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DipHIV > Pregnancy > Flashcards

Pregnancy Flashcards

1
Q

When should patient be assessed for antenatal and postnatal depression?

A

Booking, 4-6 weeks postpartum, 3-4 months postpartum

As per NICE guidance

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2
Q

When should CD4 be checked?

A

If already on ARVs - one at baseline, one at delivery

If commencing ARVs - as per routine initiation with repeat at delivery

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3
Q

If commencing ARVs in pregnancy when should VL be checked?

A

2-4 weeks after commencing
Once every trimester
At 36 weeks
At delivery

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4
Q

What other blood tests are needed regularly for women commencing ARV in pregnancy?

A

LFTs should be done with each routine blood test

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5
Q

How to manage women commenced on ARV in pregnancy with VL that is not suppressing

A 
Review adherence and concomitant meds
Perform resistance test if appropriate
Consider TDM
Optimise to best regimen
Consider intensification
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6
Q

Which ARVs should be altered during pregnancy?

A

Switch off any non standard regime (eg PI monotherapy)

Discuss risks of NTD with DTG with patient trying to conceive

Raltegravir should be 400mg BD (not 1200mg OD)

DRV/c, ELV/c - lower pharmacokinetics in pregnancy
Modify to include agents that cross placenta

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7
Q

Folic acid requirements for pregnant WLWH

A

5mg OD to 12/40 if on Dolutegravir

Any other ARV - 400ug OD as per normal guidelines

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8
Q

When to commence ARVs in pregnancy

A

Includes elite controllers

All women encouraged to start and take lifelong

VL <30,000 - ASAP in second trimester
VL 30,000-100,000 - at start of second trimester
VL > 100,000 and/or CD4 <200 - first trimester

All should be started by 24/40

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9
Q

What to prescribe women starting ARVs in pregnancy

A

Truvada or Kivexa as backbone
EFV and ATV/r have best safety data in pregnancy as 3rd agent

RPV, RAL BD, DRV/r BD alternative options

DTG only after 6 weeks gestation which must be confirmed

TAF may be prescribed after first trimester

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10
Q

When would you use AZT monotherapy in pregnancy?

A

NOT recommended

Only to be used in women declining ARVs with VL <10,000 who are willing to have c section

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11
Q

When is INSTI based regime recommended for new starters during pregnancy

A

High baseline VL >100,000 where cART is failing to suppress the virus

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12
Q

How should a woman presenting after 28 weeks be managed?

A

Start ARVs without delay

If VL >100,000 or unknown start 3 or 4 drug regime containing either BD Raltegravir 400mg or DTG 50mg OD

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13
Q

How to manage an untreated woman presenting in labour at term

A

Stat dose 200mg NVP
Commence zidovudine 300mg, lamivudine 150mg BD, Raltegravir 400mg BD
IV zidovudine for duration of labour

If delivery is not imminent consider CS

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14
Q

Why is nevirapine given to untreated women presenting in labour?

A

Rapidly crosses placenta

Within 2 hours achieves then maintains effective concentrations in neonate for up to 10 days

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15
Q

Dosing IV zidovudine in labour

A

Load with 2mg/kg for 1 hr.
Then 1mg/kg until cord clamped.

Decreases transmission from 7.5% to 2.9%

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16
Q

Where should pregnant PLWH be reported to for data collection and how

A

NSHPC online
Notification and outcome forms

Forms available for children born to these women also and breastfeeding for surveillance

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17
Q

Which infants should be reported to NSHPC

A

All, regardless of infection status

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18
Q

NSHPC data

A

89% pregnancies since 2015 have been in women diagnosed preconception

76% since 2015 conceived on ARVs

Vertical transmission rate 200-2016 2.1% - 0.28%

No evidence of increased congenital abnormalities with exposure to RAL and ELV

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19
Q

What percentage of women LWH have depressive symptoms

A

30% ASTRA study

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20
Q

Prevalence of pregnancy related domestic values in PLWH

A

14%

Always ask about DV

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21
Q

STIs in pregnancy

A

Studies from Kenya show reduced HIV RNA shedding in cervix mucosa after treatment of cervicitis

