HIV & Pregnancy.
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This information comes from a handout produced by Moira Taylor, Consultant Microbiologist, Stepping Hill Hospital.
It is used for our DRCOG course.
But should contain all the information you need for the MRCOG.
I am indebted to Moira for producing it and letting me use it here.
If you would like more information, there are some online lectures on the RCOG website.
These come from a joint RCOG / British HIV society meeting in 2012.
HIV in Pregnancy.
Key facts for the DRCOG.
Overall 0.22% (1/449) of women giving birth in
Findings from the unlinked anonymous survey of neonatal dried
blood spots show a low but significant increase in HIV prevalence among pregnant
women who have given birth outside
However
Among sub-Saharan African born pregnant women, those living
outside
In 2009 0.46 per 1000 pregnant women born in the
In 2010 657,500 pregnant women were reported to be screened
for HIV in
The proportion of pregnant women who accepted the recommended
routine antenatal HIV screening test was 96% in 2010.
Between 2006 and 2010 in the
Of all children born to diagnosed and undiagnosed HIV positive
in the
However in women with diagnosed HIV only 1% became infected.
Over the past decade in the
Around 70% of these were born to women who remained
undiagnosed during their antenatal and perinatal care.
All women are now offered screening at booking and if this is
refused offered it again at 28 weeks gestation.
HIV positive women should be given advice about safer-sex
practices and the use of condoms, to prevent transmission of HIV and other STDs
to an uninfected partner.
Confidentiality must be maintained, unless the partner is at
risk of infection and she won’t tell him.
She must be informed if the diagnosis is to be disclosed to
him.
All diagnoses should be reported to the National Study of HIV
in pregnancy & childhood at the RCOG.
Mother-to-baby (M-T-B) transmission rates are high without
intervention.
E. g. 25 – 40% in sub-Saharan
With optimum intervention M-T-B transmission is < 1%.
> 80% of M-T-B transmission takes place after 36 weeks.
< 2% of M-T-B transmissions take place under 28 weeks.
Effective interventions are:
anti-retroviral therapy, particularly HAART,
pre-labour Caesarean section,
avoidance of breast-feeding.
Low maternal viral loads are associated with
¯
M-T-B transmission.
But there is no level below which transmission does not
occur.
Risk factors for M-T-B transmission include:
advanced maternal disease,
high maternal viral load,
a resistant strain of the virus,
low maternal CD4 count,
primary HIV infection occurring during pregnancy
breast-feeding,
malnutrition, especially vitamin A deficiency,
smoking and illicit drugs,
maternal obesity,
other
female babies are more likely to be infected early
the first-born of twins (born to HIV-infected mums)
Obstetric risk factors for M-T-B transmission include:
prolonged duration of membrane rupture,
chorio-amnionitis,
pre-term delivery: especially < 34 weeks,
Obstetric factors that are not considered a risk for M-T-B if
the mothers viral load is <50 copies/ml at 36 weeks and if there are no other
risk factors at the time of delivery eg no chorioamnionitis or PROM include:
vaginal delivery,
scalp electrodes,
invasive intrapartum procedures eg forceps, ventouse
Effects of fetal infection include:
miscarriage,
IUGR,
stillbirth.
Expanded data for the MRCOG and to help the facts stick.
Despite effective therapy and prevention measures, the number
of new diagnoses of HIV infection in the
Increases in heterosexual HIV and increased life expectancy mean there is a
steady increase in the numbers of pregnant women with HIV in the
Prevalence of HIV in women giving birth varies widely across
the country and is highest in urban areas.
Risk of mother to child transmission:
Risk of mother to child transmission with intervention:
zidovudine monotherapy:
6-8%;
pre-labour C. section: 2%
C. section + zidovudine monotherapy + no breast feeding: <2%
C. section + HAART + no breast feeding: <1%.
Viral load <50 copies/ml + HAART + vaginal delivery + no
breast feeding <1%
All the above together with very low HIV viral loads may reduce the risk even further.
Breastfeeding doubles the risk of mother to child
transmission of HIV.
In recent years in the
Risk factors for transmission are:
advanced maternal HIV disease,
low antenatal CD4 count,
high maternal plasma viral load,
breastfeeding,
malnutrition esp. vitamin A deficiency;
resistant strain of virus;
illicit drug use;
smoking;
maternal obesity.
