HIV and Pregnancy Prevention of Mother-To-Child Transmission

8/12/2019 HIV and Pregnancy Prevention of Mother-To-Child Transmission

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HIV and Pregnancy: Prevention of

Mother-to-Child Transmission

Advances in Maternal and Neonatal Health


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2HIV and Pregnancy

Session Objectives

To discuss best practice for antenatal, intrapartum andpostpartum care of the HIV-positive mother to reduce mother-to-child transmission

To review the evidence supporting these practices


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3HIV and Pregnancy

HIV-Related Counseling Issues

During PregnancyEducate/counsel regarding HIV and pregnancy beforepregnancy:

Impact of HIV on pregnancy and pregnancy on HIV

Maternal health

Long-term health of mother and care for children

Perinatal transmission

Use of antiretrovirals and other drugs in pregnancy


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5HIV and Pregnancy

Adverse Pregnancy Outcomes and

Relationship to HIV InfectionPregnancy Outcome Relationship to HIV Infection

Spontaneous abortion Limited data, but evidence of possible increasedrisk

Stillbirth No association noted in developed countries;evidence of increased risk in developingcountries

Perinatal mortality No association noted in developed countries, butdata limited; evidence of increased risk indeveloping countries

Newborn mortality Limited data in developed countries; evidence ofincreased risk in developing countries

Intra-uterine growthretardation

Evidence of possible increased risk

Anderson 2001.


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6HIV and Pregnancy

Adverse Pregnancy Outcomes and

Relationship to HIV Infection (continued)Pregnancy Outcome Relationship to HIV Infection

Low birth weight Evidence of possible increased risk

Preterm delivery Evidence of possible increased risk, especially w/more advanced disease

Pre-eclampsia No data

Gestational diabetes No data

Amnionitis Limited data; more recent studies do not suggestan increased risk; some earlier studies foundincreased histologic placental inflammation,particularly in those with preterm deliveries

Oligohydramnios Minimal data

Fetal malformation No evidence of increased risk

Anderson 2001.


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7HIV and Pregnancy

Mother-to-Child Transmission

25 35% of HIV positive pregnant mothers will pass HIV to theirnewborns

In the absence of breastfeeding:

30% of transmission in utero

70% of transmission during the delivery

Meta-analysis showed 14% transmission withbreastfeeding and 29% transmission with acute maternal

HIV infection or recent seroconversion

DeCock et al 2000; Dunn et al 1992; WHO/UNAIDS 1999.


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8HIV and Pregnancy

Risk Factors for Mother-to-Child

TransmissionViral load (HIV-RNA level)

Genital tract viral load

CD4 cell countClinical stage of HIV

Unprotected sex with multiplepartners

Smoking cigarettes

Substance abuseVitamin A deficiency

STDs and other coinfections

Antiretroviral agents

Preterm deliveryPlacental disruption

Invasive fetal monitoring

Duration of membrane rupture

Vaginal delivery vs. cesarean

sectionBreastfeeding

Anderson 2001.


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10HIV and Pregnancy

HIV Testing during Pregnancy

Advantages:

Possible treatment of mother

Reduce risk of mother-to-child transmissionFuture family planning issues

Precautions against further spread

If negative, advise about HIV prevention

Counseling is important!


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11HIV and Pregnancy

Antenatal Care

Most HIV-infected women will be asymptomatic

Watch for signs/symptoms of AIDS and pregnancy-relatedcomplications

Unless complication develops, no need to increase number ofvisits

Treat STDs and other coinfections

Counsel against unprotected intercourse

Avoid invasive procedures and external cephalic versionGive antiretroviral agents, if available

Counsel about nutrition


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12HIV and Pregnancy

Antiretrovirals

Zidovudine (ZDV):

Long course

Short courseNevirapine

ZDV/lamivudine (ZDV/3TC)


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13HIV and Pregnancy

ZDV Perinatal Transmission Prophylaxis

Regimen: ACTG 076 TrialAntepartum Initiation at 14 34 weeks gestation and continued

throughout pregnancyPACTG 076 regimen: ZDV 5 times daily

Acceptable alternative regimen: ZDV 2 or 3 timesdaily (depending on dose)

Intrapartum During labor, ZDV IV over 1 hour, followed by acontinuous infusion of IV until delivery

Postpartum Oral administration of ZDV to newborn for first 6

weeks of life, beginning at 8 12 hours after birth

Anderson 2000.


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14HIV and Pregnancy

Intrapartum vs. Postpartum Regimensfor HIV-Infected Women in Labor with

No Prior Antiretroviral TherapyDrug

RegimenMaternal

IntrapartumNewborn

PostpartumData on

Transmission

Nevirapine One oraldose at onsetof labor

One oral dose atage 48 72 hours (ifmother receivednevirapine < 1 hourbefore delivery,newborn given oralnevirapine as soonas possible afterbirth and at 48 72hours)

Transmission at 6weeks 12% withnevirapinecompared to 21%with ZDV, a 47%(95% CI, 20 64%)reduction

Anderson 2001.


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15HIV and Pregnancy


No Prior Antiretroviral Therapy (contd.) Drug

RegimenMaternal

IntrapartumNewborn

PostpartumData on

Transmission

ZDV/3TC ZDV orally atonset of laborfollowed bydose orallyevery 3 hoursuntil deliveryAND

3TC orally atonset of labor,followed bydose orallyevery 12 hours

ZDV orally every12 hours

AND

3TC orally every12 hours for 7days

Transmission at6 weeks 10%with ZDV/3TCcompared to17% withplacebo, a 38%reduction

Anderson 2001.


