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Women and Adolescents Case Presentations

Women and Adolescents Case Presentations. Vivian M Tamayo-Agrait, MD, FACOG, AAHIVMS Department of Obstetrics and Gynecology University of Puerto Rico Faculty, Florida/Caribbean AETC. Disclosures of Financial Relationships.

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Women and Adolescents Case Presentations

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  1. Women and Adolescents Case Presentations Vivian M Tamayo-Agrait, MD, FACOG, AAHIVMS Department of Obstetrics and Gynecology University of Puerto Rico Faculty, Florida/Caribbean AETC

  2. Disclosures of Financial Relationships This speaker has no significant financial relationships with commercial entities to disclose. This speaker will not discuss any off-label use or investigational product during the program. This slide set has been peer-reviewed to ensure that there are no conflicts of interest represented in the presentation.

  3. Case #1: Pregnant perinatally infected adolescent • This is the case of a 17 years old G1P0 adolescent with history of HIV diagnosed at 2 y/o who comes referred from a Pediatrics Immunology Clinic due to a positive pregnancy test. • Past medical history: Bronchial asthma, lipodystrophy, major depression, suicidal attempt

  4. Case #1: Pregnant perinatally infected adolescent • Past ARV experience: • AZT and ddI (1997-1998): changed due to viremia • Lamivudine/AZT/ritonavir: ritonavir d/c due to nausea • Nelfinavir/AZT/3TC (1998-2000): changed due to viremia • Efavirenz/d4T/ddI (2000-2002) • Lopinavir/ritonavir, 3TC/d4T (2002-2004): changed to due viremia • Atazanavir/tenofovir/T-20 (2004-2006): d/c due to poor commitment with treatment • Atazanavir/ritonavir/tenofovir/3TC: treatment at initial visit

  5. Case #1: Pregnant perinatally infected adolescent • Patient brings results of three previous resistance tests (genotypes) that showed the following mutations: • 2001: I84V, M46I, L90M • 2006: no mutations detected • 2007: no mutations detected

  6. Case #1: Pregnant perinatally infected adolescent • At initial visit, patient reported poor adherence with her ARV therapy. • Latest labs: • CD4 count: 393 (31%) • HIV RNA viral load: 85,826 copies/mL • Patient was continued on current therapy and genotype was ordered which showed the following:

  7. Case #1: Pregnant perinatally infected adolescent

  8. Case #1: Pregnant perinatally infected adolescent • Based on these results, patient was started on Lopinavir/ritonavir, raltegravir, etravirine, 3TC/AZT • Importance of good adherence was stressed for both maternal and fetal reasons. • Follow-up labs after 2 weeks on treatment showed: • CD4 count: 476 (31%) • HIV RNA viral load: 5617 copies/mL

  9. Case #1: Pregnant perinatally infected adolescent • Labs after 2 months on new regimen showed: • CD4 count: 530 (36%) • HIV RNA viral load: 115 copies/mL • The patient’s pregnancy was complicated by delivery via emergency cesarean section at 28 weeks gestational age (WGA) due to eclampsia. • She delivered a baby girl, weight 3 lbs. • The baby has been followed up at the Pediatrics Immunology Clinic and is confirmed negative.

  10. Case #1: Pregnant perinatally infected adolescent • After delivery, patient was lost to F/U for more than a year. • Patient had discontinued all her medications • She had abandoned care at her Immunology Clinic • Had a new sexual partner • Adherence to medications stressed in all visits • Injectable contraception (depot medroxyprogesterone) started • Consistently shows poor compliance with treatments and appointments

  11. Case #1: Topics for discussion • Adherence difficulties in perinatally infected adolescents • Managing multi-drug resistance during pregnancy • Contraceptive alternatives for HIV infected women/adolescents

  12. Case #2: Pregnancy complicated by multiple comorbidities • This is the case of a 42 years old G4P2012 woman with history of HIV diagnosed 2 years ago (heterosexual contact), Diabetes Mellitus type 2, chronic hypertension referred for prenatal care (PNC). • Had 2 prior PNC visits with another provider, but failed to report her serostatus to him. • This is a desired pregnancy, since she has a new sexual partner (who is HIV negative) who has no children. • Comes to the first visit in our clinic at 12 WGA.

  13. Case #2: Pregnancy complicated by multiple comorbidities • Current medications: • Efavirenz/tenofovir/emtricitabine (since HIV diagnosis) discontinued medication on her own when she found out she was pregnant • Metformin 500mg twice daily • Methyldopa 250mg twice daily • Baseline: • CD4:368 (29%) • HIV RNA viral load: 6376 copies/mL • HgA1c: 8.5%, glucose=230 mg/dL • BP= 170/95

  14. Case #2: Pregnancy complicated by multiple comorbidities • Patient was admitted for metabolic control with insulin and optimization of anti-hypertension medication. • She was immediately started on Lopinavir/ ritonavir and 3TC/AZT. • Pregnancy ended at 17 WGA due to a spontaneous abortion.

  15. Case #2: Pregnancy complicated by multiple comorbidities • Post expulsion follow up: • Still desires another pregnancy • Oriented about all the co-morbidities that might also complicate a future pregnancy • Advanced maternal age • Chronic hypertension • Diabetes type 2 • Continued on same ARV regimen, antihypertensive medications and was switched back to an optimized dose of metformin

  16. Case #2: Pregnancy complicated by multiple comorbidities • Post expulsion follow up: • Continues with undetectable viral load with current regimen • Following metabolic and blood pressure control closely • Recommended folic acid supplementation • Home insemination techniques and benefits explained to the couple

  17. Case #2: Topics for discussion • Importance of pre-conceptional counseling • Managing co-morbidities in HIV infected pregnant women • New recommendations about 1st trimester use of efavirenz • Barriers to disclosure of HIV serostatus to HCP • Reproductive alternatives for HIV serodiscordant couples

  18. #3: Preconceptional counseling for sero-discordant couples • A serodiscordant couple (male HIV+, woman HIV-) is referred to our clinic for counseling on reproductive alternatives. • Woman: 30 years old G2P1A1, without history of any systemic illness. • Man: 35 years old, with history of HIV diagnosed 7 years ago due to past history of IVDA. He is ARV naïve and receiving continuous care at his local Immunology Clinic • No fertility problems suspected (both have children with previous partners)

  19. #3: Preconceptional counseling for sero-discordant couples • Baseline evaluations (woman): • Rapid HIV test: negative • Baseline evaluations (male): • CD4 count: 825 (40%) • Viral load: 3823 copies/mL • Hepatitis profile: negative • Semen analysis: normal

  20. #3: Preconceptional counseling for sero-discordant couples • Recommendations: • Infected partner should begin an effective ARV treatment • Timed intercourse and artificial insemination techniques (ideally including sperm washing) were discussed, including risk, benefits and costs • Couple referred to a Reproduction/Infertility specialist • PreP and PEP recommended prior and after insemination • Folic acid supplementation

  21. Case #3: Topics for discussion • Reproductive alternatives for serodiscordant couples • Treatment as prevention • PreP and PEP and their role in assisted reproduction

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