1 / 33

Prenatal Care and Obstetrical Management of HIV+ Women

Prenatal Care and Obstetrical Management of HIV+ Women. Deborah Cohan, MD, MPH Bay Area Perinatal AIDS Center National Perinatal HIV Consultation and Referral Service UCSF. Overview:. Antepartum management Antiretroviral therapy: Benefits, Risks Intrapartum management L&D management

blake-yates
Download Presentation

Prenatal Care and Obstetrical Management of HIV+ Women

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Prenatal Care and Obstetrical Management of HIV+ Women Deborah Cohan, MD, MPH Bay Area Perinatal AIDS Center National Perinatal HIV Consultation and Referral Service UCSF

  2. Overview: • Antepartum management • Antiretroviral therapy: Benefits, Risks • Intrapartum management • L&D management • Mode of delivery • Post-partum management

  3. Perinatal HIV in the U.S.

  4. Number of cases

  5. Perinatal HIV testing: the key to prevention

  6. Prenatal HIV Testing Strategies • Opt-in: voluntary, women sign consent to test • Opt-out: voluntary, informed that test is standard, sign if decline testing (Tennessee, Canada) • Mandatory newborn screening: regardless of maternal consent (NY, Connecticut) • Uptake of HIV testing • Opt-in (25- 69%) vs. Opt-out (71-98%) approach • CA law mandates prenatal providers to offer HIV testing (opt-in) and explain that testing is routinely done unless pt declines • Likely change in CA law Jan 2008: opt-out DHHS 2002; CDC 1998; CDC 2001; CDC 2002

  7. Antepartum management

  8. Goals of prenatal care • Optimize woman’s health and psychosocial situation • ART: total viral suppression • Opportunistic Infection (OI) prophylaxis prn • Immunization prn • Prevent vertical transmission of HIV • ART, c/section in specific situations, Bottle-feeding • Minimize maternal risks • Viral resistance, Obstetrical outcomes • Minimize/assess risks to fetus/neonate • Teratogenicity, Genetic testing • Prepare for or prevent subsequent pregnancies 

  9. Maternal Risk Factors • Other possible risk factors • STIs • Drug Use • Smoking • Anemia • Vitamin A deficiency • Clade D virus (vs. clade A) • Monocyte/macrophage tropism • Viral homogeneity • Class I HLA concordance • Certain HLA-B alleles • Rapid replication kinetics • p24 antigenemia • Primary HIV infection • Plasma viral load @ delivery • per log : • OR 3.4 (1.7-6.8) • VL <1000: • 0.7%-0.9% transmission • Genital VL @ delivery • Cell-associated • per log  : OR 2.3 (1.1-4.8) • Cell-free • OR 3.4 (p=0.001) • CD4 count • Drug-resistant HIV • ZDV GT resist OR 5.16 • ZDV PT resist OR 1.25 Landesman 1996; Thea 1997; Shapiro 2002; Tuomala 2003; Chuachoowong 2000; Goedert 2001; O'Shea 1998; Mofeson 1999; Shapiro 1999; Monforte 1991; Ometto 1995; MacDonald 1998; Arroyo 2002; Winchester 2004; Yang 2003

  10. HIV lifecycle and drug targets • Fusion inhibitors • NRTI and NNRTI • Integrase inhibitors • Protease Inhibitors www.wikipedia.org

  11. When and How Should a non-pregnant Adult Be Treated? • When • Symptomatic, at any CD4 count • CD4 count <200 (AIDS) • CD4 count 200-350: Treatment offered • How • HAART: Highly Active Antiretroviral Therapy • 2 NRTI’s plus • PI or NNRTI • Monotherapy, dual therapy, and triple NRTI regimens no longer standard of care DHHS Guidelines for the Use of Antiretrovirals in HIV-Infected Adults and Adolescents, May 2006

  12. Antiretrovirals in pregnancy • All HIV+ pregnant women should get ART regardless of CD4 count and viral load. • But… • When to start • What to choose • What to avoid

  13. ART: when to start • Goal: viral suppression by 3rd trimester • Typically start in 2nd trimester • Exceptions to starting in 2nd trimester • Continuing preconception regimen and non-teratogenic • Needs ARV immediately for own health • If not tolerating preconception regimen in 1st trimester despite anti-emetics, d/c all at once • Stagger d/c of NVP-based ART Wright, SMFM, 2003; Thorne CROI 2005

  14. ART: what to choose • Same principles as non-pregnant HIV+ adults • Resistance/prior regimens, adherence/pill burden, S/E profile, degree of immunosuppression, viral hepatitis status • Except consider… • AZT-containing regimen unless contraindicated • Purpose of ART: her health vs. prophylaxis • If not needed for own health, less potent regimens may be acceptable • Triple NRTI regimens • AZT monotherapy for baseline viral load <1000?

