Maternal Medicine - HIV and Hepatitis

Question 1

How many women a year in the UK are pregnant and HIV positive?

Answer 1

1200

Question 2

If a woman declines screening at booking when should she be re-tested according to the BHIVA guideline?

Answer 2

Further test offered with specialist

If still declines for point of care test when in labour

Question 3

What is the rate of mother to child transmission of HIV in the UK?

Answer 3

<0.25

13-30% if unaware of status

Question 4

When should treatment to reduce MCT start?

Answer 4

Third trimester or 16/40 if VL >30,000

Question 5

When should treatment start for the woman’s health?

Answer 5

If CD4<= 350 or she has an AIDS defining illness

If VL >100,000 regardless of CD4 count

Question 6

When should infection prophylaxis be given?

Answer 6

If CD4 <250

Question 7

What other precautions should be taken if a new diagnosis is made in pregnancy?

Answer 7

Screen previous children
Screen previous partners
Full STI screen including herpes (esp in Africans)
Smear test

Question 8

What advice can be given if VL is <50?

Answer 8

Can have vaginal birth but need to consider VL trajectory and review therapy if borderline

Question 9

When should a C/S be offered (ie VL)?

Answer 9

If VL is 50-399 consider C/S +/- repeat of VL depending on trajectory

If VL is >400 offer elective CS at 38-39 weeks

Question 10

What happens to the risk of MCT following SROM?

Answer 10

Increases by 2% the original risk for every hour following SROM

Question 11

What advice do BHIVA give re: VL and term SROM?

Answer 11

VL < 50 - augment immediately

VL >1000 - for C/S immediately

VL 50-999 consider C/S depending on clinical picture (ie obstetric hx etc)

Question 12

When should IV zidovudine be given?

Answer 12

If untreated HIV and in labour
If VL >1000 or unknown
Consider if on monotherapy and having el c/s

Question 13

What is the guidance for SROM < and > 34/40?

Answer 13

If >34/40 for augmentation with GBS cover

If <34/40 for steroids and conservative management while optimising VL

Question 14

What is the guidance if mum’s partner has new diagnosis of HIV and she is negative at booking?

Answer 14

Screen for seroconversion in each trimester and near to delivery
Advise barrier methods
Test baby - if negative no follow up

Question 15

What is the advice for breastfeeding in UK?

Answer 15

Advise not to
If insists on feeding needs to do so exclusively (flora in gut changed by formula - increases transmission from BF)
Carry on ART with monthly VL
Test baby monthly after 10/7 PEP

Question 16

How many have hepatitis B in the UK?

Answer 16

1 in 1000

Question 17

What is the risk of transfer of Hepatitis B to the untreated infant?

Answer 17

60-85%

Question 18

How many infected infants with become chronic carriers of Hep B?

Answer 18

90-95%

Question 19

What is the risk of chronic liver disease in neonatal hepatitis and how many will die secondary to chronicth disease/hepatocellular Ca?

Answer 19

40%

25% risk death

Question 20

What is the transmission rate in HBeAg positive mother without intervention?

Answer 20

70-90%

Question 21

What is the transmission rate in HBeAg negative monther?

Answer 21

10%

Question 22

When should immunoglobulins (HBIG) be given to baby?

Answer 22

If mum has active infection or if baby <=1.5kg

Question 23

When should mum be treated with tenofovir or lamivudine and when?

Answer 23

If advancing maternal disease or high VL

Given in third trimester (28/40)

Question 24

What is the HBV vaccine schedule for baby?

Answer 24

5 vaccines
24 hours
1 month
2 months
12 months
Preschool

Question 25

How long should babies have postnatal HIV prophylaxis for if mum was on cART antenatally following NVD?

Answer 25

4/52

Question 26

By when should all pregnant women with HIV be commenced on cART?

Answer 26

24/40 even if not reqired for own health If VL >30,000 start at 13/40 >100,000 may need earlier

Question 27

Which HIV drugs are used in pregnancy?

Answer 27

Zidovudine, lamivudine Alternatively: Tenofovir + emtricitabine Abacavir + lamivudine In combination with protease inhibitor

Question 28

When is zidovudine monotherapy used in pregnancy?

Answer 28

Planned C/S and VL<10,000 and CD4 >350 Also: elite controllers - CD4 >350, VL <50 untreated

Question 29

What ART should be used if HIV diagnosed after 28/40? And in labour?

Answer 29

Raltegravir - drops VL quickly In labour - nevirapine single dose Zidovudine + lamivudine + raltegavir IV zidovudine +tenofovir if prem

Question 30

How long should neonatal PEP be?

Answer 30

4/52 Start within 4 hours of being born (ideally immediately) If VL undetectable at 36/40 or had an elCS on zidovudine monotherapy - baby can have the same monotherapy Otherwise trriple drug combination May need PCP prophylaxis

Question 31

When should ART be continued postpartum?

Answer 31

- Hx of AIDS defining illness or CD4 <350 - If commenced with CD4 350-500 and co-infected hep - Can consider all women with CD4 350-500

Question 32

What is the recommended mode of delivery when VL >=400?

Answer 32

Elective Caesarean Section

Question 33

How often should the neonate be tested for HIV? (ie not breast fed)

Answer 33

First 48 hours then prior to discharge 6/52 3/12 18/12 for seroconversion If breast fed - also once monthly and as above

Question 34

What are the vertical transmission rates of Hep B with no intervention?

Answer 34

90% when HepB e-antigen positive 10% of surface antigen positive, e antigen-negative mother >90% neoneates infected will become chronic carriers

Question 35

By how much does vaccination and Ig administration in highly infectious mothers reduce vertical transmssion?

Answer 35

90%

Question 36

What is the neonatal vaccine schedule for hep B?

Answer 36

``` Birth 1 month 2 months 6 months 1 year - yest serlogy Preschool booster 3 yrs 4 months ```