HIV in PREGNANCY a Ready reckoner

DEFINITION 

    Infection with Human Immunodeficiency Virus – a retrovirus that attacks T lymphocytes.

AETIOLOGY 

• Source:  HIV is present in vaginal fluid, semen, blood and breast milk of infected patients.
• Transmission: sexual contact, blood-borne,infected body secretion, vertical.

ASSOCIATIONS/RISK FACTORS

o   Increased risk of vertical transmission with

o   Increased viral load

o   Decreased CD4 count,

o   Prolonged rupture of membranes (>4 hours),

o   Breastfeeding.

EPIDEMIOLOGY

Increasingly common due to increased life expectancy in individuals with HIV
infection. Prevalence varies from place to place,India has a low HIV prevalence of 0.22 %.

HISTORY

May be asymptomatic until progression to AIDS (average 8–10 years). May present with Febrile seroconversion illness.

EXAMINATION

No clinical features in HIV. May present with opportunistic infection, or Rarely AIDS-defining illness (e.g. Pneumocystis carinii pneumonia (PCP), Kaposi’s sarcoma, oesophageal candidiasis).

PATHOLOGY/ PATHOGENESIS

In women who do not breastfeed, over 80% vertical transmission occurs late in the third trimester (>36 weeks) and at delivery. Less than 2% occurs in the first two trimesters.

INVESTIGATIONS

Blood:

    o   Routine HIV testing at antenatal booking, regular viral load and CD4 count. 

    o   Monitoring for drug toxicity: FBC, U&E, LFT, lactate and blood glucose.

MANAGEMENT

    Antenatal: Aim is to suppress viral load to undetectable levels (<50 copies/mL).

     Lifelong HAART (a combination of at least three antiretrovirals TDF +3TC + EFV) to all pregnant and breastfeeding HIV infected women regardless of CD4 count and clinical stage.

    Intrapartum:

    o   If viral load detectable or non-compliant with HAART, advise aesarean section. IV zidovudine infusion given from 4 h prior to delivery until cord is clamped.  

    o   Viral load undetectable: Consider vaginal delivery, avoid fetal blood sample (FBS) and fetal scalp electrode (FSE) or rupture of membranes for >4h.

    Neonatal:

    o   Antiretrovirals for 6 weeks, 

    o   PCR testing at birth, 3 weeks, 6 weeks and 6 months, HIV antibody test at 18 months. 

    o   Avoid breastfeeding.

Side-effects of HAART –

    o   Pre-eclampsia, 

    o   Obstetric cholestasis and other liver dysfunction,   

    o   Lactic acidosis,   

    o  Glucose intolerance, GDM.

    PROGNOSIS

No evidence to suggest that pregnancy accelerates progression to AIDS.

Appropriate measures as above reduce transmission rate from 28% to <2%.