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Important points on HIV in pregnancy Least Teratogenic Infection: HIV

• M/C time of vertical transmission:

1. Peripartum period 2. During delivery

• Perinatal transmission 15–40%

• Risk depends on following factors- maternal viral load, CD4 count (inversely related), vitamin A deficiency and chorioamnionitis.

• Screening adopted for HIV is universal.

• Screening-Opt out screening (i.e patient can opt out from the test)

• HIV testing is the first step towards PPTCT (Prevention of parent to child transmission) aimed at reducing the vertical transmission of HIV infection.

• Screening test–ELISA a nd a positive or indeterminate test should be followed by a Western blot for confirmation.

• Antiretroviral therapy is given to pregnant female for 2 reasons:

1. for benefit of her own health

2. for preventing Mother To Child Transmission (HAART throughout pregnancy reduces MTCT to <2% )

• Relationship of CD4 count to development of opportunistic infections In a patient of HIV.

• All pregnant women should be given ART for two reasons:

1. For benefit of her own health– these females should continue with treatment during pregnancy and afterwards

2. HIV positive pregnant women who do not have indication for antiretro-viral therapy should have ART prophylaxis to prevent mother to child transmission

(HAART throughout pregnancy reduces MTCT to <2% )

• Salient points of WHO’s latest Nov 2009 guidelines which were revised from previous (2006) guidelines:

1. Although antiretroviral therapy among asymptomatic HIV infected nonpregnant adults and adolesents is generally delayed until the CD4 drops below 350 cells/μL, all pregnant women should be offered treatment regardless of CD4 + Two unit or viral load to reduce MTCT

For infants of mothers with HIV who are taking therapeutic ART for their own health, the duration of prophylactic ART has been increased irrespective of whether the infant is breastfeeding or not. For breastfeeding infants, it is recommended that daily NVP is instituted from birth until 6 weeks of age. For nonbreastfeeding infants: daily AZT or NVP from birth until 6 weeks of age is recommended.

2. It is recommended that antepartum ARV prophylaxis should be started in all women from as early as 14 weeks gestation (if she is not already on ARV) or as soon as possible when women present late in pregnancy, in labor or at delivary.

HAART Timings (Ref. Williams 23/e, p 1251)

Condition Begin HRT

If a female is already on HAART Continue HAART-even in 1st tri-mester and becomes pregnant

If a female is not on HAART Begin HAART after 1st trimester-and doesnot require ARV for (at 14 weeks)

her own health benefit but for MTCT prevention

Patient comes in labor for first Give Navirapine and Zidovudine drip time and is not on HAART

If pregnant female is HIV and Treat for HIV but Zidovudine is avoided.

Hepatitis B positive Give Interferon alphato female after delivery and to baby give HBIG and hepatitisB vaccine within 12 hrs of birth

• If HAART is given throughout pregnancy it reduces MTCT (Mother to Child transmission) to <2% and in such cases vaginal delivery can be done as cesarean will not decrease further risk of transmission.

• If mother is not properly covered with ARV: Elective cesarean section at 38 weeks should be done or if woman is on ARV and still viral load is > 1000 copies/ml then also elective cesarean section is done.

• After rupture of membranes the advantage of reducing Mother to child transmission by LSCS is lost, hence emphasis is laid on elective cesarean at 38 weeks.

• Drug supplied by NACO: Free of cost-NEVIRAPINE (both for mother and baby)

• If vaginal delivery is being done: Artificial Rupture of Membranes/Forceps/Vaccum//Fetal Scalp Electrodes are contraindicated.

• First born twin has more risk of infection than second of twin.

• After delivery: Breast feeding is not C/I in developing countries.

Decision regarding the type of feed, i.e. breastfeed or replacement

feed, should be made during antenatal period itself depending upon whether replacement feed is Acceptable, Feasible, Affordable, Sustainable and Safe (AFASS): As mixed feed is associated with increased rate of HIV transmission as compared to breastfeed alone, it is suggested the weaning must be complete and abrupt after six months of breastfeed or earlier if replacement feed is AFASS.

