HIV positive mother -Added risk to mother and neonate , infant -Risk to what extent

 

HIV positive mother -Added risk to mother and neonate , infant -Risk to what extent We Obstetrician have to counsel that “ toxicity  to antiretroviral therapy like  chances of hepatic  failure and lactic acidosis  with nucleoside  reverse transcriptase  inhibitor therapy may cause  maternal deaths”  > A hard fact albeit  rare . Can antiretroviral therapy kill  a pregnant mother by Lactic acidosis  but we can’t withhold  anti retroviral   therapy during antenatal and intra natal period  and treating  newborns with ARV.

  

Ans& Reasoning: --  Acquired immunodeficiency syndrome caused by human   immunodeficiency virus was first described  in 1981  and since then the management  of HIV  infection has  evolved very  rapidly . HIV   infection in young children is mostly due to mother to child transmission and prevention of MTCT   will greatly  reduce  the infection  in young generations . The rate of MTCT  can be reduced by antenatal screening  anti retroviral   therapy during antenatal and intra natal period  and treating  newborns with ARV.

Clinical  implications for the mother and fetus when mother in HIV +ve and on antiretroviral therapy

Pregnancy does not influence the course of the disease and neither has it affected the survival of the HIV infected mother. Women  and infants  transmission study did not show difference in CD4+ lymphocyte count  or HIV RNA  trajectory or clinical  AIDS  rate in one or more pregnancies after diagnosis  with HIV .

 Hormonal  effect of pregnancy may increase the toxicity  to antiretroviral therapy like  chances of hepatic  failure and lactic acidosis  with nucleoside  reverse transcriptase  inhibitor therapy may cause  maternal deaths with long  term therapy.

What symptoms of Lactic acidosis & hepatic failure?  Pregnant women  should be  warned  regarding the signs and symptoms  of liver  failure  and lactic  acidosis like nausea,  vomiting , fatigue,  tachycardia,   dyspnea and hyperventilation and abdominal  pain and can mimic normal sign  symptoms  of pregnancy  and may be overlooked.

Perinatal complication  is increased. There is an association with  A) preterm  delivery  B) low birth weight  C)  fetal growth  restriction D)  still birth and F) infant  death in HIV  positive  mothers with  or without  ARV  medications . Mothers receiving  antiretroviral  therapy  with low CD+4 counts have an additional risk factor for adverse  outcome. HAART therapy specifically with protease inhibitors  has increased risk of preterm delivery  in some studies.

What about Perinatal transmissions??  

Risk of perinatal transmission of HIV  to the infant is a matter  of serious concern. A) In untreated women without  breast feeding chances of transmission is 20-30 %  of which two third  of tis transmission will occur  at delivery  and one third during late antenatal period  Breast  fed child has an additional  transmission  risk of 15-20% .  Maternal HIV  RNA level is most important predictor for transmission. ART during pregnancy  and neonatal period reduces the risk of transmission.

What are the factors which has an effect on  MTCT?

1.High maternal viral load

2. Decreased CD4+ count

3. Lack  of HIV neutralizing antibody

4. Advanced  clinical disease

5. Primary infection

6. First born twins

7. Chorioamnionitis

8.Mode  of delivery

9. More than four hrs of ruptured membrane

 

Estimated number of perinatally affected babies has decreased due to implementation  of routine prenatal HIV testing and antiviral therapy 

 

Presentation

Incubation period is days  to weeks and in an average are 3-6 weeks. After acute attack there is chronic  viremia. Progression from asymptomatic viremia to AIDS takes average  10 years Factors  affecting progression are route of infection pathogenicity  of viral strain initial viral inoculums and immunological   status of the host. A CD4+ count <200/mm 3 is also considered to be a definitive diagnosis of AIDs

Common symptoms of acute HIV infection

1.  Fever

2.  Night sweats

3.  Fatigue

4.  Rash

5.  Headache

6.  Lymphadenopathy

7.  Arthralgia

8.  Pharyngitis

9.  Myalgias

10.                Nausea

11.                Vomiting

12.                Diarrhoes

 

 

Clinical  manifestation of disease progression

1.  Generalized lymphadenopathy

2.  Oral  hairy leucoplakia

3.  Apthous  ulcers

4.  Thrombocytopenia

5.  Esophageal candiadiasis

6.  Pulmonary  tuberculosis

7.  Cytomegaloviral pneumonia

8.  Retinitis

9.  Gastro intestinal disease 

10.                Molluscumcontagiosum

11.                Pneumocystis  jiroveci pneumonia

12.                Toxoplasmosis

13.                CNS  symptoms

14.                Menstrual  anomalies

15.                Genital  neoplasia

16.                Other  STIs

 

