Post on 04-Apr-2018
transcript
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
1/34
DR.JAVED ALI, MD(O&G)
ASSIATANT PROFESSOR
GMCH,GUWAHATI
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
2/34
1-2 Per thousand pregnant women in US.
Less than 0.5% in most asian countries.
In India the rate varies from 0-2.4%.
54 seropositive women detected in departmentof O&G GMCH.
14 cases underwent caesarian section and 33
cases had vaginal delivery in our department. The rate of transmission from mother to child is
in between 15-48%.
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
3/34
Over 5,90,000 children are infected with HIVeach year by vertical transmission.(USAIDreport 1997).
Estimated risk of infection to the health careproviders after parenteral or mucousmembrane exposure is 0.36%.
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
4/34
A. MATERNAL viral load Biological prototype of virus Unprotected sex during pregnancy Smoking & illicit use of drugs in mother Maternal level of CD4 & lymphocyte count. Low maternal vit A level. Presence of RT9/ST9 in mother. Time of rupture of membranes & choriomeningitis Episiotomy & operative vaginal delivery Presence & amount of virus in genital tract.
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
5/34
B.FETAL
Fetus can ingest the virus
Fetal scalp electrode, scalp blood sampling &
umblical blood sampling.
Duration of exposure to maternal secretions( first twin).
Via breast milk depending upon the immuneresponse of the fetus, duration of breastfeedingand infectivity of mother.
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
6/34
Does not enhance disease progression.
Serious infections do occur if CD4 count is
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
7/34
Fertility not impaired in initial stages.
Late HIV disease may cause IUGR, pretermdelivery, IUD, neonatal death, higher incidence
of birth canal sepsis, and opportunisticinfections.
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
8/34
KNOWN HIV+VE CASE Booked/Unbooked
DETECTED ONLY IN LABOUR
PRESENTING WITH AIDS
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
9/34
THE KEY
1. Optimal care of the pregnancy- Nutritious diet
- Prevent anaemia, hypoprotenemia- Choice of MTP/continuation of
pregnancy
- Discontinue smoking, illicit drugs
- Regular check up
- Detect & treat opportunistic infections
- Proper intranatal care in hospital
2. Care of the HIV infection
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
10/34
PERVENT VERTICAL TRANSMISSION
PREVENT SPREAD OF INFECTION
Take universal precaution
Proper disposal wastes Disinfection and sterilisation of linens and equipments.
THE APPROACH-
KEEP UTMOST SECRECY
BE NON INSISTENT BUT GENTLE.
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
11/34
SHAVING
ENEMA
CATHETERISATION
PV EXAMINATION
IV CANULATION
INJECTION
DRAWING BLOOD OR COLLECTIING URINESAMPLES
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
12/34
SHOULD WE DO ELECTIVE CESAREANSECTION?
OR
ALLOW VAGINAL DELIVERY?
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
13/34
Each time after examining the patient, washhand in automatic water tap with soap.
Always keep delivery tray ready with linen
and cord clamp. Take universal precautions while conducting
delivery
Never deliver a women without gloved
hands(taxi/toilet delivery) Never keep sharp instruments around
perineum on delivery table to avoid cut tomother/ baby or to the health worker.
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
14/34
Avoid repeated per vaginal examination to avoidinfection
Avoid catheterisation unless indicated. Drape perineal area with sterile linen while
delivering a woman or suturing episiotomy andperineal tears. A maternal sample for plasma viral load should be
taken at the time of delivery. Amniotomy, application of scalp electrodes, scalp
blood sampling should better be avoided. Mechanical suctioning(
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
15/34
Never guide the needle with fingers
Non touch technique is the best.
Any spillage of blood or fluid over skin areashould be washed immediately.
Put wash proof band aid over any cut or abrasionbefore putting on gloves.
In case of accidental needle prick or spillage overskin or mucus membrane with breach, takeimmediate prophylaxis, triple therapy for 4 wks.
Cord should be clamped early.
Baby should be bathed immediately.
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
16/34
Double gloves Special puncture resistant glove if available. Using eye glasses, shield, special gowns and boots. Spinal anaethesia preferable Liberal incision There should not be active bleeding from incision
wound while extracting the baby. Disinfection of anesthesia equipments.
Other precautions already mentioned inprecautions in vaginal delivery.
Universal precautions by anaethetist andpaediatrician.
