HIV & Vaginal Infections in Pregnancy v2.pptx

HIV & Vaginal Infections in Pregnancy v2.pptx

1. HIV & Vaginal Infections in Pregnancy 2025/01/01

2. HIV in Pregnancy 01 Vaginal Infections 02 Prevention & Cases 03 CONTENTS

3. HIV in Pregnancy 01 Part.

4. In the UK, the prevalence of HIV among pregnant women is approximately 2 per 1,000 maternities. This highlights the importance of targeted screening and intervention strategies to manage and reduce the impact of HIV in pregnancy. UK Prevalence Epidemiology & Vertical Risk Without intervention, the risk of vertical transmission of HIV can reach 15–45%. However, with integrated antenatal screening and antiretroviral therapy, this risk can be reduced to below 1–2%, emphasizing the critical role of early detection and treatment. Transmission Risk Early identification through antenatal screening is pivotal in preventing mother-to-child transmission of HIV. It allows for timely initiation of antiretroviral therapy and other preventive measures to protect the health of both mother and child. Prevention Importance

5. Mother-to-child transmission of HIV can occur in utero across the placenta, intrapartum through contact with blood and secretions, and postpartum via breastfeeding. Each stage presents unique challenges and requires specific preventive measures. Mother-to-Child Transmission In addition to mother-to-child transmission, HIV can spread through sexual contact, sharing contaminated needles, and blood products. Blocking these routes is essential to protect the health of the entire household. Other Transmission Routes Transmission Pathways

6. The risk of vertical transmission increases with higher maternal viral load. Effective antiretroviral therapy to suppress viral load is crucial in reducing this risk and improving pregnancy outcomes. Maternal Viral Load Maternal & Fetal Risk Factors A low CD4 count in pregnant women with HIV is associated with higher transmission risk and poorer health outcomes. Monitoring and managing CD4 levels is essential for maternal and fetal health. Low CD4 Count Obstetric factors such as prolonged membrane rupture and chorioamnionitis can increase the risk of HIV transmission. Careful management of these conditions is vital to protect the fetus. Obstetric Complications Mixed feeding practices, combining breastfeeding with other foods or liquids, can heighten the risk of HIV transmission. Exclusive breastfeeding or formula feeding should be considered based on local guidelines. Mixed Feeding Practices

7. Offer opt-out HIV testing at the initial antenatal visit and repeat in the third trimester for high-risk women. Rapid testing should be available for unbooked labor presentations to ensure timely diagnosis. Confirmatory serology, baseline CD4 count, viral load, full blood count, renal and hepatic function tests, and syphilis screening are essential for guiding therapy and delivery planning. Confirmatory Tests Ultrasound examination may be indicated to assess fetal development and identify any complications related to HIV infection or pregnancy progression. Ultrasound Assessment Screening & Diagnostic Work-up Antenatal Screening

8. Initiate combination antiretroviral therapy (ART) as early as feasible in pregnancy to achieve undetectable viral load by 36 weeks. Early treatment is crucial for preventing mother-to-child transmission. Early Initiation Preferred pregnancy regimens include TDF/3TC/EFV, with alternatives for renal impairment or prior exposure to NVP. Lifelong continuation of ART ensures maternal health and prevents resistance. Preferred Regimens ART Strategy for PMTCT

9. Delivery & Intrapartum Care Plan an elective caesarean section when the maternal viral load exceeds 50 copies/mL near term. This reduces the risk of intrapartum transmission. Elective Caesarean Section If the viral load is below 50 copies/mL at 36 weeks, a planned vaginal delivery may be appropriate. Avoid invasive procedures like fetal scalp electrodes to minimize transmission risk. Vaginal Delivery Shorten the duration of ruptured membranes and consider intrapartum IV zidovudine if the viral load remains elevated. These measures help reduce the risk of intrapartum transmission. Intrapartum Management

10. Postnatal & Infant Management Provide 4 weeks of zidovudine monotherapy if the maternal viral load is suppressed, or a 3-drug PEP regimen if the risk is higher. Prophylaxis is crucial for preventing neonatal HIV infection. Neonatal Prophylaxis Schedule PCR tests at birth, 3 weeks, 6 weeks, and 6 months to confirm infant HIV status. Early diagnosis allows for timely intervention and management. Infant Diagnosis Support formula feeding where safe and acceptable alternatives are available. Feeding choices should be guided by local policies to ensure optimal infant health. Feeding Guidance Clamp the cord immediately after birth and bathe the newborn soon. Early cord clamping and prompt bathing help reduce the risk of neonatal infection. Immediate Postnatal Care

11. Vaginal Infections 02 Part.

12. Normal vs Pathological Discharge Normal Discharge Physiological pregnancy discharge is typically white, non-offensive, and has a pH of ≤4.5. This is a normal part of pregnancy and does not indicate infection. 01 Pathological discharge presents with odor, itch, color change, or discomfort. It requires speculum exam, pH strip, saline and KOH microscopy, and whiff test to distinguish between BV, trichomoniasis, and candidiasis. 02 Pathological Discharge

