HIV + pregnancy Flashcards
(129 cards)
1
Q
What is the prevalence of women living with HIV and giving birth in the UK?
A
2%
2
Q
Prior to antenatal screening for HIV and ART in pregnancy what was the rate of vertical transmission?
A
25%
3
Q
What is the current rate of vertical transmission of HIV if the mother is on ART and undetectable?
A
VERY low
0.1%
4
Q
What is the currently stable number of perinatal HIV infections occurring in the UK?
A
30-40 per year
5
Q
Does genital HSV increase the risk of vertical transmission of HIV?
A
No studies have confirmed
one study showed reduced HIV replication in genital tract when aciclovir added - unclear if clinical relevance
6
Q
What is the recommendation for women who are pregnant and have previously had genital HSV?
A
offer
ACICLOVIR 400mg three times daily
from week 32
7
Q
What scenarios are associated with increased vertical transmission of HIV?
A
chorioamnionitis
prolonged rupture of membranes (PROM)
premature birth
8
Q
What organism or condition is implicated in chorioamnionitis?
A
Ureasplasma urealyticum
ie BV
9
Q
When should a pregnant WLW HIV be screened for STI including BV?
A
early in pregnancy
&
28 weeks
10
Q
What is the recommendation for a women who is pregnant and due ROUTINE cervical smear?
A
DEFER to 3 months post partum
11
Q
When should colposcopy take place for a women who is pregnant and has ABNORMAL cytology from cervical smear?
A
late FIRST or early SECOND trimester
12
Q
When should colposcopy take place for a women who is pregnant and is HPV POSITIVE on cervical smear?
A
Defer until after pregnancy
13
Q
When should colposcopy take place for a women who is pregnant and has had recent treated or untreated CIN?
A
can be deferred until after pregnancy
however
follow up should be seen
14
Q
What is the recommendation for a women who is pregnant and requires FOLLOW UP COLPOSCOPY following treatment for CIN2 or 3?
A
Do not delay
15
Q
When should CD4 count be measured in women who are pregnant with HIV?
A
BASELINE & DELIVERY or as per ART start
16
Q
When should VL be measured in women who are pregnant with HIV?
A
2-4 weeks after ART start
every TRIMESTER
36 weeks
DELIVERY
17
Q
In women presenting late pregnant and new diagnosis of HIV what is the potential benefit of a VL 2 weeks after ART start?
A
more rapid assessment of ADHERENCE
18
Q
When should LFTs be performed in women who are pregnant with HIV?
A
with all ROUTINE bloods
19
Q
What can deranged LFTs be a sign of in women who are pregnant with HIV?
A
ART toxicity obstetric cholestasis pre-eclampsia HELLP acute fatty liver
20
Q
If a women who is pregnant with HIV is not undetectable on ART what are the principles of management?
A
check ADHERENCE RESISTANCE test consider therapeutic DRUG MONITORING OPTIMISE best regimen consider INTENSIFICATION
21
Q
Which ART readily crosses the placenta?
A
TENOFOVIR DF
RALTEGRAVIR
NEVIRAPINE
22
Q
Which is the only ART licensed in pregnancy?
A
Zidovudine
23
Q
If a women is on effective ART and becomes pregnant, what is the general recommendation?
A
Remain on current ART
24
Q
If a women is on ART and becomes pregnant which regimens should consider switch or change in dosing schedule?
A
pharmokinetics: COBICISTAT boosted ART RAL daily dosing neural tube defect: DOLUTEGRAVIR if 1st trimester ???
25
What is the recommended NRTI backbone in pregnancy?
TDF/FTC
or
ABC/3TC
26
What is the recommended 3rd ART in pregnancy?
EFAVIRENZ
or
ATAZANAVIR/ritonavir
27
Which ART combination demonstrated increased risk of neonatal death and premature deliver in PROMISE trial?
TDF/FTC
+
LOPINAVIR/ritonavir
28
Why is the ART combination TDF/FTC + LOPINAVIR/ritonavir not recommended?
increased risk of
neonatal DEATH
&
PREMATURITY
29
What are alternative 3rd ART in pregnancy other than efavirenz or atazanavir?
Darunavir/ritonavir
Raltegravir BD
Rilpivirine
Dolutegravir (after 6 weeks)
30
If a pregnant women on ART has intermittent drug exposure due to hyperemesis gravidarum, what is the recommendation?
Stop ART until hyperemesis controlled
31
When should ART be started in pregnant women who are elite controllers of HIV?