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
17/34
UNIVERSAL PRECAUTIONS
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
18/34
nn
NEONATOLOGIST(WITH UNIVERSAL PRECAUTIONS)
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
19/34
MEMBERS OF THE OPERATING TEAM
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
20/34
ISSUES-
- Gestational age
- Severity ( viral load/ CD4 count)
- Tolerance of regimen during pregnancy
- Potential adverse effects
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
21/34
ACTG O76 TRIAL-
Zidovudin-100mg 5times a day from 14wksuntil labour.
During labour-2mg/kg over 1st 2hrs
maintainence dose of 1mg/kg/hr until
deliveryzidovudin syrup- 2mg/kg 4times a day for the6 weeks to the neonate
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
22/34
SHORT COURSE ZDV-
300mg zidovudin twice daily from 36wks until onsetof labour then every 3hrs till delivery
neonate is given 2mg/kg ZDV syrup QID for 1 week
HIV NET 02-
Nevirapin 200mg 2 tabs to mother at the time ofdelivery
neonate- Nevirapin syrup 2mg/kg in single dosewithin 72 hrs
In case of LSCS- Nevirapin is given 4 hrs beforeprocedure
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
23/34
IF ON ART OPTIONS ARE-
Suspend therapy temporarily during 1sttrimester.
Continue the same therapy Change to a different regimen
If not on ART- prophylaxis (PPTCT)
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
24/34
ART may be delayed if in the 1st trimester
Weigh the severity of the disease and thepotential benefits/risks of delaying ART until
after 1st trimester. For the women who are severely ill, the benefit
of early initiation of ART may outweigh therisk to fetus.
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
25/34
Postpartum care
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
26/34
Actual HIV status of the baby can only beascertained by PCR and P24 Antigen.
After 15 months of breastfeeding HIV-1transmissions to the infant is around 32%
The mother should be counseled regarding therisks and benefits. She should be helped to makean informed choice.
In India because of the potential risks of diarrhoeaand other diseases involved in alternative feeding,
breastfeeding has not been routinely disregarded. If breast feeding is chosen as an option, encourage
exclusive breastfefeeding and advise earlycessation.
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
27/34
Awareness about infection-
Burning micturation
Fever
Foul smelling lochia
Cough sputum,shortness of breath
Redness,pain,pus,discharge from
incision/episiotomy Lower abdominal pain
She should be told about disposal of sanitary
pads etc. and care of perineum and breast.
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
28/34
COTRACEPTIVE ADVICE-
- condoms
- sterilization
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
29/34
Regular gynecological care including papsmears.
Regular HIV/AIDS care- medical follow up/
visit to ART centre. Nutrition and dietary care
Family planning services.
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
30/34
1.RED CONTAINER/BAGS-syringes, canula , catheter, needles , blood bag, drip set ,gloves& any infectious item.
2. YELLOW CONTAINER/ BAGS-Blood soaked articles like cotton bandages, dressings, plasters,pathological and anatomical wastes and other laboratorywastes.
3. BLUE CONTAINER/ BAGS-Broken glass , blades, scalpels.
4. BLACK CONTAINER/BAGS-
Office wastes, kitchen& canteen wastes. other non infectiouswastes
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
31/34
Put soiled linen, gloves and instruments in 10%hypochloride solution/ bleach solution for 10minutes before washing. A toothbrush may beused for cleaning the instruments.
Pour bleach solution on labour table for half anhour. It can also be disinfected using 10% lysol or2% gluteraldehyde.
Put the placenta in a bag with bleaching powder-either incinerate or burry with bleaching powder
all around. Floor soiled with blood or amniotic fluid should be
cleaned with antiseptic/ bleach solutionimmediately.
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
32/34
Disposable syringes and needles should bedisinfected using bleach solution/gluteraldehyde/mutilation/ shredding.
Universal precautions should also be adoptedby workers in the labour room.
Heavy duty gloves or utility gloves best beused.
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
33/34
Every obstetrician or maternity service provider hasalready delivered or will deliver HIV+VE motherknowingly or unknowingly.
We must keep abreast with the recent developments in
HIV/AIDS. Need not be panicked. Keep secrecy, be non insistent,
but gentle this will help her not to disappear.
Proper care can help prevent vertical transmission and
as well as prevent spread of the disease. There is a little risk to service provider if universal
precaution is adopted.
7/30/2019 Perintal Care of Hiv+ Ve Mother- New
34/34
THANK YOU!