HIV/AIDS in Pregnancy

Related to Pregnancy

1. HIV / AIDS DURING PREGNANCY PRESENTED BY: LAMNUNNEM HAOKIP MSC (N) 2 ND YEAR SNSR, SU UNDER THE SUPERVISION OF DR. SHANTI IDA PROF.CUM HOD (OBG) SNSR, SU

2. INTRODUCTION Human Immunodeficiency Virus (HIV) causes an incurable infection that leads ultimately to a terminal disease called Acquired Immunodeficiency Syndrome (AIDS). Worldwide 25 – 30% of infected patients are women and 90% of them are 20 – 49 years of age.

3. DEFINITION Human Immunodeficiency Virus (HIV) : It belongs to retrovirus family which is the causative agent of Acquired Immunodeficiency Syndrome (AIDS).   Acquired Immunodeficiency Syndrome (AIDS): A disease in which there is a severe loss of the body's cellular immunity, greatly lowering the resistance to infection and malignancy.

4. IMMUNOPATHOGENESIS The target for HIV is the CD4 receptor molecule. Cells within the immune system that have this molecule are : CD4+ T lymphocytes, monocytes, macrophages and other antigen presenting cells like fibroblasts, neurons, renal, hepatic and intestinal cells. Following infection, there is profound cellular immunodeficiency as the CD4+ are progressively depleted by cytopathic effects of HIV.

5. Immunological markers that are used to determine the progression of the disease are as follows: CD4 T lymphocytes count – patients with count from 200 – 300 cells/mm 3 are likely to have HIV related symptoms and count <200 cells/mm 3 is taken into AIDS defining criteria. Measurement of HIV RNA levels by RT-PCR and the bDNA assays.

6. MODE OF TRANSMISSION Multiple partners, prostitution. IV drug abusers Multiple transfusion of blood and blood products Parent to child

7. CLINICAL PRESENTATION Acute infection syndrome is characterized by: Fever Skin rash Arthralgia Lymphadenopathy Diarrhoea - This is called seroconversion illness. It lasts less than 2-3 weeks and resolves spontaneously.

8. AIDS related complex refers to subjects having nonspecific clinical features like: Weight loss Fever, diarrhoea, herpes simplex, oral or recurrent genital candidiasis, oral or genital ulcers. Pelvic Inflammatory Disease Tubo -ovarian abscess. Thrombocytopenia.

9. PARENT TO CHILD TRANSMISSION Vertical transmission to the neonates is about 14 – 25%. Trans-placental transmission occurs 20% before 36 weeks and over 80% of transmission around the time of labour and delivery. Vertical transmission is more in cases with pre-term birth and with prolonged membrane rupture.

10. Risks of vertical transmission are directly related to maternal viral load and inversely to maternal immune status. Maternal Antiretroviral Therapy reduces the risk of vertical transmission by 70%. The maximum risk of transmission form parent to child is the peri-partum period and intra-partum period.

11. PREVENTION OF PARENT TO CHILD TRANSMISSION : Guidelines by National AIDS Control Organization (NACO): HIV testing is recommended in all pregnant women which is opt-out approach. Antiretroviral therapy is recommended for all HIV positive women irrespective of their CD4 counts. Vaginal delivery is recommended, Caesarean section is not the only option.

12. INTERVENTION RISK OF HIV TRANSMISSION FROM MOTHER TO CHILD No intervention and continue breastfeeding 30 – 45% No ART and stop breastfeeding 20 – 25% ART and continue breastfeeding 2% ART and no breastfeeding 1%

13. PROPHYLAXIS ON ANTIRETROVIRAL THERAPY(ART) Initiate antiretroviral therapy in pregnancy as soon as diagnosed with HIV positive. Once started, it should be life-long. Starting ART for the first time : Triple drug regime: Tenofovir – 300 mg Lamivudine – 300 mg Efavirenz – 600 mg (considered safe in pregnancy in all the trimester by world health organization).

14. Women already on Antiretroviral Therapy If the mother is already on ART, she should continue the regime. Recommendations for delivery Vaginal delivery Caesarean section for obstetric indications. Minimize the vaginal examination Avoid early rupture of membrane. Avoid prolonged labour (Oxytocin can be used). .

15. Avoid routine episiotomy. Avoid unnecessary instrumentation During post-partum, methergine is avoided because ART drugs and methergine potentiates increase risk of hypertension. According to world health organization, there is no rush in early cord clamping.

16. Recommendations for Infant Prophylaxis After birth the infant should also get ART prophylaxis irrespective of the mode of feeding of the infant (breastfed and replacement fed babies). Mother who has taken ART more than 4 weeks during pregnancy, the infant should be given Syrup Nevirapine for 6 weeks after delivery / birth.

17. Mother has taken ART less than 4 weeks during pregnancy, the infant should be given Syrup Nevirapine for at least 12 weeks. For a mother who took Nevirapine in the past or previous pregnancy, for the infant Syrup Zidovudine .

18. STANDARD SAFETY MEASURES Prenatal Care: Screening should be offered voluntarily. Counselling about the risks of HIV transmission from parent to child. Tuberculin test should be test to find out any associated factors which can leads to HIV/AIDS.

19. Intra-partum Period Avoid instrumentations during labour. Careful handling of fluids of the mother. Use of personal protective equipment. Post-partum Period Counsel regarding the breastfeeding and help to informed choice. Keeping the perineal area clean with antiseptic solutions to prevent infections

20. The followings are the safety measures to prevent form transmission of HIV/AIDS from one person to another: HIV testing and linkage to care, HIV medications and Access to condoms Prevention programs for people with HIV and their partners Prevention programs for people at high risk for HIV infection Substance abuse treatment and access to sterile syringes Sexually Transmitted Infections screening and treatment. Use of personal protective equipments .

21. SUMMARY & CONCLUSION

22. BIBLIOGRAPHY / REFERENCE DC Dutta’s . Hiralal Konar . Textbook of Obstetrics. 8 th Edition. Jaypee The Health Sciences Publishers. Page no. 350 – 353. Anamma Jacob. A cComprehensive Textbook of Midwifery and Gynaecological Nursing. Fourth Edition. Jaypee The Health Sciences Publishers. Page no. 321 – 323. DC Dutta’s Hiralal Konar . Textbook of Gynaecology. 7 th Edition. Jaypee the health sciences publishers. Page no.126 – 128. Park K. Park’s Textbook of Preventive and Social Medicine, twenty fifth edition. Banarsidas Bhanot Publishers; page no. 310 – 8. https://youtu.be/xIOqLQGQthQ

23. https://www.acog.org/womens-health/faqs/hiv-and-pregnancy#:~:text=During%20pregnancy%2C%20HIV%20can%20pass,breaks%20(her%20water%20breaks) . Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, Royal College of Anaesthetists, Royal College of Paediatrics and Child Health. Standards for Maternity Care. Report of a Working Party. London: RCOG Press; 2008 [http://www.rcog.org.uk/ womens -health/clinical-guidance/standards-maternity-care].