Start ART immediately, no delay
32
What dose of folic acid for women trying to conceive on dolutegravir?
5mg daily
33
Timing of ART start - pregnant woman - VL <30 000?
asap SECOND trimester
34
Timing of ART start - pregnant woman - VL 30 000 - 100 000?
EARLY SECOND trimester
35
Timing of ART start - pregnant woman - VL >100 000?
FIRST trimester
36
Timing of ART start - pregnant woman - CD4 <200?
FIRST trimester, regardless of VL
37
By what gestation should all pregnant woman have started ART?
24 weeks
38
What is the median length of ART treatment associated with no vertical transmission in women starting ART in pregnancy?
16 weeks
39
Starting ART after what gestation is associated with increased risk of VL TRANSMISSION?
30 weeks
40
Starting ART after what gestation is associated with REDUCED likelihood of VL SUPPRESSION?
20 weeks
41
How does a history of previous premature delivery alter ART start timing in a pregnant woman?
Start ART earlier and independent of viral load
42
What dosing schedule should be considered if using darunavir/ritonavir in pregnancy?
TWICE daily
| 600mg/100mg
43
When can TAF be considered as ART in pregnancy?
after first trimester
44
What is the preferred PI in pregnancy?
ATAZANAVIR
45
What is the definition of late presentation with HIV in pregnancy?
28 weeks gestation onwards
46
What ART class must be included if a pregnant women with HIV presents >28 weeks?
INTEGRASE inhibitor
47
Pregnant women presenting in labour with HIV and not on ART - how many steps to IMMEDIATE management AT TERM?
FOUR steps
48
Pregnant women presenting in labour with HIV and not on ART - step 1?
NEVIRAPINE 200mg STAT
49
Pregnant women presenting in labour with HIV and not on ART - step 2?
ORAL ZIDOVUDINE 300mg
+
LAMIVUDINE 150mg TWICE daily
50
Pregnant women presenting in labour with HIV and not on ART - step 3?
RALTEGRAVIR 400mg TWICE daily
51
Pregnant women presenting in labour with HIV and not on ART - step 4?
For duration of labour:
IV ZIDOVUDINE 2mg/kg LOAD over 1 hour
then
IV zidovudine 1mg/kg until cord clamped
52
Pregnant women presenting in labour with HIV and not on ART - how long is IV ZIDOVUDINE?
Duration of LABOUR
| until cord CLAMPED
53
Pregnant women presenting in labour with HIV and not on ART - what is the BENEFIT of oral nevirapine STAT?
rapid crossing of placenta
| effective concentrations in neonate
54
How LONG does effective nevirapine concentrations last in the neonate following maternal stat dose?
up to TEN days
55
How QUICKLY can effective nevirapine concentrations be achieved in neonate following maternal stat dose?
within TWO hours
56
Pregnant women presenting in labour with HIV and not on ART - recommended mode of delivery?
C-section
57
Pregnant women presenting in labour with HIV and not on ART - what additional ART should be given if preterm labour?
TENOFOVIR DF DOUBLE dose
58
What is the benefit of double dose tenofovir in pregnant woman with HIV presenting in PRETERM labour and not on ART?
rapidly crosses placenta
preloads neonate
useful if oral route for PEP in neonate delayed
59
BHIVA guidance - risk of neural tube defect in pregnancy on DOLUTEGRAVIR?
DTG 2 per 1000 births
| nonDTG 1 per 1000 births
60
At what gestation does the neural tube close?
within 6 weeks
61
Are additional anomaly scans recommended for pregnant women exposed to dolutegravir in first trimester?
No
| As per national guidance only
62
What physiological changes occur in pregnancy?
```
INCREASED
- gastrointestinal pH
- gut transit time
- body water and fat
- cardiac output, ventilation, liver and renal blood flow
DECREASE
- plasma protein concentration
CHANGE
- to metabolic enzyme pathway in liver ie CYP450
```
63
What change to nevirapine in pregnancy should be considered?
switch 400mg MR to
| 200mg BD
64
In what scenarios is darunavir/ritonavir recommended to be given twice daily in pregnancy?
- starting ART in pregnancy
- known PI resistance
- HIV 2
65
What is the risk of vertical transmission for HIV2 vs HIV1?
less common than HIV1
| 0-4%
66
What is the recommended ART regimen in pregnancy and HIV2?
