The University of the Gambia

School of Medicine & Allied Health sciences

Department of Medicine

Course: OBSTETRICS AND GYNEACOLOGY BLOCK

POSTING

TOPIC: ASSIGNMENT ON
HIV IN PREGNANCY

WRITTEN & COMPILED BY:

AJIE YAMA BADGIE
MAT#21618085
 QUESTION
How would you manage a 30year old medical doctor G2P1001, who came for
booking and diagnosed HIV positive two weeks ago?

ANSWER
The management of the pregnant woman with HIV infection has evolved
significantly over the past 25 years in light of advancements in drug development
and a greater understanding of the prevention of perinatal HIV transmission. In the
United States, Europe and, The Gambia the risk of HIV transmission from mother
to infant has declined to historically low levels with the use of antiretroviral
medications. Contributions to this successful prevention effort include universal
testing of pregnant women for HIV infection, the use of cesarean delivery (when
appropriate), and avoidance of breastfeeding, when feasible.

Management of HIV usually entail the following four WHO comprehensive

strategic approach in the prevention of transmission of HIV from mother to child:

 Primary prevention of HIV infection among women of childbearing age.

 Preventing unintended pregnancies among women living with HIV.
 Preventing HIV transmission from a woman living with HIV to her infant;
and
 Providing appropriate treatment, care and support to mothers living with
HIV and their children and families.

Therefore with the above strategies in mind, management of this patient will be
categorized into three (3) stages:

 ANTEPARTUM CARE
During pregnancy there is a 5-10% chance of trans placental transfer of the
virus from mother to fetus with chances higher in the third/last trimester.
HIV may cause placental infection and subsequently intrauterine infection of
fetus. This possibility is supported by the findings that some placental cells
express CD4, and the fact that two peaks of HIV positivity can be detected
in the infected neonate: 38% of the HIV infected infants tested positive with

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HIV DNA PCR within 48 hours of life and almost all the rest at 2 weeks.
Risk factors is exponentially increased when there is presence of high
maternal viral load, low maternal CD4 count, progression to AIDS, vitamin
A deficiency, illicit drug use, Amniocentesis especially in the 3rd trimester,
unbooked, late booking or lack of antenatal care (ANC).
 During ANC, provider initiated HIV counselling and testing (PICT)
should be offered as routine part of a standard package of care to
reveal and confirm HIV positive mothers.
If she were not pregnant but planning to get pregnant and happens to
be HIV positive, preconception counselling, specialized ANC, use of
Antiretroviral therapy (ART) in pregnancy, mode of delivery,
prevention of MTCT, possibility of breastfeeding and paediatric
management will be addressed in order to prepare her on what to
expect before, during and after pregnancy.
 Immunological assessment of the woman’s clinical stage such as CD4
cell count and viral load should be assessed routinely as clinical stage
does not always correlate with CD4 count or viral load and many HIV
infected persons appear clinically asymptomatic despite
advanced/severe immune suppression.
 Extended booking workup is recommended such as Hepatitis B & C,
Toxosoplasmosis, Rubella, cytomegalovirus and Hepatitis (TORCH)
screen.
 In the past termination of pregnancy (TOP) based on maternal
infection is no longer justified as about 70% of newborns born
without interventions are not infected.
 Initiation and maintenance of ART of reduce risk of mother to child
transmission of HIV.

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 INTRAPARTUM CARE
During labour and delivery there is a 15-20% chance of exposure of the
fetus/infant to maternal blood, amniotic fluid and cervico-vaginal secretions.
Chances are increased depending on cervicovaginal HIV levels, mode of
delivery, prolonged rupture of membranes, premature delivery, vaginal
laceration, episiotomy, invasive fetal monitoring and instrumental delivery.

 Vaginal delivery is appropriate for HIV-infected pregnant women

who have been maintained on ART and who have viral loads of 1,000
copies/mL or less at or near delivery. These women can be managed
in a manner similar to HIV-uninfected women. Duration of rupture of
membranes before delivery is not an independent risk factor for
maternal-child transmission in women who are otherwise
appropriately virally suppressed and is not a consideration regarding
route of delivery.
 For women who are untreated or suboptimally suppressed because of
poor adherence, resistance to their ART regimens, or inadequate time
on ART to attain suppression, with viral loads more than 1,000
copies/mL at term, a scheduled medically indicated early-term
cesarean delivery at 38 weeks of gestation should be offered, in
conjunction with peripartum maternal antiretroviral therapy
(intravenous ZDV) administered 3-hours preoperatively. In these
women, early-term cesarean delivery, ideally before the onset of labor
and before rupture of membranes, reduces the risk of HIV
transmission.
 As with all complex clinical decisions, the choice of delivery should
be individualized. Discussion of the option of scheduled cesarean
delivery and its advantages in the situation of suboptimal viral
suppression should begin as early as possible in pregnancy with every
pregnant woman with HIV infection to give her an adequate
opportunity to ask questions and consider her decision-making
concerning the delivery plan. The patient's decision regarding her
route of delivery should be respected after maternal and neonatal risks
have been discussed.