Untreated STI doubles risk of spontaneous preterm birth in PWLWH

BV and maternal fever associated with increased risk of HIV transmission (as chorioamnionitis) - study of abx for this showed no benefit in reducing vertical transmitting

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22
Q

STI screening

A

Including BV - at disclosure of pregnancy and repeat at 28 weeks

In context of full suppression unclear whether increased transmission risk

Sexual transmission risk increased with concomitant STI if detectable

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23
Q

Drugs that are not as effective in pregnancy

A

Elvitegravir
Cobicistat
Darunavir

All trough levels too low to allow complete suppression/avoid resistance

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24
Q

HSV management in pregnancy

A

No conclusive evidence that treating decreases risk of vertical HIV transmission

As per BASHH/RCOG for aciclovir 400mg TDS from 32/40 to delivery

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25
Q

Cervical cytology in pregnancy

A

As per national guidance for all women

If due - defer until 3/12 postpartum

If previous normal colposcopy should still have repeat during pregnancy if due

Unless a clinical contraindication women referred for colp can have it in 1st and 2nd trimester

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26
Q

Can truvada plus kaletra be used in pregnancy?

A

PROMISE study - RCT - showed increased risk of neonatal death and prematurity with tdf/FTC + lpv/r (lpv/r given at higher than standard dose though)

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27
Q

Use of efavirenz in pregnancy

A

Lots of evidence for use of EFV - safe.
However - EFV no longer preferred regime for starting in general
Could use in pregnancy then switch postpartum

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28
Q

Can dolutegravir be used in pregnancy?

A

Only recommended after 6 weeks (confirmed) until further data available

5mg folic acid OD

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29
Q

How to intensify if not suppressing or baseline >100,000

A

Use INSTI - RAL or DTG

Median time to suppress 7 days (compared for 35 in non INSTI arm of study)

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30
Q

Tsepamo study

A

DTG and NTD

Comparable rates of NTD as in those with non-dtg regimes

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31
Q

Risk of NTD with DTG

A

2 per 1000 births vs 1 per 1000 births with other types of ARV

If woman accepts this risk can continue DTG - no need to switch of past 6 weeks by the time we are made aware

Needs incr dosed folic acid

Same scans as normal population

32
Q

Darunavir in pregnancy

A

If already suppressed on OD darunavir pre pregnancy continue and monitor

If initiating - BD

33
Q

How should HIV2 be managed in pregnancy?

A

Transmission less common than with HIV1
Recommend case discussion with HIV2 expert
Truvada, darunavir, ritonavir would be recommended

Baby pep - discuss with expert - zidovudine monotherapy or triple therapy incl ral

34
Q

Affect of HBV coinfection on pregnancy

A

Negligible effect on pregnancy

However the HIV infection increases HBV disease progression

35
Q

Tests when diagnosing new HBV infection in pregnancy

A

HBV DNA quantification, e antigen status, hep A, C and D screening, non invasive liver tests (eg for haemochromatosis, AIH)

LFT repeat 2 and 4 weeks after starting ART (risk iris and hepatotoxicity) then regular monitoring

Liver biopsy and fibroscan contraindicated
Use blood fibrosis markers eg fib4index

36
Q

Management of HBV conifection in pregnancy

A

If not already on ARVs - start tenofovir based regime immediately - ideally with FTC rather than 3TC

Close monitor LFT

Acute hep B possible if already on 3TC but less likely to occur if patient on TDF

Risk from high HBV DNA - acute hepatitis, increased transmission risk - likely to be mitigated by patient likely to already be on TDF with 3TC or FTC

37
Q

For those already on ART for HIV plus Hep B pre pregnancy should regime be changed when discover are pregnant??

A

TDF FTC and 3TC - should not change if virally suppressed as benefit outweighs risk to foetus

Entecavir - in general should only be used with full ARV regime, avoid in pregnancy as has carcinogenic potential

TAF safe after first trimester (IMPAACT 2010)

38
Q

When should hepatitis A vaccine be given in non-immune HIV/HBV coinfected pregnant women?

