1. MANAGEMENT OF HIV IN PREGNANCY
Dr. Ahmed Eltigani Elmahdi
Consultant Obstetrician & Gynaecologist
Cavan General Hospital, IRELAND
Khartoum Feb 2012

3. PRECONCEPTUAL COUNSELING
✴ Educate patients about perinatal transmission rate
✴ To avoid unintended pregnancy
✴ Counsel patients about safe methods to concieve
✴ Choose anti-retrovials which is known to be effective in reducing
perinatal HIV transmission
✴ Attain stable, maximally suppressed viral load
✴ Optimize medical and nutritional status

4. PRECONCEPTUAL COUNSELING
✴ Couple who are serodiscordant should advised to use condoms
✴ Couple who are serodiscordants where the female partner is HIV
negative should be advised that assisted conception with either donor
insemination or sperm washing is significantly safer than timed
unprotected intercourse
✴ Couple should be advised to delay conception until plasma viraemia
is suppressed
✴ Prophylaxis against PCP is no longer required
✴ Apportunistic infections should be treated
✴ All women who are HIV positive are recommended to have an annual
cervical Cytology

5. ANTENATAL SCREENING
✴ HIV screening is recommended as part of IDiPS Screening.
✴ Women choice.
✴ Negative at booking, high risk, repeat.
✴ Documentation.
✴ Fourth generation Laboratory.
✴ Urgent, late booking > 26 weeks (24 hours).
✴ Rapid HIV test, In Labour (20 minutes).

7. Pregnancies in diagnosed HIV positive women
in the UK & Ireland reported between 1989-2011

8. Children born to HIV positive womenand &
reported by December 2011
(Infection status and region of the first report)

10. Professional Approach to the Antenatal Care
of Women Who are HIV Positive
✴ Multidisciplinary Team.
✴ Newly diagnosed HIV Positive.
✴ Confidentiality.
✴ Disclose Their HIV status.
✴ Avoid Inadvertent Disclosure.
✴ Safe Sex Practice.
✴ Women with Existing Children of Unknown HIV Status.
✴ Women Refuse Interventions to Reduce the risk of Vertical transmission.
✴ National Study of HIV in Pregnancy & Childhood (www.nshpc.ucl.ac.uk).
✴ Antiretroviral Pregnancy Registry (www.apregistry.com)

11. Intervention to Prevent Disease Progression
in The Mother
✴Highly Active Anti-Retroviral therapy (HAART).
✴ Prophylaxis against Pneumocystitis Carinii Pneumonia (PCP).

13. Possible Routes of Transmission

15. Intervention to Prevent Mother to Child
Transmission of HIV
✴Brest feeding
✴Anti-Retroviral Therapy
• Women who require HIV treatment for their own health, HAART.
• Women who do not require treatment for their own health, HAART.
• Women who do not require treatment for their own health, & have:
a. Plasm viral load of less than 10000 copies/ml.
b. Planned to be delivered by Caesarean Section,
Zidovudine (ZDV) monotherapy 250mg orally, and IV at delivery

16. Intervention to Prevent Mother to Child
Transmission of HIV
✴ Mode of Delivery (decision should be made by 36 weeks of gestation)
• Elective Caesarean Section at 38 weeks
a. Women taking HAART who have plasma viral load > 50 copies/ml
b. Women taking ZDV monotherapy as an alternative to to HAART
C. Women with HIV & Hepatitis C virus infection
• Planned Vaginal Delivery (women taking HAART & have Plasma viral
load < 50 copies/ml.
• Elective Caesarean Section at 39 weeks
Obstetric indication or Maternal request (plasma viral load <50 copies/ml

17. Antenatal Care for pregnant women who are
HIV Positive
✴ Screening for Syphilis, Hepatitis B & Rubella
✴ Additional tests for Hepatitis C, Varicella Zoster, Measles & Toxoplasma
✴ Women Taking HAART at booking should be screened for G.Diabetes
✴ Vaccination (Hepatitis B & Pneumococcal, Influenza, Varicella Zoster,
Measles, Mumps & Rubella)
✴ Genital Infection Screening at booking & 28 weeks
✴ Screening for Aneuploidy
✴ Invasive Diagnostic Testing
✴ Dating and Anomaly Scans
✴ Monitoring of Plasma Viral Load & Drug Toxicities
✴ A plan of care for ART & Mode of delivery should be made at 36 weeks

18. Management of Antenatal complications
✴ Women who is HIV positive who becomes
acutely unwell in pregnancy
✴ HIV-related complications should also be
considered is a cause of of acute illness in
pregnant women whose HIV status is unknown