TDF/FTC
+
DARUNAVIR/ritonavir TWICE daily
67
For viral hepatitis infection in pregnancy, what assessment of fibrosis can take place?
Blood based fibrosis score (ie Fib4)
| fibroscan or biopsy contraindicated
68
In HIV+viral hepatitis co-infection, when should LFTs be checked following ART start?
TWO & FOUR weeks
69
In HIV+viral hepatitis co-infection, why should LFTs be checked 2 & 4 weeks after ART start?
- ART hepatotoxicity
| - hepatitis flare due to IRIS
70
What anti-HBV agents can be used in pregnancy?
```
TDF
emtricitabine
lamivudine
(TAF - after 1st trimester)
TELBIVUDINE
```
71
Which popular antiHBV agent cannot be used in pregnancy?
ENTECAVIR
72
Why is ENTECAVIR not recommended in pregnancy?
CARCINOGENIC potential
73
What are the benefits of emtricitabine vs lamivudine?
longer INTRACELLULAR half life
| resistance less rapid
74
Which ART should be avoided in HIV+viral hepatitis co-infection?
Nevirapine
Zidovudine
Didanosine
Stavudine
75
Viral hepatitis + HIV in pregnancy - when is hepatitis A vaccination recommended?
after first trimester
| 0 and 6 months
76
Viral hepatitis + HIV in pregnancy - in what scenario is a THIRD dose of hepatitis A vaccine recommended?
CD4 <300
| 0, 1 & 6 months
77
Postpartum viral hepatitis flares - what factor is a predictor of risk of flare?
eAg positive
78
Viral hepatitis + HIV in pregnancy - what is the recommended mode of delivery?
Dependent on HIV VL
| - can be vaginal irrespective of HBV viral load
79
What FOUR situations does the neonate require Hepatitis B immunoglobulin?
maternal HBV DNA >10^6
eAg positive
eAntibody negative
eAntibody status unknown
80
Within what time period should hepatitis B immunoglobulin be given to the neonate post party, if indicated?
24 hours
81
What HBV DNA viral load seems to result in reduced vertical transmission?
<200 000
82
What THREE things reduce risk for HBV vertical transmission?
DNA <200 000
Neonatal HBIG (if eAg +ve, eAb -ve or unknown, high DNA)
Neonatal HBV vaccine
83
What is the rate of Hepatitis C vertical transmission?
5%
84
What impact does hepatitis C + HIV co-infection have on the risk of vertical transmission of either?
Increased risk of vertical transmission
85
If a person is treated for PEG interferon for viral hepatitis, the function of which gland should be monitored?
THYROID
86
How long should pregnancy/conception be avoided following RIBAVARIN treatment?
SIX months for both MEN and WOMEN
87
If a women with hepatitis C is planning pregnancy, what action should be taken?
PRIORITISE for DAA treatment
88
What is the hepatitis B vaccine schedule recommended in women with either HIV or HCV and pregnant?
Accelerated course
0, 1 and 4 months
after first trimester
89
When does HCV vertical transmission most likely take place?
IN UTERO
90
What antenatal screening is recommended for pregnant women with HIV?
```
as per national guidelines
Trisomy 13, 18, 21 screening
11-14 weeks
US for foetal anomaly
18-21 weeks
```
91
What impact can HIV have on the tests used for screening for trisomy?
increased BHCG
BHCG is associated with Downs
therefore HIV can result in false-positive trisomy screen
92
At what stage can amniocentesis be considered in pregnant women living with HIV?
viral load <50
93
Pregnant women + HIV, not on ART, needs amniocentesis urgently - what ART do you start?
3 or 4 drug regimen including RALTEGRAVIR
+
NEVIRAPINE 2-4 hours BEFORE procedure
94
When can external cephalic version (for breech position) be offered to women with HIV?
VL undetectable
| from 36 weeks
95
At what gestation must the viral load be <50 to allow vaginal delivery?
36 weeks
96
If viral load is between 50 and 399 at 36 weeks gestation what is the recommendation for delivery?
Pre-labour C-section
| consider actual viral load, trajectory, length of ART, women's views and obstetric factors
97
If viral load is between >400 at 36 weeks gestation what is the recommendation for delivery?
Pre-labour C-section
98
What is the increased risk of vertical transmission with every increase in 1 log^10?
