obstetrical condition

1. HIV in Pregnancy
Dr. ARCHANA VERMA

2. INTRODUCTION
– (HIV) Human immunodeficiency virus is a lentivirus (a
member of the retrovirus family) that causes
Acquired Immunodeficiency Syndrome (AIDS)
– Discovered in 1983
– HIV has been divided into two primary strains
• HIV-1 and HIV-2
– HIV is highly a variable virus which mutates very
readily.

3. CHARACTERISTICS OF HIV
 HIV is a retrovirus that is believed to have
evolved from a simian immunodeficiency
virus.
Group - Group VI (-ssRNA)
Family - Retroviridae
Genus - Lentivirus
 HIV can be characterized primarily by its;
• Structure
• Viral genome.

4. STRUCTURE OF HIV
• It is composed of two copies of positive
single-stranded RNA.
• A matrix composed of the viral protein
surrounds the capsid.
• It has a viral envelope
• It has glycoprotein's/receptors on its envelope

5. STRUCTURE OF HIV
HIV is different in structure
from other retroviruses.

6. EPIDEMIOLOGY
WHO estimated that Sub-Saharan Africa remains
by far the worst-affected region, with an
estimated 22.5 million people currently living
with HIV (67% of the global total), and 1.8 million
new infections (69% of the global total).
 However, the number of new infections
declined by 19% across the region between 2001
and 2009, and by more than 25% in 22 sub-
Saharan African countries during this period.
 Asia is the second-worst affected region, with
4.9 million people living with HIV (15% of the
global total).

7. EPIDEMIOLOGY
The first case of HIV in Ghana was reported in
March 1986.
HIV PREVELANCE BY REGION(%), 2009.

8. EPIDEMIOLOGY
HIV PREVALENCE BY AGE GROUP(%), 2009

9. ETIOLOGY
The 3 main route of transmission is via;
o blood, blood products
o sexual contact
o mother to child in intrauterine infection,
perinatal transmission, or the mother’s milk.
 NB. Infection via saliva or insect bite has not
been confirmed.

10. PATHOGENESIS
Mode of Transmission
o Blood Products
o Blood transfusion
o Infected blood coming into contact with open wounds
o Sexual contact
o Mother to child
o Child birth
o Breast feeding

11. Entry into host cell
o HIV enters macrophages and CD4+ T cells by the
adsorption of glycoproteins on its surface to receptors
on the target cell.
o Followed by fusion of the viral envelope with the
cell membrane and the release of the HIV capsid into
the cell.
Replication and Transcription
o On entry of the viral capsid, there is reverse
transcription of the +ssRNA, into a complementary
DNA molecule by the reverse transcriptase.
o The enzyme integrase, integrates the viral DNA into
the host cell genome.
o This integrated viral DNA may then lie dormant, in the
latent stage of HIV infection.

12. Assembly and Release
o Structural proteins, functional proteins and
enzymes are packaged.
o After assembly of the viral particle in the plasma
membrane it buds out of the cell, thus acquiring
an envelope in the process.

13. Stages of Infection
The stages of infection can be grouped into four.
• Stage 1 – Primary
• Short, flu-like illness - occurs one to six weeks
after infection
• no symptoms at all
• Infected person can infect other people

14. • Stage 2 – Asymptomatic
• Lasts for an average of ten years
• This stage is free from symptoms
• There may be swollen glands
• The level of HIV in the blood drops to very low
levels
• HIV antibodies are detectable in the blood

15. • Stage 3 – Symptomatic
• The symptoms are mild
• The immune system deteriorates
• emergence of opportunistic infections and
cancers
Stage 4 - HIV  AIDS
• The immune system weakens
• The illnesses become more severe leading to
an AIDS diagnosis

16. Laboratory Diagnosis
Detection of HIV is tackled on three different
fronts;
o Blood
o Urine
o Oral

17. Blood Detection Tests
• Enzyme-Linked Immunosorbent Assay/Enzyme Immunoassay
(ELISA/EIA)
• Radio Immunoprecipitation Assay/Indirect Fluorescent
Antibody Assay (RIP/IFA)
• Polymerase Chain Reaction (PCR)
• Western Blot Confirmatory test

18. Urine Testing
• Urine Western Blot
– As sensitive as testing blood
– Safe way to screen for HIV
– Can cause false positives in certain people at high
risk for HIV

19. Oral Testing
• Orasure
– The only FDA approved HIV antibody.
– As accurate as blood testing
– Draws blood-derived fluids from the gum tissue.
– NOT A SALIVA TEST!

20. PROGNOSIS
Without treatment, the net median survival time
after infection with HIV is estimated to be 9 to 11
years, depending on the HIV subtype, and the
median survival rate after diagnosis of AIDS in
resource-limited settings is 6 and 19 months.
. In areas where it is widely available, the
development of HAART as effective therapy for
HIV infection and AIDS reduced the death rate
from this disease by 80%, and raised the life
expectancy for a newly diagnosed HIV-infected
person to 20–50 years.