• Answer to case study: Women who have been receiving antiretroviral treatment for their HIV-1 infection should continue same treatment during pregnancy, intrapartum and postpartum period except for Efavirenz (EFV). NVP(Nevirapine) should be substituted for EFV, although exposure to EFV during pregnancy is not an indication for abortion for women who become pregnant while receiving an EFV-containing regimen and are in the first trimester of pregnancy.

NOTE:

1 Women who are receiving EFV and are in the second or third trimester of pregnancy can continue the current regimen.

2. NVP should be given in women with CD4 count of 200-350 cells/

mm3: There are data to show that women with a CD4 count of >

250 cells/mm3 face a higher risk of severe hepatotoxicity with NVP.

21. The answer is (a) i.e VDRL in mother and baby 22. The answer is (c) i.e Penicillin

Syphilis in Pregnancy

• Bullous leisons on the body of the infant and presence of periostitis suggests the diagnosis of congenital syphilis. The only option related to syphilis is VDRL.

Congenital syphilis:

– Transmission of T pallidum across the placenta from a syphilitic woman to her fetus may occur at any gestational age but fetal damage occurs when transmission occurs after 16weeks.

– Thus adequate treatment before 16 weeks may prevent fetal damage

– Untreated infection leads to fetal loss in 40% cases, IUD, stillbirth and abortions.(stillbirths being more common than abortions)

Early Congenital Late congenital Residual stigmata

syphilis syphilis

• Appears within • Appears after 2 • Hutchinsons teeth first 2 years of life, years of life. (Centrally notched M/C time is 2-10 • Subclinical in most widely spaced peg

weeks age of the cases. shaped upper cen

• Earliest manifes- • Features- inter- tral incisor tation-rhinitis/ stitial keratitis • Mulberry molars

snuffles • Eighth nerve

• M/C-bone changes- deafness osteochondritis • Recurrent

• Periostitis arthropathy

• Mucocutaneous • B/L knee effusion

leison k/a Cluttons joint

• Hepatospleeno- • Asymptomatic

megaly neurosyphilis

• lymphadenopathy • Gummatous periostitis

In asymptomatic infants:

• If mother has been treated with penicillin in 1st/2nd trimester-No treatment for infant

• If mother has not been treated/received treatment with penicillin in third trimester –

Treat infant with penicillin

SYPHILIS TREATMENT during pregnancy

Ref. Williams 23/e, p 1238

• Syphilis therapy during pregnancy is given to eradicate maternal infection and to prevent congenital syphilis.

• Parenteral penicillin G remains the preferred treatment for all stages of syphilis during pregnancy.

• There are no proven alternative therapies for syphilis during pregnancy Erythromycin may be curative for mother, but because of limited transplacental passage, it does not prevent all congenital disease.

Women with H/O penicillin allergy, first penicillin desensitization should be done and then followed by penicillin injection.

Drug of Choice

Infection Doc in Pregnancy

Bacterial vaginosis Metronidazole to patient only 1st trimester-clindamycin

Pneumocystis carinii Sulphamethozole-trimethoprim Typhoid Third gen cephalosporins/azithromycin Syphilis < 1 year >1year Benzathine penicillin 2.4 million U.i.m sigle dose

Benzathine penicillin 2.4 million U. i.m weekly x 3doses

Gon orrhea Inj Ceftriaxone 125 mg i.m single dose or, Tab cefixime 400mg single dose or, Inj Spectinomycin 2g i.m single dose

Chlamydia Azithromycin single dose or Amoxicillin 500 mg TDS × 7days 2^nd choice-Erythromycin Grp B streptococci Penicillin 2^nd best- Ampicillin Penicillin

resistant-cefazolin

Malaria-prophylaxis Treatment Resistant cases (mostly d/t P. falciparum)

Chloroquine Chloroquine Quinine + clindamycin (mefloquine is currently not recommended ...williams 23/e, p1228)

Appendicitis Immediate appendicectomy

Red degeneration Conservative mgt (no termination of pregnancy and no myomectomy)

Thyrotoxicosis Propylthiouracil

23. The answer is (d) i.e rapid urine b hcg measurement