A

After first trimester at 0 and 6 months as per normal schedule

Additional dose at 1m if CD4 <300

39
Q

Postpartum management HBV/HIV coinfection

A

Do not stop ARVs - high risk of acute HBV flare

40
Q

Delivery recommendation for HIV/HBV Coinfected woman

A

If VL suppressed can have NVD regardless of HBV VL

41
Q

Neonatal immunisation - HBV/HIV coinfected mother

A

HBV vaccine

Plus HBIG if

  • maternal HBV DNA >10
  • and/or eAg pls
  • or anti-HBe negative/unknown

Aim HBV DNA <200,000 at birth - lowers transmission risk

42
Q

Management of HCV coinfection in pregnancy

A

Increased transmission compared to non HIV infected, hep c infected women - therefore ARVs reduce vertical transmission
Higher transmission risk if higher viraemia

43
Q

Investigations for new HCV coinfection in pregnancy

A 
RNA, genotype, subtype
Liver function 
Autoimmune liver 
?haemachromatosis
Hep a, hep b
Ultrasound if suspect advanced liver disease

Biopsy and fibroscan contraindicated in pregnancy

44
Q

HCV/HIV monitoring in pregnancy

A

LFTs 2 and 4 weeks after starting ARVs

Regular monitoring of RNA - not for treatment during pregnancy

Hep A and B vaccines if needed

45
Q

HCV treatment in women of childbearing age

A

Not during pregnancy

Stop if becomes pregnant

Avoid pregnancy during treatment and for 6 months after stopping if ribavarin - if either mum OR dad taking

Need 2 forms of reliable contraception

Prioritised for DAA therapy so can stop as soon as possible in order to become pregnant sooner

46
Q

Delivery for women with HCV/HIV coinfection

A

Irrespective of HCV VL if HIV well controlled on ARVs can be recommended for normal vaginal delivery

47
Q

Antenatal screening

A

As per normal guidelines

BHCG can be increased with PI and NNRTI cART increasing false positives for Downs and increase number of invasive tests offered

Invasive tests should be deferred until VL <50 but if not commence Raltegravir and also stat dose NVP 2-4hrs before procedure

48
Q

ECV

A

Can be offered if VL <50

49
Q

Decision about delivery

A

Made at 36/40

<50 - normal vaginal delivery
40-400 - pre labour Cs should be considered
> 400 pre labour CS recommended

50
Q

Monitoring in labour

A

Amniotomy, fetal scalp electrodes, instrumental delivery, episiotomy all ok if suppressed on ARVs

Evidence reassuring regarding inductions

51
Q

VBAC

A

Can be offered if VL <50

52
Q

When to schedule CS

A

If for high VL needs to be 38-39/40 to avoid onset labour

If only for obstetric complications >39/40

This is to balance against risk of transient tachypnoea of newborn

53
Q

Management of SROM

A

Expedite - should deliver within 24hrs if VL <50

Cs or deliver within 24h if 50-400
CS within 24hrs if >400

54
Q

SROM 34-37 weeks

A

Will need GBS prophylaxis as well as deliver within 24hrs

55
Q

SROM <34/40

A

IM steroids and oral erythromycin
Optimise hiv control
MDT discussion of timing and mode of delivery
Induction recommended to reduce risk of developing chorioamnionitid
Load with ARVs as preterm neonate may not be able to swallow

56
Q

When is IV zidovudine used?

A

For women with VL> 1000 who present in labour, STOM or planned CS

Untreated women presenting in labour or SROM with unknown VL

CAN BE CONSIDERED if 50-1000 but oral will do

57
Q

Where should women with HIV give birth?

A

A facility with direct access to paediatric care

58
Q

Can WLWH have water birth?