21. Effect of HIV in pregnancy

22. Effect of pregnancy on HIV
• CD4 counts fall during pregnancy but return to
pre pregnancy levels post partum.
• No increased risk of accelerated
immunosuppression.

23. 23
Effect of AIDS on Pregnancy
• Infertility
• Repeated abortions
• Prematurity
• Intrauterine growth retardation
• Stillbirths
• Congenital abnormalities
• Embryopathies

24. Antenatal management
• Screening for HIV should be offered early in
pregnancy because appropriate antenatal
interventions can reduce maternal-to-child
transmission of HIV infection.
• positive HIV antibody test result should be
given to the woman in person by an
appropriately trained health professional.

25. Confidentiality
• Confidentiality is important.
• Information may be disclosed to a known
sexual contact of the woman

26. multidisciplinary team
HIV positive patients should be managed by a
multidisciplinary team.
• HIV physician
• an Obstetrician
• a Midwife
• a Paediatrician
• a Psychiatric team
• support groups

27. Booking visit
• Additional tests
– Lymphocyte subsets
– Quantitaive RNA PCR measurement of viral load
– Hepatitis B & C
– Cervical & vaginal swabs to check for
STDs,Bacterial vaginosis & Group B streptococcus.
– CD4 count should be tested every trimester or
more frequently if maternal viral load is high.

28. Antenatal care
• Screening for Down syndrome and fetal
anomalies should be offered.
• A detailed ultrasound scan for fetal
anomalies is important after first-trimester
exposure to HAART

29. invasive prenatal diagnosis
• The risk of mother-to-child transmission with
chorionic villus sampling or second-trimester
amniocentesis hasn’t been estabilished.
• If invasive prenatal diagnosis is
contemplated, the advice of the fetal
medicine specialist and HIV physician should
be seeked and prophylaxis with HAART
considered.

30. Treatment Options

31. Antiretroviral therapy
• 2 reasons
– prevention of mother-to-child transmission
(therapy usually discontinued at, or soon after,
delivery)
– secondly for treatment of the mother to prevent
maternal disease progression (therapy continued
indefinitely after delivery)

32. Antiretroviral therapy
• anti-retroviral therapy is recommended for all
HIV positive women during pregnancy and at
delivery to prevent MTCT.
• The optimal regimen is determined by an HIV
physician on a case-by-case basis.
• The decision to start,modify or stop anti-
retroviral therapy
– should be undertaken by an HIV physician
– in close observation with other health professionals
• obstetrician
• paediatrician.

33. Antiretroviral therapy
• Women who are not on HIV treatment for their own
health need anti-retroviral therapy to prevent mother-to-
child transmission.
• Anti-retroviral therapy is usually started between 28 and
32 weeks of gestation and should be continued
intrapartum.
• A maternal sample for plasma viral load is taken at
delivery.
• Maternal anti-retroviral therapy is usually stopped soon
after delivery but the precise time of discontinuation
should be discussed with the HIV physician.
• Zidovudine is usually administered orally to the neonate
for four to six weeks.

34. Antiretroviral therapy
• Timing
– Antenatally
– Intrapartum
– Neonatal period(4-6 weeks)
• Choice of antiretroviral therapy & Timing is
decided by HIV physician.
• Plasma viral load & CD4 counts regularly
monitored.

35. Antiretroviral therapy......
• Patients on antiretroviral therapy should be
monitored for toxicity
• full blood count
• urea and electrolytes
• liver function tests
• Lactate
• blood glucose
• Patients should also have detail ultrasound
scan to detect foetal anomalies.

36. Drug toxicity
• Presentation with symptoms or signs of
• pre-eclampsia
• Cholestasis
• other signs of liver dysfunction during pregnancy
– may indicate drug toxicity

37. Lactic acidosis
– is a recognised complication of certain HAART
regimens.
• presenting symptoms
• often nonspecific
• include
– gastrointestinal disturbance
– fatigue
– fever
– breathlessness.

38. Types of HIV drugs
• Reverse transcriptase inhibitors
– Nucleoside reverse transcriptase inhibitors
– Non nucleoside reverse transcriptase inhibitors
• Protease inhibitors
• Entry inhibitors
• Integrase inhibitors

39. Prophylaxis of Pneumocystis carinii
• PCP prophylaxis is usually administered when
the CD4 T-lymphocyte count is below 200
• The first line treatment is cotrimoxazole(a
folate antagonist).
• Folic acid 5 mg should also be given
• Nebulised pentamidine is another alternative.

40. Screening for genital infections
• All pregnant women who are HIV positive
should be screened for genital infections.
• When to do ?
• This should be done as early as possible in pregnancy
• repeated at around 28 weeks.
• Any infection detected should be treated.

41. Mother to child transmission
• Non breast feeding women in Europe 15-20%
• Breast feeding mothers in Africa 25-40%
• Breast feeding is associated with 2 fold
increase in transmission.