Obstetric risk factors include:
vaginal delivery (if high viral load),
prolonged labour,
long duration of membrane rupture,
chorioamnionitis,
preterm delivery (especially before 34 weeks gestation),
active genital ulcer disease.
Fetal scalp electrodes, vaginal lacerations and episiotomy were previously thought to be associated with an increased incidence of HIV but it is unclear whether this is merely related to the prolonged rupture of membranes that is associated with these situations.
Therefore
in women in whom it is deemed appropriate for them to have a vaginal delivery,
if an interventional or operative vaginal delivery is needed clinically, this
should be carried out.
Currently there is insufficient evidence for a plasma viral
load threshold below which transmission never occurs but there is a relatively
lower risk at viral load titres <1000copies/ml.
Rare transmissions have occurred with extremely low levels of
plasma viraemia.
Over 80% of HIV transmissions from mother to child occur
after 36weeks, mainly during labour and delivery.
Less than 2% of transmissions occur during the 1st
and 2nd trimesters.
All pregnant women should be offered screening for HIV in
early pregnancy – Department of Health Guidelines
If screening has been refused in early pregnancy screening should be offered again at a later stage in pregnancy (approx 28 weeks).
Women booking after 26 weeks gestation should have a request for an urgent HIV test with a result within 24hrs.
Rapid point-of-care tests should be done on women who arrive in labour with unknown HIV status.
The uptake of screening has to be audited.
The 1999 DoH targets advised that by 2002 90% of antenatal patients should be tested for HIV antenatally and that at least 80% of all HIV infections should be diagnosed prior to delivery.
In 2010 an estimated 96% of antenatal women were tested for HIV.
The comparable figures for 1999 was 70% and for 2005 was 89%.
In 2009 41% of diagnosed HIV-infected women were identified through antenatal screening in the current pregnancy.
These are therefore women who would not have been diagnosed in the absence of antenatal screening.
Early detection of infection in mothers and preventive
therapy has reduced mother to infant transmission to 2% in the
More recent studies suggest that with HAART, transmission has recently decreased
further to <1% in the
All pregnant women should be offered an HIV test.
Some women are at particular risk of HIV infection and should
be especially targeted for screening: women who have arrived in the
Consideration should be given to re-screening women who have
continuing high risk of HIV acquisition in the third trimester.
Women presenting in labour or with rupture of membranes without a documented HIV result should be offered a POCT.
A positive HIV POCT result should be acted on immediately
without awaiting confirmation.
In certain situations it is beneficial to test both the pregnant mother and her partner for HIV.
If the pregnant mother is negative but her partner is positive advice can be given about avoiding transmission of HIV during pregnancy.
This is especially important as the risk of transmission to
the unborn baby is great if the mum acquires HIV infection during pregnancy.
If a mother is found to be HIV positive, her other children
should be tested for HIV but this may be deferred until after delivery of her
unborn child.
Studies in North America and
The risks to the pregnancy of HIV infection include
miscarriage, stillbirth and intrauterine growth retardation.
Women diagnosed as HIV positive during pregnancy should be managed by a multidisciplinary team including an HIV physician, an obstetrician, a midwife, a paediatrician, as well as support workers especially if social difficulties e.g. housing or drug problems.
Specialist antenatal classes are also important to avoid
inappropriate emphasis on breastfeeding and vaginal delivery.
In the rare event of a women refusing interventions to reduce
M-T-B transmission, a planning meeting should be held with social services to
address safeguarding issues.
Confidentiality regarding HIV status must be maintained at
all times.
As a very last resort a women’s HIV diagnosis may be
disclosed to known sexual partners if it is believed the women has not disclosed
this but the women must be aware of the disclosure.
All women with HIV during pregnancy should be reported by a named respondent to the National Study of HIV in Pregnancy and Childhood at the Royal College of Obstetricians and Gynaecologists.
Babies born to infected women should be reported via the
British Paediatric Surveillance Unit of the Royal College of Paediatrics and
Child Health.
The pregnancies of all women taking anti-retroviral therapy
should also be reported to the Antiretroviral Pregnancy Registry.
All pregnant women who are HIV positive should be screened and treated for genital infections early in pregnancy and this should be repeated during the third trimester and also in the event of threatened or established preterm labour and preterm prelabour rupture of membranes.
Chlamydia, gonorrhoea, bacterial vaginosis, genital ulceration especially should be looked for as these are associated with a greater risk of HIV disease.