A

Scant safety evidence

Can be supported if VL <50

59
Q

Infant PEP

VERY LOW RISK

A

2 weeks zidovudine monotherapy even if maternal zidovudine resistance

IF
cART >10 weeks
VL <50 after 36 weeks
2x VL <50 at least 4 weeks apart in pregnancy

60
Q

Infant PEP

LOW RISK

A

4 weeks zidovudine even if maternal zidovudine resistance

If not all criteria are fulfilled but VL <50 at 36 weeks
Or
If infant born <34 weeks but maternal VL <50

61
Q

Infant PEP

HIGH RISK

A

4 weeks zidovudine/lamivudine/nevirapine (2 weeks NVP)

VL > 50, or unknown, or uncertainty about maternal adherence

If maternal resistance start anyway then seek guidance

62
Q

When to start neonatal PEP

A

ASAP at least within 4 hours

63
Q

Infant PEP dosage

Low/very low risk

A

> 34 weeks - 2 or 4 weeks of AZT oral 4mg/kg BD or IV 1.5mg/kg IV QDS over 60mins

30-34 weeks - oral 2mg/kg bd 2 weeks THEN 2mg/kg TDS for 2 weeks . if IV 1,5mg/kg bd until 34 weeks then 4 weeks 1.5mg/kg QDS for 4 weeks

Less than 30 weeks - 2mg/kg oral BD 4 weeks - if IV 1.5mg/kg for 4 weeks BD

64
Q

Infant PEP doses

HIGH RISK

A

3TC 4mg/kg bd 4/52

NVP - if mother not on NVP 2mg/kg OD one week then 4mg/kg one week
If mother >3 days NVP - 4mg/kg OD for 2 weeks

AZT
>34/40 - oral 4mg/kg bd 4 weeks (iv 1.5mg/kg QDS 4/52)
30-34/40 - 2mg/kg bd 2 weeks then tds 2 weeks (if IV 1.5mg/kg bd to 34 weeks, then QDS for 4 more weeks)
<30/40 - oral 2mg/kg bd 4 weeks (1.5mg/kg bd 4 weeks)

65
Q

Why is neonatal nevirapine only for 2 weeks

A

Long half life, risk of resistance if transmission has occurred and on nvp monotherapy

66
Q

Infant PEP with maternal HIV2 infection

A

Low and very low risk as per hiv 1

Nevirapine not effective so give AZT, 3TC and RAL if high risk

67
Q

Infant pep after 2/4 weeks

A

Shouldn’t be restarted or continued even in breastfeeding- reassess if significant exposure

68
Q

PCP prophylaxis

A

If HIV PCR positive at any time start from 1 month old- stop if proven to be hiv negative

69
Q

Infant immunisation

A

As per national schedule
Rotavirus unless confirmed to be infected and severely immunosuppressant
If low or very low risk give BCG at birth

70
Q

PROMISE trial

A

Transmission rate 0.3% at 6 months, 0.6% at 12 months

71
Q

Breastfeeding

A

Formula is recommended as no data to support U=U

If want to BF - can be supported if fully suppressed, good adherence, strong engagement with MDT.
exclusive BF whilst adhering to CART for first 6 months
Monthly clinic reviews and baby testing until 2 months after stopping BF

72
Q

Testing for non breastfed infants

A

During first 48hrs and prior to discharge. A
At 6 weeks.
At 12 weeks.
At 2 weeks of high risk.

Antibody testing - if no maternal antibody documented should be tested at first sample from infant, 22-24 months for seroreversion

73
Q

Testing for breastfed infants

A

Within 48hrs or predischarge
At 2 weeks
Monthly during breastfeeding
4 and 8 weeks after cessation of breastfeeding

Antibody testing - first sample from infant if maternal not documented, 22-24months or minimum 8 weeks after finishing breastfeeding if this is later

74
Q

Management of infant HIV infection

A

Septrin from 4 weeks
Refer to a specialist centre
Feed back to obstetric team for investigation into avoidable factors in transmission

75
Q

Postnatal care

A

Lifelong ARVs
Follow up at 4-6 weeks
Mental health assessment
Condoms until first review then discuss contraception
Smears can restart after 3 months
If new diagnosis in pregnancy - children and partner need testing

DipHIV (7 decks)

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