13. Bacterial vaginosis (BV) is a polymicrobial overgrowth that raises vaginal pH above 4.5. It is associated with an imbalance in the vaginal microbiome. BV Definition Amsel criteria for BV diagnosis include three of four findings: thin homogeneous discharge, clue cells, positive whiff test, and elevated pH. These criteria help in accurate diagnosis. Amsel Criteria BV is correlated with increased risk of preterm rupture of membranes (PROM), preterm birth, and puerperal infection. Timely diagnosis and treatment are essential to mitigate these risks. Associated Risks Bacterial Vaginosis Overview

14. Use metronidazole 250 mg orally three times daily for seven days or clindamycin 300 mg twice daily. Intravaginal preparations are alternatives after the first trimester. Partner treatment is generally unnecessary for BV. However, condoms and avoidance of douching can reduce recurrence and improve overall vaginal health. Prevention Strategies 02 BV Treatment in Pregnancy Treatment Options 01

15. Clinical Presentation Diagnostic Methods Associated Risks Trichomonas vaginalis infection presents with frothy yellow-green discharge, vulvar itch, dysuria, and possible strawberry cervix on examination. 1 Motile flagellates on saline microscopy confirm the diagnosis of trichomoniasis. Accurate diagnosis is crucial for appropriate treatment. 2 Infection with Trichomonas vaginalis increases the risk of preterm rupture of membranes, preterm delivery, and acquisition of HIV. Timely treatment is essential. 3 Trichomoniasis Features 「LOGO」

16. Trichomoniasis Therapy Prescribe single 2 g oral metronidazole or 500 mg twice daily for seven days. Tinidazole is an alternative for resistant cases. Treatment Regimens Treat sexual partners simultaneously and advise condom use until both are symptom-free. This helps prevent reinfection and protects sexual health. Partner Management

17. Vulvovaginal Candidiasis Clinical Presentation Candida overgrowth presents with intense itch, thick cottage-cheese discharge, dyspareunia, and dysuria. These symptoms can significantly impact the quality of life. 1 Risk Factors Risk factors for vulvovaginal candidiasis include pregnancy, diabetes, recent antibiotic use, and immunosuppression. Identifying these factors aids in management. 2 Diagnostic Methods KOH microscopy reveals budding yeast or pseudohyphae, guiding the choice of antifungal therapy. Culture may be considered in recurrent cases. 3

18. Apply topical azoles such as clotrimazole or miconazole pessaries and creams for seven days. These are effective and safe during pregnancy. Topical Azoles For recurrent disease, extended therapy may be required. Investigate underlying factors such as diabetes and hygiene practices to prevent recurrence. Recurrent Disease Management Candidiasis Treatment

19. Prevention & Cases 03 Part.

20. Promote consistent condom use to reduce the risk of sexually transmitted infections, including HIV and other vaginal infections. Condom Use Prevention & Counseling Encourage partner testing and treatment to prevent reinfection and protect the health of both partners. Partner Testing Ensure adherence to antiretroviral therapy for HIV-positive individuals to maintain viral suppression and reduce transmission risk. ART Adherence Advise balanced nutrition and regular antenatal visits. Provide culturally sensitive feeding guidance and ensure follow-up for both HIV and vaginal infections. Nutrition & Follow-up 01 02 03 04

21. A 28-year-old G2P1 at 20 weeks receives a new HIV diagnosis. Baseline CD4 and viral load are drawn immediately to guide management. Initial Diagnosis Combination ART is started immediately, coordinated by an HIV specialist, to achieve viral suppression and reduce transmission risk. ART Initiation Viral load is rechecked at 36 weeks to dictate mode of delivery. Infant prophylaxis and feeding counseling are arranged per local protocol. Delivery Planning Case 1: HIV-Positive Gravida

22. At 34 weeks, a woman reports itching and thick white discharge. pH <4.5 and KOH microscopy show budding yeast, indicating vulvovaginal candidiasis. Clinical Presentation Case 2: Vaginal Discharge Clotrimazole pessaries are prescribed for seven days. If instead, pH >4.5 with clue cells and fishy odor, metronidazole 250 mg tid for seven days would be indicated for BV. Treatment Plan

23. Early initiation of ART achieves viral suppression and cuts vertical HIV transmission to under 1%. This is crucial for maternal and child health. ART Importance Delivery mode and infant PEP hinge on late-pregnancy viral load. Timely and appropriate care ensures the best outcomes for the newborn. Delivery & Infant Care Bedside tests guide targeted antibiotic or antifungal therapy for vaginitis, reducing preterm birth and maternal morbidity. Accurate diagnosis is key. Vaginitis Management Key Take-Home Messages

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