2.4 fold increase
99
When should pre-labour C-section be scheduled for in pregnant women with HIV?
if VL >50
- 38-39 weeks
if VL <50 and C-section for obstetric reason
- 39 weeks
100
When should maternal corticosteroid be considered for pregnant women undergoing pre-labour C-section?
if C-section planned before 39 weeks
101
Following term spontaneous rupture of membranes in a woman with HIV, when should delivery complete by?
within 24 hours
102
What is the management of intrapartum pyrexia following SROM in woman with HIV?
low threshold for antibiotics
| chorioamnionitis associated with vertical transmission
103
SROM at 34-37 weeks gestation + HIV - what is the management?
Delivery by 24 hours
| Group B streptococcus prophylaxis
104
SROM at <34 weeks gestation + HIV - what is the management?
Intramuscular steroids
+/- erythomycin
Discuss delivery with MDT
105
When is IV zidovudine recommended intrapartum?
VL >1000
Untreated woman
VL unknown
Consider if VL 50-1000
106
In what type of birth centre should women with HIV deliver?
with onsite paediatric care for neonatal PEP
107
Within what time period must PEP be administered to neonate following delivery?
within 4 hours
108
Neonatal PEP - VERY LOW RISK - criteria?
- ART >10 weeks
- TWO viral load <50 FOUR weeks apart
- viral load <50 on or after 36 weeks
109
Neonatal PEP - LOW RISK - criteria?
```
- less than 10 weeks ART
or
- less than TWO undetectable viral loads
and
- viral load <50 on or after 36 weeks
```
110
Neonatal PEP - HIGH RISK - criteria?
- viral load expected or known >50
111
Neonatal PEP - LOW RISK - treatment?
- oral zidovudine FOUR weeks
112
Neonatal PEP - VERY LOW RISK - treatment?
- oral zidovudine TWO weeks
113
Neonatal PEP - HIGH RISK - treatment?
- oral nevirapine TWO weeks
| - oral zidovudine & lamivudine FOUR weeks
114
Neonatal PEP for HIV2 - HIGH RISK - treatment?
Seek advice, nevirapine NOT effective
- oral RALTEGRAVIR
- oral zidovudine & lamivudine
115
What situation might indicate infant PEP out with the neonatal period?
significant HIV exposure
| eg. detectable viral load + breastfeeding
116
What dose of ZIDOVUDINE is given as neonate PEP?
Based on gestation and weight
| 2mg - 4mg/kg TWO to THREE times daily
117
What dose of LAMIVUDINE is given as neonate PEP?
2mg/Kg TWICE daily
118
What dose of NEVIRAPINE is given as neonate PEP?
2mg/Kg daily for 1 week then 4mg/kg daily
or
4mg/Kg daily (if mother has had 3 days NVP before delivery)
119
When is PCP prophylaxis for infant indicate?
From 4 weeks
| If HIV PCR +ve
120
Neonate vaccination + exposed to HIV - recommendation?
Follow national vaccine schedule if low or very low risk of vertical transmission
121
What SIX factors increase the risk of HIV transmission via breast milk?
1) DETECTABLE viral load
2) ADVANCED maternal DISEASE
3) Longer DURATION of breastfeeding
4) Breast and nipple INFLAMMATION
5) Infant MOUTH or GUT inflammation
6) mixed feeding
122
What is the difference of HIV transmission via breast feeding for 6 and 12 months?
6 months 0.3%
| 12 months 0.6%
123
BHIVA recommendation for breastfeeding?
High income country
- FORMULA feed safest option
- no transmission risk
124
What is the benefit of CABERGOLINE for women post party?
Suppresses lactation
125
What is the mechanism of action of CABERGOLINE?
Dopamine agonist
| Suppresses prolactin release
126
If a woman with HIV chooses to breastfeed - what is required?
1) Monthly VL - mother and baby
2) Exclusive breast feeding
3) Stop breastfeeding if breast inflammation or mother or infant GI upset
127
If a woman with HIV chooses to breastfeed - how should weaning to solids be managed?
standard UK guidance
| gradual introduction
128
Infant HIV follow up - non-breast fed?
```
HIV DNA (or RNA):
-48 hours
- 4-6weeks (2 weeks after PEP)
- 12 weeks (8 weeks after PEP)
HIGH RISK (additional)
- 2 weeks
then
HIV antibody
- 18 -24 months
```
129
Infant HIV follow up - BREASTFED?
```
HIV DNA (or RNA):
-48 hours
- 2 weeks
- monthly
then
4 & 8 weeks after stopping breast feeding
then
HIV antibody
- 18 -24 months
```