Bacterial vaginosis causes problems by being associated with pre-term labour too.
Also routine antenatal serological screens for rubella,
hepatitis B and syphilis should be carried out. Syphilis serology should be
repeated in the third trimester. All HIV positive pregnant women should also be
tested for HCV (Hepatitis C virus), varicella zoster, measles and toxoplasma.
Hepatitis B and pneumococcal vaccine are recommended for all HIV positive individuals and can be safely given in pregnancy as can influenza vaccination if indicated.
VZV and MMR must NOT be given in pregnancy.
But should be considered postpartum depending on CD4 counts.
Women taking HAART at the time of booking should be screened
for gestational diabetes.
The risks of mother to child transmission when chorionic villus sampling and or second trimester amniocentesis is performed is unknown.
Counselling in a foetal medicine unit and an HIV physicians
guidance on HIV prophylaxis should be considered before carrying out any
invasive monitoring.
Screening for Down’s and other foetal anomalies should be
offered according to local protocols.
A detailed ultrasound scan for fetal anomalies should be
carried out at 21 weeks gestation if anti-retroviral therapy or prophylaxis for
pneumocystis with folate antagonists (e.g. Septrin (Co-trimoxazole)) has been
used during the first trimester.
The risk of HIV transmission needs to be balanced with the
risk of the toxicities of therapy.
Women taking HAART are at risk of premature labour and should
be counselled about this.
Little evidence of any increase in congenital malformations in humans with first trimester exposure to any antiretroviral therapy to date.
But inadequate data to exclude a teratogenic risk for most drugs.
Mitochondrial depletion and haematological effects have been
noted in infants exposed to anti-retroviral therapy but the clinical importance
of this is uncertain.
Pregnant women with HIV should be monitored regularly for
drug toxicity.
Women with drug toxicities due to antiretrovirals may present
with signs of pre-eclampsia, cholestatis, liver dysfunction, lactic acidosis,
glucose intolerance, diabetes, rashes.
Zidovudine is the antiretroviral for which the most extensive safety data is available regarding use in pregnancy.
Zidovudine monotherapy is an option for the woman with low levels of HIV viraemia and with a sensitive strain if she does not need HAART for her own health.
However, delivery by caesarean section is advisable.
Women with HIV who need antiretrovirals to control disease should be treated with HAART with many of the same regimes as if they were not pregnant but certain combinations of drugs e.g. dual NRTI (non-reverse transciptase inhibitors); Stavudine + didanosine (risk of lactic acidosis) should be avoided.
If HAART is commenced prior to conception this should usually be continued throughout pregnancy and post-partum.
Likewise pneumocystis prophylaxis should be continued if this
is needed.
Determine HIV genotype pre-treatment; if viraemic on
established treatment; at delivery if on monotherapy;
within 6 weeks of stopping suppressive treatment.
Investigation and management of opportunistic infections is
rarely altered in pregnancy and should not be delayed.
Women who do not need antiretrovirals to control disease need to be given HAART to prevent mother to child transmission initiated between 14 and 24 weeks until delivery.
An alternative is zidovudine for those who have HIV viral loads of less than 10,000copies/ml and a CD4 count of >350 and are happy with an elective caesarean section.
Antiretrovirals should be started earlier in multiple pregnancies or if a previous pre-term delivery.
Care should be taken when stopping the individual components
of the short-term HAART to avoid unplanned monotherapy after stopping –i.e. the
drugs need stopping at different times dependent on expected half-life.
A blood sample should be taken from HIV positive women at least every 3 months; at 36 weeks and at delivery in women on established therapy to determine viral load.
CD4 counts should also be checked at least a couple of times.
Viral load and CD4 count should also be checked 2 weeks after
starting or changing therapy and at delivery.
A plan of care for anti-retroviral therapy and mode of
delivery should be made at 36 weeks, following detailed discussion with the
mother.
A planned caesarean section should be offered to all HIV positive women with an HIV plasma viral load greater than 50 copies/ml and/or who are not taking HAART at approx 38-39 weeks.
Planned caesarean section may be considered if there is
co-infection with hepatitis B or C but is not necessary if the HIV viral load is
<50 copies/mll.
A planned vaginal delivery should be offered to women taking
HAART who have a plasma viral load of less than 50 copies/ml.
