HIV in Pregnancy

Question 1

A HIV positive G1P0 is concerned about vertical transmission. How would you advise and manage?

Answer 1

Impression
Concerned about HIV positive status in pregnancy.

Main priority is preventing vertical transmission to baby in ante- and postpartum period. Vertical transmission can occur during pregnancy, birth, or through breastfeeding. early preventative measure can reduce the risk of transmission to <2%.

Would conduct thorough Hx/Ex/Ix, clarify patient’s existing understanding of condition, engage in appropriate counselling, advise optimal management program.

Question 2

HIV in Pregnancy - History

Answer 2

History

• sx: ask about sx of AIDS: fatigue, lethargy, myalgia/arthralgia, opportunistic infections, malignancies, fevers, weight loss, night sweats
• PC: details of HIV diagnosis. timing, treatment, viral load,
• RISKS: IVDU, sexual practices
• O&G hx: GTPAL, other STI hx, fetal movements, yellow card, scans to-date
• PMHx
• Medications
• SNAP

Question 3

HIV in Pregnancy - Examination

Answer 3

Examination

• general appearance + vitals
• systems review: evidence of opportunistic infections/AIDS defining illnesses
• Antenatal examinations

Question 4

HIV in Pregnancy - Investigations

Answer 4

Investigations
- Bedside: Confirm pregnancy w ß-HCG, 
For HIV
- confirm diagnosis w ELISA/Western Blot assay
- HIV RNA viral load
- CD4 T cell count

Screen for associated diseases:
- CMV, EBV, HEPA/B/C, TB

Baselines for HAART monitoring
- Bloods: FBC, UEC, LFT, ESR/CRP, HbA1C, BSL, Lipid panel

Question 5

HIV in Pregnancy- Management

Answer 5

Management
Key components
- referral to high-risk unit/ maternal fetal medicine unit
- referral to HIV clinic/ physician/ ID physician
- yellow-card confidentiality; HIV not recorded but medications are
- patient education, psychosocial support/ referrals
- counselling: risk of transmission is 2% on HAART, 20% untreated, and 40% untreated + breastfeeding

Definitive

• initiate HAART treatment prior to 2nd trimester
• plan mode of delivery based on viral load closer to due date, can go for NVD if low viral load, otherwise caesarean.
• minimise mixing of maternal/fetal blood,
• IV zidovudine if viral load >400 copies/mL

Infant

• referral to HIV/ID physician
• start medical treatment (NRTI) either PO or IV depending on risk of transmission having occurred, escalate to additional treatments if high-risk
• regular follow-up for 5 years