  15. Perinatal HIV Transmission U.S. Studies from 1993-2002 ZDV HAART  % Transmission 1993: 1994: 1997: 1999: 2001: 2002: WITS PACTG PACTG WITS PACTG PACTG 076 185 247 316 Adapted from Fowler 2004

  16. Adverse effects of antiretrovirals in pregnancy

  17. Maternal Risks and ARVs • Lactic acidosis and d4T (and ddI) • 12 reports of maternal LA (3 fatal) • Avoid d4T and ddI if possible • Think of LA if • N/V, abdominal pain, SOB, leg and arm weakness • Hepatic Toxicity and NVP • 1st 6 wks NVP, may persist even when d/c NVP • Distinguished from other etiologies (ob and non-ob) • Avoid starting NVP if CD4 > 250 • Gestational DM and PIs • Conflicting data, most studies don’t find association • Not a reason to avoid using PIs

  18. Obstetrical Risks and ARVs • Preterm delivery and ARVs? • Conflicting data; all based on observational cohorts • Europ Collaborative & Swiss Mother+Child HIV: yes • U.S. Collaborative (n=2123): no • Meta-analysis: PTD only if preconception or 1st trimester ARV • Pre-Eclampsia and ARVs? • Conflicting preliminary data • ARVs increase risk? • ARVs restore immune system to allow Pre-E to occur? Euro Collaborative Study and Swiss Mother+Child 2000; Thorne CROI 2004; Tuomala 2002; Cotter JID 2006; Wimalasundera Lancet 2002; Suy AIDS 2006

  19. Fetal/Neonatal Risks

  20. FDA Drug Classification • A • B • NRTI: ddI, FTC, TDF (monkey osteomalacia @ high dose) • PI: ATV, NFV, RTV, SQV • FI: T-20 • C • NRTI: ABC (rats 35x dose), 3TC, d4T, ddC, ZDV • NNRTI: NVP • PI: APV (rat thymic elongation/ skeletal ossification), f-APV, IDV, LPV/r • D • EFV (monkey 15% CNS malformations; 3 human NTD, 1 Dandy Walker) • Avoid using preconception/1st trimester EFV • 2nd/3rd trimester EFV only if no other options DHHS 2005

  21. Nelfinavir • Sept. 2007, Pfizer sent a letter to providers regarding the presence of low levels of ethyl methane sulfonate (EMS) in nelfinavir. EMS is teratogenic, carcinogenic, and mutagenic in animals. No human data exist. • Not recommended unless no other alternative is available.

  22. Benefits >>>> Potential Risks

  23. Intrapartum Management • Shorten duration of ruptured membranes • No evidence of c/section to shorten ROM • Minimize # exams to  risk of chorio • Avoid FSE, fetal scalp sampling • PPROM??? • Balancing MTCT vs. prematurity • Management should be based on maternal viral load and NICU capabilities

  24. Standard Intrapartum ART • Intrapartum AZT regardless of antepartum ART • 2mg/kg IV load, then 1mg/kg IV qhr until delivery • Loading dose can be given over 20min-1hr • D/C d4T when receiving AZT • Give 3-4 hrs of IV AZT prior to elective c-section • Continue oral ART, even if getting cesarean Dorenbaum JAMA 2002

  25. Cesarean Delivery and MTCT

  26. Elective Cesarean and MTCT • 38 weeks, no labor, no ROM • Benefit seen in early studies • AZT alone, observ studies didn’t adjust for VL • Studies in the HAART era: limited benefit • PACTG 367 cohort, 1998-2001; 72 U.S. sites, n=2875 singleton births • Transmission 2.9% overall • MTCT by pre-delivery maternal viral load • <1000: 0.7% vs. 1000-9999: 2.1% vs. 10,000+: 5.9% • Elective c/s vs. vaginal delivery by maternal VL • <1000: 0.8% vs. 0.7% • 1000-9999: 2.8% vs. 1.9%: OR 1.5 (0.4-5.0) • 10,000+: 4.1% vs. 7.3%: OR 0.5 (0.2-1.5) • No RNA in chart: 8.3% vs. 22.4%: OR 0.3 (0.1-0.9) The European Mode of Delivery Collaboration, 1999; International Perinatal HIV Group 1999; Shapiro CROI 2004

  27. Elective Cesarean and MTCT: Cochrane Collaboration • “Elective c/section is a good intervention for the prevention of MTCT among HIV-infected women not taking antiretrovirals or taking only zidovudine… • Among women with less advanced or well-controlled HIV disease…the short-term risk of the intervention may exceed the long-term benefit.” Read and Newell 2005

  28. Post-partum maternal care • For those continuing on ART post-partum: • Reinforce medication adherence • Dose maternal and neonatal ART on similar schedules • Remove breastfeeding literature from educational packs • Contraception

  29. Post-partum vaccination • Tdap • Complete hepatitis A/B series prn • Flu vax (if didn’t get antepartum) • Rubella vax • MMR: live-attenuated vaccine • Case report of measles pneumonitis • Advisory Committee on Immunization Practices: • Recommends in susceptible, asymptomatic HIV • Not recommended if cd4 <200 or <14% • Check titers at 3 months and revaccinate prn Advisory Committee on Immunization Practices 1998; Brady CROI 2002

  30. Conclusions • Prevent perinatal HIV transmission through 1° prevention among women • Ensure access to HIV testing: preconception and during pregnancy • Ensure access to contraception and abortion services • Keep woman healthy and preserve future ART options • HIV-specific prenatal care • Consider Cesarean • if high viral load, no HAART, no labor/rupture of membranes • Avoid intrapartum interventions • Bottle feed (formula or banked human milk)

  31. Resources • Clinical consultation • National Perinatal HIV Consultation and Referral Service (NCCC) • 24/7 coverage, based at SFGH • 1-888-448-8765 (1-888-HIV-8765) • Bay Area Perinatal AIDS Center (BAPAC) • 415-206-8919 (M-F, 8a-5p) • Reproductive Infectious Disease Fellows • 719-8726 (24/7 coverage) • Web-based resources • www.aidsinfo.nih.gov (Perinatal HIV Guidelines) • www.womenchildrenhiv.org

  32. Thank you

More Related