Risks and benefits of caesarean section need to be considered
e.g. risk of caesarean section in someone returning to a country where there is
no opportunity for caesarean section in the future may be risky.
For women having an elective caesarian section who are taking zidovudine IV zidovudine prophylaxis should be given during delivery.
The zidovudine infusion should be commenced
4 hours prior to the section and this should be continued until the cord
is clamped. IV zidovudine prophylaxis is not usually indicated for mothers not
on zidovudine treatment or for mothers with <50 HIV RNA copies/ml plasma on
HAART.
The cord should be clamped and the baby bathed as soon as
possible after delivery.
The use of fetal scalp electrodes and fetal blood sampling
should be avoided in HIV infection.
If HAART is not used studies have shown that rupture of membranes for more than 4 hours is associated with double the risk of HIV transmission.
Therefore artificial rupture of the membranes should be
avoided.
Perioperative antibiotics should be given for all caesarean
section deliveries and immediately if membranes rupture during the first stage
of labour.
Delivery should be expedited if there is term pre-rupture of membranes and consideration should be given to expediting delivery if there is pre-term pre-labour rupture of membranes after 34 weeks gestation.
An urgent multidisciplinary team meeting should be held to
decide on appropriate prophylaxis for the mum and neonate.
Women with pre-term pre-labour rupture of membranes should
receive erythromycin prophylaxis.
Corticosteroids should be given for threatened pre-term
delivery.
All women in the
An immediate post-delivery dose of oral cabergoline should be
given to suppress lactation.
Breast feeding increases the overall mother-to-child HIV
transmission rate by 14% for women infected with HIV before birth and by 30% in
mothers infected postnatally.
Zidovudine is usually given orally for 4 weeks to all
neonates of mothers with HIV if the mothers plasma viral load is <50 copies/ml.
This should be started within 4 hours of birth.
HAART as PEP (post-exposure prophylaxis) should be given to
infants born to untreated mothers or mothers with viral load >50 copies/ml
despite HAART. HAART as PEP should be give to the neonate for 4 weeks.
PCP prophylaxis with co-trimozaxole should given to all
babies at 4 weeks of age if the mother had a viral load >1000 copies/ml; where
the viral load at 36 weeks or delivery was unknown or where the baby has
positive molecular tests for HIV.
Maternal antibodies cross the placenta to most neonates of HIV positive mums regardless of whether the baby is infected or not.
A negative HIV antibody test in an 18 month old baby confirms
that the baby has not been infected with HIV.
Earlier diagnosis of HIV infection in neonates may be predicted by carrying out DNA PCR of the baby’s blood at one day, 6 weeks (i.e. 2 weeks after finishing zidovudine or HAART); 3 months of age and at other times if risk factors such as breast-feeding are present.
For non-breast fed babies over 99% of those testing HIV negative by PCR in all these tests will be uninfected.
However HAART therapy in neonates may delay diagnosis of
infection.
In vitro fertilisation is now considered ethically acceptable
for couples with subfertility.
For HIV discordant couples practice safe sex but if want to
conceive:-
Couples should be advised to delay conception until:
plasma viraemia is suppressed,
prophylaxis against pneumocystis is no longer needed
and any opportunistic infections have been treated.
Woman HIV +ve, man –ve – self-insemination of partner’s semen
at time of ovulation is advised.
Fertility assessment is indicated if conception has not
occurred after 6-12 months of self-insemination.
Woman HIV –ve, man +ve – risk of infection in the woman is 0.03% to 1% per sexual act.
Sperm washing or donor insemination is advisable as safe sex except at the time of ovulation may carry unacceptable risks.
However sperm washing is expensive and only carried out in
few centres.
Woman and man both HIV +ve practice safe sex except at
ovulation as the partners may have different strains with differing
sensitivities.
Additional
British HIV Association – Pregnancy guidelines – very
comprehensive – www.bhiva.org (the guidelines are being reviewed at the moment
(2012) and a consultation document is available
from which a lot of the above information has been taken)
RCOG guidelines – Management of HIV in Pregnancy – June 2010 – NB v. important
HPA website –
www.hpa.org.uk
- topics a-z – HIV –interesting - many of the figures presented above came from
the Annual report on this site. There are many more figures in the report than
presented here!!!! – suggest don’t worry about the prevalence figures too much
as they are changing yearly – the trends are more important.
Reducing Mother to Child Transmission of HIV Infection in the
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