HIV IN PREGNANCY

Dr.Neha Bharadwaj
PG2 OBS GYNAE
REFERENCES:NACO:2021/2013
ACOG
RCOG
• STRUCTURE OF HIV

HIV, a RNA retrovirus causes a serious infection which in about 8-10 years leads to AIDS in which the immune system is so depleted
that unusual bacterial and viral infections develop. Causative agents are HIV 1 & HIV2.Most cases worldwide are due to HIV1.
ETIOPATHOFENESIS
MODES OF TRANSMISSION
 Sexual(major):Homosexual
Heterosexual(most common)

 Parentral :transplacental transmission

Exposure to infected blood and blood products(most potent)
Blood transfusion with infected blood(90-95%)
Exposure to infected tissue fluids
Injectable drug users

 Vertical : Intrauterine transplacental before 36 weeks(20%)

Intrapartum(50%)
Post partum breastfeeding (30%)
PPTCT ESSENTIAL PACKAGE

 PREGNANT WOMAN WITH:

1. ACTIVE TB: The TB treatment should be started first and followed by ART as soon as
feasible(usually after 2 weeks)

2. HIV 2 infection: Women infected with HIV2 alone should follow treatment with 2
NRTIS’S +Lopinavir/tenofovir

3. With Hepatitis B/C virus co infection:

Hep B:treatment should be started irrespective of CD4 count
Hep c:No specific change in ART
 ANC PATIENT PRESENTATION
EARLY TRIMESTER PRESENTATION
NACO: Start ART as soon as HIV is detected
ACOG AND BHIV: To start ART IN 2ND Trimester
BHIV States that if viral copies>10,000 then ART
should be started immediately
PATIENT PRESENTING IN LABOR
Patient presenting directly in labor
Found HIV positive using whole blood finger prick
testing in labor room/delivery ward
Collect blood sample for CD4 and send sample next
day to ART centre.initiate maternal
ART(TDF+3TC+EFV)
Next morning:counselling and confirmation of HIV
status and blood sample collection for CD4 testing
(Mother:will continue ART after delivery)
Infant: daily syrup Mother:link with ART centre to continue
Nevirapine from birth ART as soon as possible
Until 6 weeks(minimum)
INTRAPARTUM MANAGEMENT

Check the woman’s HIV status and details of the ART drugs
 during pregnancy. If her HIV status is unknown and she is in the first stage of labour,
 offer HIV counselling and testing using Whole Blood Finger Prick Testing. If found
positive, she should be administered the first dose of ART

 LSCS: in HIV positive pregnant women should be performed for obstetric indications
only
 False labor: Continue ART
 Safer delivery techniques:
 Do NOT rupture membranes artificially
 Minimize vaginal examination and use aseptic techniques.
 Avoid invasive procedures like foetal blood sampling, foetal scalp electrodes.
 Avoid instrumental delivery as much as possible(unless required):
if indicated:low cavity forceps is preferable to ventouse
 Avoid routine episiotomy
POST PARTUM MANAGEMENT

 Breastfeeding: NACO: exclusive breastfeeding should be done for 6 months

ACOG &BHIV: Top feeding over breast feeding should be
considered
 Mixed feeding is not recommended
 Contaception :Insertion of Cu-T (temporary contraceptive method) for HIV infected
mother at 6 weeks if a post-partum IUD (PP-IUD) has already not been inserted within 48
hours in addition to the use of condoms will prevent unwanted pregnancies (dual
protection)
 Encourage male sterilization in father (No Scalpel Vasectomy (NSV) between 18 months
to 2 years when baby’s survival has been ensured).
 To look for post partum depression
Counsel and follow up mother baby pairs(m-b pair):
 Counsel mother for her post-natal checkup at 6 weeks to coincide with the infant’s first
immunization visit.
Cotrimoxazole preventive therapy

 Provision of Syrup Nevirapine for the new born infant from birth till 6 weeks of age
(minimum).
 At the end of 6 weeks, CPT should be initiated and baby to be linked to the EID
programme. CPT continued to baby from 6 weeks up to 18 months or until the
confirmatory test of the baby is done using all three Rapid Antibody Tests.
 If baby is confirmed positive, then CPT will be continued.
 Investigations
 Pregnant women with HIV infection needs to be assessed with the following:
 Thorough history and physical examination
 Routine ANC PROFILE and tests for other STDS and serum creatinine ,bacteriuria screening
 Serological testing of husband for HIV should be offered.
 Plasma HIV RNA quantification :”viral load”,CD4 T cell count(Repeated in each trimester),and anti
retroviral resistance testing
 Serum hepatic aminotransferase levels
 HSV-1 and 2, cytomegalovirus, toxoplasmosis, and hepatitis B and C serological screening
 Baseline chest radiograph,LFT
 Tuberculosis testing with purified protein derivative (PPD) skin testing, or interferon-gamma release
assay
 Evaluation of need for pneumococcal, hepatitis A, hepatitis B, Tdap, and influenza vaccines
 Sonographic evaluation to establish gestational age
Treatment

 Naco:States that ART should be started in 1ST TRIMESTER ITSELF

 BHIV AND ACOG :recommends ART To be started in 2nd trimester
DRUGS MECHANISM OF ACTION SIDE EFFECT
1.TENOFOVIR Inhibits reverse transcriptase Nephrotoxicity,
Hypophosphaetemia
2.LAMIVUDINE Competes with cytosine triphosphate Very few side effects:hypersensitivity,
for incorporation into developing viral Rarely pancreatitis
strands

3.EFAVIRENZ Inhibits reverse transcriptase enzyme Neuro-psychiatric symptoms like

hallucinations,suicideal
ideation,nightmares,vivid dreams

4.LOPINAVIR/RITONAVIR Inhibits protease and thus proteolysis of GI disturbances,glucose intolerance,

gag polyprotein,results in production of lipodystrophy and hyper lipidemia
immature non infectious viral particle

5.DOLUTEGRAVIR Inhibits HIV integrase and blocks Increased ast/alt,deranged lipid

retroviral DNA integration in the host profile,hyperglycemia,
cell insomnia,increased bilirubin
6.ZIDOVUDINE Inhibits hiv reverse
transcriptase
7.NEVIRAPINE Binds to reverse transcriptase
and blocks RNA dependent
and DNA dependent DNA
polymerase
Head ache,neutropenia(bone
marrow toxicity),anorexia
Rash,Hepatotoxic,jaundice
(dark urine,clay coloured
stools)
POST EXPOSURE PROPHYLAXIS

 Best started within 2 hours of exposure

 Tenofovir 300 mg+Lamivudine 300 mg+ Efavirenz 600 mg once daily for 28 days
 Should be started immediately in case of exposure where source person is on ART