes SROM( 34 - 37 w) ?

A

🔴 Delivery within 24h + GBS prophylaxis
If viral load <50 👉 immediate induction of labour +GBS prophylaxis
If viral load >50 👉 immediate CS + GBS prophylaxis

32
Q

What is the management in women with HIV+ & preterm SROM < 34w?

A

1- IM steroids
2- optimization of viral load
3- MDT: to take the decision of the time & mode of the delivery.

33
Q

When to double the dose of medication given to HIV+ women before giving birth?

A

Preterm delivery

34
Q

When is intrapartum IV zidovudine in women with HIV+ recommended ?

A

🍀If viral load > 1000 & in labour or
SROM or PLCS
🍀untreated women presented in labour
CONSIDER IV zidovudine if viral load 50 - 1000 in labour

35
Q

What is the place of birth recommended in HIV + women?

A

Has direct access to paediatric care
Co located birth center
Or obstetric unit

36
Q

About neonatal care of HIV+ women
When to consider the neonate very low risk? How to manage?

A

1- women have been on cART > 10W
&2- two documented maternal viral load < 50 during pregnancy at least 4 weeks apart
&3- maternal viral load <50 at 36w or after
🎀 management: 2 weeks zidovudine monotherapy started within 4h

37
Q

About neonatal care of HIV+ women
When to consider the neonate low risk? How to manage?

A

1- if criteria in ( very low risk) aren’t fulfilled + maternal viral load < 50 at 36w
2- the infant born prematurely & most recent maternal HIV viral load < 50
🎀 management: zidovudine for 4 w
Started within 4h

38
Q

About neonatal care of HIV+ women
When to consider the neonate high risk? How to manage?

A

If maternal viral load > 50 on the day of birth
Or if viral load is unknown
🎀 management: cART ( 3 drugs) 4w
Started within 4h

39
Q

About neonatal care of HIV+ women
When to give IV zidovudine to the neonate instead of orally?

A

Premature infants until enteral feeding is started

40
Q

If the neonate is HIV+ , how to prevent pneumocystic pneumonia?

A

Co trimoxazole from 1 month of age

41
Q

For neonates of HIV+ women how vaccinations should be given?

A

As per the national schedule
* Rotavirus vaccine: is NOT contraindicated unless the baby is HIV+ & severely immunosuppressed
* BCG should not be delayed if indicated in very low risk & low risk babies

42
Q

What are the factors that increase the HIV transmission via breast milk when women are not on cART ?

A

1- detectable HIV viral load
2- advanced maternal HIV disease
3- longer duration of breastfeeding
4- infant mouth infection
5- nipples infection
6- mixed feeding: solid food given to infant less than 2 months

43
Q

What is the breastfeeding advice for women with HIV ?

A

NO BREASTFEEDING

44
Q

What is the criteria to breast feed in women with HIV ?

A

Small on going risk of transmission :
1- suppressed viral load ( during the last trimester of pregnancy)
2- good adherence history
3- monthly attendance to do HIV viral load for her & the baby during breastfeeding and 2 months after stopping breastfeeding

45
Q

What is the maximum duration of breastfeeding in women with HIV allowed?

A

6 months
No solid food / no mastitis / no infant gastrointestinal symptoms/ no detectable viral load

46
Q

When to perform HIV infection test in non breast feed infants ?

A

2 days
Prior to discharge
2 weeks IF HIGH RISK at delivery
6 weeks
12 weeks

47
Q

In non breast feed infants of women with HIV when to check HIV antibodies?

A

*From the first sample from the baby
When the maternal antibodies status is not documented
* (22 - 24) months for seroconversion
* 18 months

48
Q

In breastfed infants of women with HIV , when to test HIV antigen ( molecular diagnostics) ?

A

1- 2 days of age and prior to discharge
2- At 2 weeks
3- Monthly at the duration of breastfeeding
4- 4 w and 8w after cessation of breastfeeding

49
Q

In breastfed infants of women with HIV , when to do antibodies testing?

A

1- First sample from the baby when the maternal antibodies status isn’t documented
2-( 22 - 24) months for seroversion
3- 8 weeks after cessation of breastfeeding

50
Q

When women with HIV should be seen for postpartum follow up?

A

4 - 6 weeks postpartum by a member of MDT

51
Q

Case :
Pregnant 13 w screened HIV+ & counseled to commence cART at 14w what to do now ?

A

Screen for STD
LFTs
CD4 counts

21 - Maternal Infections (13 decks)

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