42. Prevention
• Maternal child transmission is prevented by
– Antenatal HIV screening
– Antiretroviral therapy
– Elective Caesarean section
– Avoiding breast feeding
– Reduced from 25-30% to less than 2 %

43. Prevention of MTCT
• 2 choices of antiretroviral therapy
– Single agent-Zidovudine
– START(short term antiretroviral therapy)
• HAART for short duration in pregnancy and continued
intrapartum

44. Zidovudine Vs START
Zidovudine START
may allow the emergence of resistant
virus
maternal plasma viraemia is more likely to
be suppressed to undetectable levels
exposure of the mother and fetus to
larger numbers of potentially toxic drugs

45. advanced HIV
• likely to have symptomatic HIV infection and
– a falling or low CD4 T-lymphocyte count less than
350
– And / or a high viral load (greater than 10 000–20
000 copies/ml).

46. advanced HIV
• These women should be treated with a
HAART regimen.
• The start of treatment should be deferred
until after the first trimester, if possible, and
should be continued after delivery.

47. advanced HIV
• Women who conceive while taking HAART
should continue their HAART regimen if it is
effectively suppressing plasma viraemia.
• For women whose regimen is not
suppressing viraemia, a change in therapy
after the first trimester may be indicated.

48. Mode of delivery
• Elective Caesarean section is beneficial
– HIV positive women who are not taking HAART
during pregnancy
– for women with a detectable plasma viral load
• Value of elective caesarean section is
uncertain
– in women taking HAART who have an
undetectable plasma viral load at the time of
delivery.

49. LSCS in HIV women
• A zidovudine infusion
– should be started four hours before beginning the
caesarean section
– Should continue until the umbilical cord has been
clamped.
• A maternal sample for plasma viral load should
be taken at delivery.
• The cord should be clamped as early as possible
after delivery and the baby should be bathed
immediately after the birth.

50. LSCS in HIV women....
• a technique of ‘bloodless’ caesarean section
may further reduce the risk of mother-tochild
transmission.
– opening the uterus with a staple gun,which
simultaneously cuts and giveshaemostasis.

51. Casarean section
• This should be sheduled at 38 weeks to
reduce the risk of spontaneus labour or
membrane rupture.
• Contamination of the baby with maternal
blood should be avoided
– Secure the bleeding points
• Cord clamped as soon as possible

52. Casarean section
• Drainage should be used and they should be
used to closed suction system
• Universal precautions :gloves, aprons & face
protection should be employed.

53. Labour in HIV woman
• Women who opt for a planned vaginal delivery should have their
membranes left intact for as long as possible.
• Use of fetal scalp electrodes and fetal blood sampling should be
avoided.
• Women should continue their HAART regimen throughout labour .
• If an intravenous infusion of zidovudine is required it should be
commenced at the onset of labour and continued until the
umbilical cord has been clamped.
• A maternal sample for plasma viral load should be taken at
delivery.
• The cord should be clamped as early as possible after delivery and
the baby should be bathed immediately after the birth.

54. Vaginal delivery
• Forceps preferred to Vacuum
• Remove maternal blood stain with alcohol
wipe prior to Vitamin K injection
• Universal precautions :gloves, aprons & face
protection should be employed.

55. SROM in HIV
• SROM-spontaneus rupture of Membranes
– ruptured membranes for more than four hours ,
associated with double the risk of HIV
transmission.
– These studies also demonstrated a 2%
incremental increase in transmission risk for every
hour of rupturedmembranes up to 24 hours.
– The relevance of these studies for women taking
HAART who have undetectable viral loads is
uncertain.

56. PPROM in HIV
• PPROM-preterm prelabour rupture of
membranes
– If there is preterm rupture of membranes, with or
without labour, the risk of HIV transmission
should be set against the risk of preterm delivery.
– Preterm infants are more likely to be infected with
HIV.
– There is no known contraindication to the use of
short-term steroids to promote fetal lung
maturation.

57. Postpartum
• women with HIV advised not to breast feed
• Neonate infections.
– PCR is done as maternal antibodies cross the placenta
– Typically, tests are carried out at birth, then at three
weeks, six weeks and six months.
– definitive test is the HIV antibody test: a negative result at
18 months of age confirms that the child is uninfected.

58. Management of the neonate
• All infants born to women who are HIV
positive should be treated with anti-
retroviral therapy from birth.
• Usually treatment is discontinued after four
to six weeks

59. Recommendation for for HIV-infected
mother in labor who had no prior
therapy
1. Single dose Nevirapine during labor and a
single dose to the neonate at age 48h.
2. Intrapartum AZT, the 6 weeks of AZT to the
neonate.(2mg/kg 4 times daily)
3. The two dose Nevirapine combined with
the intrapartum and 6 weeks AZT regimen.

60. • IN case of maternal HIV antiretroviral
resistance:
AZT is still recommended to the infant, plus
other medications based on maternal HIV
resistance pattern.

61. THANK YOU