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16HIV and Pregnancy



RegimenMaternal

IntrapartumNewborn

PostpartumData on

Transmission

ZDV IV bolus, followedby continuousinfusion of everyhour until delivery

Orally every 6hours for 6weeks

Transmission10% with ZDVcompared to27% with no ZDVtreatment, a 62%(95% CI, 19-82%)reduction

Anderson 2001.


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17HIV and Pregnancy



RegimenMaternal

IntrapartumNewborn

PostpartumData on

Transmission

ZDV andNevirapine

IV bolus, thencontinuousinfusion untildeliveryANDNevirapine singleoral dose atonset of labor

Orally every 6hours for 6weeksANDNevirapine singleoral dose at age48 72 hours

No data

Anderson 2001.


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18HIV and Pregnancy

Obstetric Procedures

Because of increased fetal exposure to infected maternal bloodand secretions, increased transmission may come from:

Amniotomy

Fetal scalp electrode/sampling

Forceps/vacuum extractor

Episiotomy

Vaginal tears


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19HIV and Pregnancy

Delivery: Cesarean vs. Vaginal Birth

Risk of mother-to-child transmission increased 2% each hourafter membranes have been ruptured

Cesarean section before labor and/or rupture of membranesreduces risk of mother-to-child transmission by 50 80%compared with other modes of delivery in women on noantiretroviral therapy or on ZDV alone

No evidence of benefit with cesarean section after onset oflabor or membranes have been ruptured

Cesarean section, however, increases morbidity and possiblemortality to mother

Give antibiotic prophylaxis for cesarean section in HIV-infectedwomen

International Perinatal HIV Group 1999;Semprini 1995.


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20HIV and Pregnancy

Recommended Infection

Prevention PracticesNeedles:

Take care! Minimal use

Suturing: Use appropriate needle and holderCare with recapping and disposal

Wear gloves, wash hands with soap immediately after contactwith blood and body fluids

Cover incisions with watertight dressings for first 24 hours


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21HIV and Pregnancy

Recommended Infection

Prevention Practices (continued)Use:

Plastic aprons for delivery

Goggles and gloves for delivery and surgeryLong gloves for placenta removal

Dispose of blood, placenta and waste safely

PROTECT YOURSELF!


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23HIV and Pregnancy

Breasfeeding Issues

Warmth for newborn

Nutrition for newborn

Protection against other infectionsSafety unclean water, diarrheal diseases

Risk of HIV transmission

Contraception for mother

Cost


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24HIV and Pregnancy

Breastfeeding Recommendations

If the woman is:

HIV-negative or does not know her HIV status, promoteexclusive breastfeeding for 6 months

HIV-positive and chooses to use replacements feedings,counsel on the safe and appropriate use of formula

HIV-positive and chooses to breastfeed, promote exclusivebreastfeeding for 6 months


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25HIV and Pregnancy

South Africa Breastfeeding Trial:

Objective and DesignObjective: To assess whether pattern of breastfeeding is acritical determinant of early mother-to-child transmission ofHIV

549 HIV-infected women studied

Compared newborns at 3 months that had been:

Exclusively breastfed

Breastfed and formula-fed

Never breastfed

Coutsoudis et al 1999.


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26HIV and Pregnancy

South Africa Breastfeeding Trial:

Results and ConclusionRisk of transmission in:

156 newborns who were never breastfed: 18.8% (95% CI12.6 24.9)

288 newborns who were breastfed and formula fed: 24.1%(95% CI 19.0 29.2)

103 newborns who were exclusively breastfed: 14.6 (95% CI7.7 21.4)

Conclusion: Newborns who were exclusively breastfed for atleast 3 months did not have any excess risk of HIV infectioncompared to newborns who were not breastfed

Coutsoudis et al 1999.


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27HIV and Pregnancy

Conclusion

Voluntary counseling and testing

Antenatal, intrapartum and postpartum care to mother candecrease risk of mother-to-child transmission

Antiretroviral therapy can also reduce risk of transmission

Newborn care: Feeding


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29HIV and Pregnancy

References (continued)

International Perinatal HIV Group. 1999. The mode of delivery and the riskof vertical transmission of human immunodeficiency virus type 1. N Engl JMed 340(14): 977 987.Mandelbrot L et al. 1996. Obstetric factors and mother-to-childtransmission of human immunodeficiency virus type 1: The Frenchperinatal cohorts. Am er J Obs te t Gynecol 175(3 pt 1): 661 667.Semprini AE et al. 1995. The incidence of complications after cesareansection in 156 women. AIDS 9:913 917.Shaffer N et al. 1999. Short-course ZDV for perinatal HIV-1 transmission inBangkok, Thailand: A randomized controlled trial. Lancet 353: 773 780.

Sperling RS et al. 1996. Maternal viral load, ZDV treatment, and the risk oftransmission of HIV type 1 from mother to infant. N Engl J Med 335(22):1621 1629.UNICEF/UNAIDS/WHO Technical Consultation on HIV and Infant Feeding.1998. HIV and Infant Feeding: Implem entation o f Guidelines . WHO:Geneva.World Health Organization (WHO)/Joint United Nations Programme onHIV/AIDS (UNAIDS). 1999. HIV In Pregn ancy : A Review . WHO/UNAIDS:

Geneva

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HIV and Pregnancy Prevention of Mother-To-Child Transmission

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