 

Investigation and diagnosis

Pre natal HIV screening is done for all pregnant women using opt out approach which means that the women is notified that HIV  testing is included in a comprehensive set of ante natal tests but  testing may be declined . In areas where  incidence is high  as 1/1000  person years  or in high risk  women ACOG recommends  repeat  testing in third trimester. Rapid  HIV  test is done. This  test has high  specificity and  sensitivity   . National AIDS control Organization of India  recommends opt  out HIV testing for all antenatal  mothers.  If positive then a through  history  and physical examination with baseline fundus examination neurological   and pelvic  examination  are done. Investigations offered to HIV   positive  women are :

1.  Complete  haemogram

2.  Urine  for Bacteriuria

3.  Blood group 

4.  Tests  for Hepatitis  B, Gonorrhea syphilis , Chlamydia and herpes

5.  Serological  tests  toxoplasmosis and CMV  infection

6.  Tests  for tuberculosis

7.   Baseline  chest radiography

8.  Serology  of husband   for HIV 

9.  LFT

10.                Sonographic evaluation of gestational age 

11.                Initial  HIV  viral load and in each  trimester 

12.                Initial  CD4+  hymphocyte  count and repeat  in each trimester

 

 

Management 

Pre conceptional counselling – counselling should be  done regarding effective contraception risks of MTCT  education   for decreasing high risk  sexual behavior to prevent  transmission and acquisition of other   STIs  , ART in pregnancy  should be discussed in detail with couples Patients  should have effective  decrease of viral  load  before  pregnancy

Antepartum management – A positive woman  should be treated in collaboration with physicians treating HIV  positive  cases or ART centres in hospitals

Anti  Retroviral  therapy- WHO recommends ART in all HIV  positive women  in pregnancy which  is accepted by NACO in 2013 . Anti retroviral  therapy is highly effective in reducing the viral  load and perinatal  transmission

Criteria  for ART Initiation

All HIV infected pregnant women  should receive lifelong ART.

 

This  treatment serves two key  purposes :

1.  Improves  health and prolongs survival  of the mother 

2.  Reduces the risk of HIV transmission from mother  to child during pregnancy labour  delivery  and throughout  the breast feeding  period.

 

 

 

Initiation of ART in pregnant women  needs to be done at the earliest and after adequate treatment preparedness for adherence to maintain her own health  and also to prevent  HIV virus  transmission to the unborn baby. In HIV infected pregnant women  the dictum should be do not delay ART initiation . the eligibilitycriteria for  initiaing ART in HIV  positive pregnant women  are as below

 

 

ART eligibility in pregnant women :

Initiate  lifelong ART in all pregnant women with  confirmed HIV  infection regardless of WHO clinical stage or CD4  cell count. TDF  + 3TC + EFV  is recommended as first line ART in pregnant  and breastfeeding women if there is n prior  exposure to NNRTIs 

ART shall be initiated only at ART centre.

Indications for  co trimozaxole  Prophylactic Therapy   in pregnancy

The  indications for co trimozaxole  initiation in pregnant  women are same as those for other adilts . Co trimoxazole prophylaxis is helpful in reducing morbidity  and mortality as it  prevents  . Opportunistic Infections such as Pneumocystis jiroveci pneumonia toxoplasmosis  diarrhea as well as other  bacterial infections .

Starting co- trimaxazole in pregnancy

Co  trimoxazole should be started if CD4  count is < 250 cells /mm3  and continued through  pregnancy, delivery  and breastfeeding as per national guide liens

Ensure that  pregnant women  take their folate supplements regularly

Infants  of mothers  who are receiving  ART  and are  exclusively breastfeeding or doing exclusive replacement   feeding should  receive at least  six weeks of infant prophylaxis  with daily SypNevirapine

Infant  prophylaxis should begin at birth or when HIV  exposure  is known.

ART Regimen for Pregnant Women having Prior Exposure to NNRTIs for PPTCT

HIV infected pregnant women who have previous exposure  to Sd NVP  for PPTCT  prophylaxis  in prior  pregnancies an NNRTI based ART regimen such as TD F + 3TC + EFV may not be fully effective due to persistence of archieved mutation toNNRTIs. Thus  these women  wil require  a protease inhibitor based ART regimen viz

TDF + 3TC + LPV