19. Management of preterm delivery & preterm
preterm prelabour rupture of membranes
✴Genital infection screen
✴ Usual Indications for steroids
✴ Risk of preterm delivery associated with HAART
✴ Threatened preterm labour
✴ Established Preterm labour (choice of anti-retroviral therapy)
✴ PPROM occurs after 34 weeks
✴ PPROM occurs before 34 weeks

20. Management of Delivery
✴A clear plan of care of ART & Mode of delivery should be in place
✴ Maternal plasma viral load & CD4 count should be taken at delivery
✴ Women taking HAART should have their medication administered < or>

21. CONTINUE Management of Delivery
Caesarean Section
✴ If IV ZDV indicated , the infusion should be started 4 hours before the
beginning of the CS and and should continue until the U.C has been clamped
✴ Good Haemostasis & avoid rupturing the membranes until the head is
delivered through the surgical incision
✴ Peripartum Antibiotics

22. CONTINUE Management of Delivery
Planned Vaginal Delivery
a Should only be offered to women taking HAART who have a viral
load < 50 copies/ml
b. when a women presents in labour her plan of carecare should be reviewed
and recent vir.al loadresults should be confirmed as < 50 copies/ml
c. HAART should be administered throughout labour
d. Invasive procedures such as FBS & FSE are contra indicated
e. If labour progress is normal amniotomy when delivery is imminent
f. Amnitomy and possible use of oxytocin may considered for augmentation
g. If instrumental delivery is indicated, low cavity forceps preferable to vacuum

23. CONTINUE Management of Delivery
Prelabour rupture of membranes at term
✴Delivery should be expedited if:
a. The viral load < 50 copies/ml
b. No obstetrics contraindication
AUGMENTATION MAY BE CONSIDERED
✴ Broad-spectrum iv antibiotics should be administered if there
evidence of genital tract infection or chorioamnionitis

24. CONTINUE Management of Delivery
Prolonged pregnancy
✴Women on HAART
✴with plasma viral load < 50 copies/ml, the decision
regarding induction of labour should be individualised
✴There is no contraindication to membrane sweep or to use of PGE2

25. CONTINUE Management of Delivery
Vaginal Birth after caesarean section VBAC
✴A trial of scar may be considered for a women on HAART whose
plasma viral load is < 50 copies/ml

26. CONTINUE Management of Delivery
HIV diagnosed in Labour

27. CONTINUE Management of Delivery
HIV diagnosed in Labour
Women diagnosed HIV positive during labour
a. Paediatricians should be informed
b. HIV physician urgent advise regarding optimum HAART
c. Delivery by Caesarean Section, and where possible, this
should be timed with respect to anti-retroviral administration

28. Postpartum Management of women who are
HIV positive
✴ Women should be given advise about formula feeding
✴ An immediate dose of oral Cabergoline should be
given to suppresslactation
✴ Women taking HAART should have their medication administered
✴ Guidance about contraception should be given
✴ MMR & Varicella Zoster immunisation may be indicated, according
to the CD4 lymphocytes count

29. BREAST FEEDING
Replacement
feeding
If no AFASS then
exclusive
breastfeeding for 6
months

32. Management of the Neonates
✴ All neonates should be treated with anti-retroviral therapy within four
hours of birth
✴ Most neonates should be treated with ZDV monotherapy but those with
at high risk of infection should be treated with HAART
✴ Prophylaxis against PCP is recommended only for neonates at high
risk of HIV infection
✴ Infant should be tested at: 1 day, 6 weeks and 12 weeks
“if all these tests are negative and the baby is not breast feeding= Neg”

36. Academic institutions and professional bodies
British HIV Association http://www.bhiva.org
Children’s HIV Association http://chivauk.org/
Collaborative HIV Paediatric Study (CHIPS) http://www.chipscohort.ac.uk/
Royal College of Obstetricians and Gynaecologists http://www.rcog.org.uk/
Royal College of Paediatrics and Child Health http://www.rcpch.ac.uk/
British Paediatric Surveillance Unit http://bpsu.inopsu.com/
Health Protection Agency http://www.hpa.org.uk/
Health Protection Scotland http://www.hps.scot.nhs.uk/
Institute of Child Health http://www.ich.ucl.ac.uk/
University College London http://www.ucl.ac.uk/
Charities and support organisations
Terrence Higgins Trust http://www.tht.org.uk/
Positive Nation http://www.positivenation.co.uk/
Positively UK http://www.positivelyuk.org/
National AIDS Trust http://www.nat.org.uk/
Body and Soul http://www.bodyandsoulcharity.org/
HIV in young persons network (HYPNet) http://www.networks.nhs.uk/networks/page/873
Neonates born to women who are HIV infected are reported to the National Study of HIV
in Pregnancy and Childhood: http://www.nshpc.ucl.ac.uk