MANAGEMENT OF HIV

POSITIVE PREGNANT WOMAN

G VINOD PRABHU
 EFFECT OF HIV ON
PREGNANCY
• Spontaneous abortion
• Ectopic pregnancy
• Genital and urinary tract infections
• Abruptio placenta
• Pre term labour
• Pre mature rupture of membranes
• Low birth weight, still birth
• Post partum infections
 EFFECT OF PREGNANCY ON
HIV

• Earlier believed to accelerate the progress

of infection. Prospective studies have not
confirmed findings
• Decrease in CD4 and CD8 cell count
following pregnancy not statistically
significant
 MOTHER TO CHILD
TRANSMISSION

• Europe and USA - 15 - 25%

• African and Asian - 25 - 40%
• occurs in utero, during labour and delivery,
post natally through breast feeding
• 90% infection in children
• reduced to 2% by anti-retroviral therapy
 FACTORS AFFECTING
TRANSMISSION
Viral Load, Genotype and Phenotype,Resistance

Maternal Immunological, nutritional and clinical status

Behavioural factors, Antiretroviral Treatment

Obstetrical Prolonged rupture of membranes,

Mode of Delivery, Intrapartum haemorrhage,
Obstetrical procedure, Invasive foetal
monitoring

Foetal Prematurity, Genetic,Mutiple pregnancy

Infant Breast feeding, Gastrointestinal factors

Immature immune system
 STRATEGIES FOR
PREVENTION

• Termination of pregnancy
• Behavioural interventions
• Therapeutic interventions
• Obstetric interventions
• Modification of infant feeding practises
 BEHAVIORAL
INTERVENTIONS

• Reduction in the frequency of unprotected

sexual intercourse during pregnancy
• reduction in the number of sexual partners
during pregnancy
• life style changes including avoidance of
drug abuse and smoking in pregnancy
 THERAPEUTIC
INTERVENTIONS

• Anti retro viral therapy: zidovudine alone

or in combination long- or short- regimen
• vitamin A and other micro nutrients
• immuno therapy
• treatment of STI
 OBSTETRIC INTERVENTIONS

• Avoidance of invasive tests

• birth canal cleansing
• caeserian section delivery
 MODIFICATION OF FEEDING
PRACTISES

• Avoidance of breast feeding

• early cessation of brest feeding
• heat treatment of expressed breast milk
 VOLUNTARY HIV TESTING AND
COUNSELLING IN PREGNANCY

• Testing of ante natal women

• pre test counselling
• post test counselling
• counsellimg about pregnancy related issues
 TESTING OF ANTENATAL
WOMEN
• Routine testing without consent or counselling -
unacceptable practice and disadvantages may negate
benefit
• Benefits of voluntary testing-early counselling and
treatment ,preventing transmission to child and sexual
partners, decisions on continuation of pregnancy and
future fertility.
• Best predictors of return for counselling -counsellor skills
and time spent for counselling.
• ELISA and WESTERN BLOT
 PRETEST&POSTTEST
COUNSELLING

• Essential elements of management of HIV in

pregnancy
• Pretest enables to make informed decisions
• post test is an integral part of management
of HIV positive persons and provides
oppurtunity for risk reduction for HIV
negative persons
 MANAGEMENT OF HIV
POSITIVE PREGNANT WOMAN

• Antenatal care
• obstetrical management
• examination and investigations
• medical treatment during pregnancy
• antiretroviral therapy
• care during labour and delivery
• post partum care
• care of neonate
 ANTENATAL CARE

• Asymptomatic and no major obstetrical

problems
• no need in increase in number of antenatal
visits
• counselling and support-integral part of
management
• advice on possible risks of unprotected
intercourse
 OBSTETRIC MANAGEMENT

• Invasive diagnostic procedures, such as

chorion villus sampling,amniocentesis
orcordocentesis should be avoided
• external cephalic version of a breech fetus
can cause potential maternal- fetal
circulation leaks
 EXAMINATION AND
INVESTIGATIONS

• Full physical examination at first visit

• signs of HIV related infections - TB,
oral/vaginal thrush, lymphadenopathy
• shingles - herpes zoster
• co existent STD’s
• weight monitoring, HB estimation, T cell
investigation
• viral load estimation - for prognosis
 MEDICAL TREATMENT DURING
PREGNANCY
• Pregnancy not a CI for ART-
better avoided in the first trimester
• VIT A supplementation
• anti malarials in highly endemic areas
• prophylaxis of opportunistic infections - TB,
PCP, other dermatological conditions
 ANTI RETROVIRAL THERAPY
• Long course zidovudine treatment
AFTER 14 WKS - ORAL
DURING LABOUR - IV
NEONATES - FOR 6 WKS
• Short course zidovudine treatment
300 mg oral twice daily from 36 wks
to onset of labour
300 mg every 3 hrs from onset to
delivery
• combination therapy with lamivudine
 CARE DURING LABOUR AND
DELIVERY

• Avoid prolonged rupture of membranes

• avoid routine episiotomy
• forceps preferred to vacuum delivery, if
assisted
• increasing evidence that caeserian section
prevents transmission
 POST PARTUM CARE

• Require private facilities to lessen the social

stigma associated with not breast feeding
• observe signs of infection - UTI, chest,
episiotomy and caeserian section wound
infections
• instructions on perineal care
• full discussion on care of babies and risks
and benefits of infant feeding choices
 CARE OF NEONATES

• Handle babies with gloved hands

• HB monitoring - anemia with zidovudine
• Hepatic transaminases elevation
• infant feeding - mother’s choice
• potential modifications include complete
avoidance of breast feeding, early
cessation, pasteurisation of breast milk,
avoid feeding in the presence of breast
abscesses or cracked nipples
 REFERENCE

• HIV in Pregnancy - A Review by WHO and

JOINT UNITED NATIONS PROGRAMME
on HIV/STD
THANK YOU