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 POSTPARTUM CARE
After delivery there is a 15-25% chance of viral transfer via breastfeeding
and chances are also increased depending on duration of breastfeeding.
 Breastfeeding is not recommended for HIV positive women and their
infants; this is consistent with the World Health Organization
Guidelines (2004). If the woman decides to breastfeed they should be
advised to breast feed exclusively i.e. not to supplement with artificial
milks or other drinks and she must be made aware that the baby
continues to be exposed to the risk of mother-to-child transmission
during breastfeeding.
 Mothers need to be given skilled help with positioning and attachment
to avoid cracked nipples and mastitis that may increase the risk of
transmission. As mentioned above the longer the duration of
breastfeeding, the greater the risk of transmission. Breastfeeding
should be discontinued as soon as feasible and certainly not for more
than 6 months. Extra postnatal stay may be required for support with
artificial feeding and teaching parents administration of newborn
ARVs Consider lactation suppression for the mother’s comfort.
Unless the baby is ill, there is no reason for him/her to be routinely
admitted. Every effort should be made to keep mother and baby
together.
 Infant Follow-Up and Postnatal Prophylaxis - regardless of maternal
viral load, after birth, all babies born to HIV-infected women should
be bathed immediately to remove any potentially infectious maternal
secretions. Baseline complete blood counts and HIV diagnostic testing
by HIV DNA PCR are to establish or rule out HIV infection, followed
by ZDV prophylaxis. Within 12 hours after birth, and ideally no later
than 24 hours, all neonates born to HIV positive mothers should
receive a course of ZDV therapy, which will be continued for 6
weeks; however, a 4-week regimen can be considered for full-term
infants whose mothers had maintained HIV viral suppression
antenatally.

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  All HIV-infected women should have a routine postpartum follow-up
visit with their obstetric provider. After delivery, establishing
retention in HIV care is critical, with referral to an infectious disease
specialist. Counseling patients regarding adherence to ART,
irrespective of CD4 count, is very important, as some HIV-infected
women become noncompliant with ART during follow-up after
delivery.

Healthy pregnancies and having a healthy baby

The prevention of MTCT does not necessarily equate a healthy baby. The health
status of a newborn may suffer on several fronts:
(a) Negative impacts of maternal HIV disease - HIV disease may confer a
worsened pregnancy outcome.This may be mediated through associated
risks such as drug use and poor access to antenatal care as well as the disease
itself.
(b) Fetal exposure to antiretrovirals - While potent antiretrovirals may
decrease MTCT and control maternal disease, the fetus may suffer adverse
effects and possible teratogenicity. With the exception of efavirenz and
delavirdine, there is no human evidence of teratogenicity with the current
antiretroviral therapy, though data are limited for many of the newer drugs
and their combination.
(c) Expert paediatric care - The prevention of MTCT does not stop at
delivery. Expert paediatric care has to be provided for optimal continuation
and monitoring of antiretrovirals, establishment of HIV diagnosis, initiation
of PCP prophylaxis, and the supervision of replacement feeding.

Maternal well-being
The quest for preventing the baby from HIV infection should not compromise the
welfare of the mother. Potential dilemna may occur in the following
circumstances:
(a) continuation or initiation of antiretrovirals for maternal disease in the
first trimester of pregnancy,
(b) use of antiretrovirals for prevention of MTCT in a mother whose disease
does not require treatment yet,
(c) The potential impacts of elective CS on maternal morbidity, and
(d) Avoidance of breast feeding which is important for maternal baby
bonding.
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NOTE: These issues are complex and all pros and cons should be fully explained
to the mother to allow her to make an informed decision.

The social and psychological impacts

A diagnosis of maternal HIV infection carries enormous social and psychological
implications, which arise largely as a result of the stigma attached to the infection.
The health care provider is faced with the following challenges:
(a) Encouraging partner referral for HIV testing,
(b) Preparing the mother for the dual challenge of preventing transmission to
the baby and taking care of her own health,
(c) Enlisting support from social service agencies, this is especially
important for those mother/couples where social support is usually weak,
(d) Creating a supportive environment for the newborn baby, which poses a
challenge also to the sick mother, and
(e) The need to accomplish the above in a relatively short time.

Today, the science of HIV treatment and prevention against MTCT is complicated
and advancing rapidly. To ensure that the best management is offered, negative
psychosocial factors in the patients and staff should be handled with tact and
sensitivity. This may turn out to be the most difficult of all.

CONCLUSION
Although the relative proportion of MTCT among all local HIV infection is small
(19 reported cases of perinatal infection as of the end of 2006), it is the single most
important route by which a child is infected with HIV, now that all donated blood
is screened. MTCT is unique in the sense that a window of opportunity exists
whereby appropriate biomedical intervention can prevent the occurrence of the
infection.

Furthermore, as HIV infected women are enjoying better general health while
receiving highly active antiretroviral therapy (HAART), they may be more keen to
start a family and rear a child, whereas in the past most would avoid or terminate
pregnancy. This is also reflected in the local demand of infertility service from
HIV infected couple. Against the background of rising number of infected women,
the HIV positive pregnancy will likely be more common in the future.

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 REFERENCES
 Anderson JR (ed). A Guide to the Clinical Care of Women with HIV/AIDS,
2005 edition. Rockville:DHHS, 2005. Available from
http://hab.hrsa.gov/publications/womencare05 (accessed 16 December
2006).
 Prevention of mother to child transmission of HIV infection in HIV
treatment manual by Mr Mathew Anyanwu. Revised and updated 2017
 Briand N, Jasseron C, Sibiude J, Azria E, Pollet J, Hammou Y, et al.
Cesarean section for HIV-infected women in the combination antiretroviral
therapies era, 2000–2010. Am J Obstet Gynecol 2013;209:335.e1–12.
 Scott RK, Chakhtoura N, Burke MM, Cohen RA, Kreitchmann R. Delivery
after 40 weeks of gestation in pregnant women with well-controlled human
immunodeficiency virus. Obstet Gynecol 2017;130:502–10.
 www.who.int/hiv/pub/guidelines/pmtctguidelines3.pdf “Guidelines for
Maternity Providers offering antenatal HIV screening in New Zealand”. Feb
2008.