LOGHMAN HAKIM HOSPITAL Dr.AMINZADEH LOGHMAN HAKIM HOSPITAL

HIV & PREGNANCY

MANAGEMENT OF HIV INFECTION IN PREGNANCY

INTERACTION BETWEEN HIV & PREGNANCY

ARE OUTCOMES OF PREGNANCY AFFECTED BY HIV INFECTION? PREMATURITY LOW BIRTH WEIGHT INTRAUTERINE GROWTH RETARDATION STILLBIRTH INCREASED MORTALITY OF INFANT NO MALFORMATION

ANTIRETROVIRAL THERAPY DURING PREGNANCY &RISK OF ADVERSE OUTCOME

NRTI ZIDOVUDINE© 300mg/12h LAMIVUDINE© 150mg/12h DIDANOSINE(B) <60kg:125mg/12h,>60kg:200mg/12 STAVUDINE© <60kg:30mg/12,>60kg:40mg/12h ZALCITABINE© ABACAVIR©

NRTI WELL TOLERATED & CROSS PLACENTA NO TERATOGENIC BIND TO MITOCHONDRIAL DNA POLYMERASE GAMMA & CAUSE MITOCHONDRIAL DYSFUNCTION:MYOPATHY,CARDIOMYOPATHY,NEUROPATHY, LACTIC ACIDOSIS, FATTY LIVER. BOTH CLINICIAN& PATIENT SHOULD BE AWARE OF THE SPECIFIC SYMPTOMS OF LIVER DYSFUNCTION&LACTIC ACIDOSIS. ROUTIN MEASUREMENT OF BLOOD LACTATE IS NOT RECOMMENDED. LACTAT TESTING MAY BE HELPFUL IF SUGGESTIVE SYMPTOMS ARE PRESENT.

NRTI THE RISK OF MITOCHONDRIAL TOXIC EFFECTS IN AN INFANT DUE TO NRTI THERAPY DURING PREGNANCY APPEARS SMALL. NO TUMOR OR DEATH FROM CANCER IN CHILDREN WITH PRENATAL EXPOSURE TO ANTIRETROVIRAL DRUGS.

NNRTI EFAVIRENZ© DELAVIRDINE© NEVIRAPINE© 100mg/12hfor 2w,then 200mg/12h

NNRTI EFAVIRENZ: IN THE EARLY STAGES OF PREGNANCY IS NOT RECOMMENDED BECAUSE BIRTH DEFECTS (ANENCEPHALY, ANOPHTHALMIA,CLEFT PALATE). USE DURING THE LATER STAGE. DELAVIRDINE: HEART DEFECT. NEVIRAPINE: HEPATITIS, RASH. THE MOST COMMON TOXIC EFFECT OF NNRTI IS RASH.

PROTEASE INHIBITORS INDINAVIR© 800mg/12h in combination with RITONAVIR 200mg RITONAVIR(B) 600mg/12h SAQUINAVIR(B)400mg/12hin combination with400mg RITONAVIR NELFINAVIR(B) 1250mg/12h or 750mg/8h AMPRENAVIR© LOPINAVIR©

THE GOALS OF ANTIRETROVIRAL THERAPY FOR PREGNANT WOMEN

INDICATION FOR ANTIRETROVIRAL THERAPY DURING PREGNANCY FOR ALL HIV-INFECTED PREGNANT WOMEN IN ORDER TO REDUCE THE RISK OF PERINATAL TRANSMISSION HAART IS INDICATED FOR MATHERNAL HEALTH:CD4<350cell/ml OR HIV RNA LEVEL>55000copies/ml. HAART SHOULD BE CONSIDERED FOR THE PREVENTION OF HIV TRANSMISSION WHEN THE HIV RNA LEVEL >1000 AZT MONOTHERAPY FOR HIV RNA LEVELS<1000 FOR REDUCTION OF TRANSMISSION.

ONGOING THERAPY IF THE PREGNANCY IS DISCOVERED ARTER THE FIRST TRIMESTER, THERAPY SHOULD BE CONTINUED. A DETAILED ULTRASONOGRAPHIC EXAMINATION SHOULD BE PERFORMED AT 18 TO 20 WEEKS OF GESTATION TO CONFIRM THE GESTATIONAL AGE OF THE FETUS & TO SCREEN FOR DETECTABLE ANOMALIES. OPTIONS DURING THE FIRST TRIMESTER: * CONTINUING THE REGIMEN * CHANGING THE REGIMEN *DISCONTINUING ALL DRUGS & REINSITUTING THEN AFTER THE FIRST TRIMESTER.

ANTEPARTUM CARE IMMUNIZATION:Hepatitis B,Influenza& Pneumococcal vaccines may be given pregnancy for the usual indications but should be administered after HIV RNA has been suppressed to undetectable levels with Antiviral therapy. Ophthalmic examination: if CD4<50/mm3 Frequent evaluation(every 2-4 w)for new symptoms & laboratory abnormalities is indicated during the first 1-2 m of therapy. LFT&ELECTROLYTES/M DURING THE THIRD TRIMESTER&WHENEVER NEW SYMPTOMS OCCUR. (con)

ANTEPARTUM CARE HIV RNA level: 4 w after a change or initiation of therapy,then monthly until undetectable then every 3 month while therapy remain stable, & at 34-36 w for planning of delivery. CD4 lymphocyte counts should be evaluated every 3 month. PPD Test, Toxoplasma, CMV,Hepatitis C antibody status if unknown. If an invasive prenatal procedure is planned for an HIV-infected woman ,she should be receiving optimal antiretroviral &has undetectable HIV RNA before procedure.

Mother to child transmission(MTCT) or VERTICAL TRANSMISSION IN UTERO INTRAPARTUM POSTPARTUM

RISK FACTORS HIGH MATERNAL PLASMA VIREMIA ADVANCED CLINICAL HIV-1 DISEASE REDUCED MATERNAL IMMUNOCOMPETENCE VAGINAL DELIVERY INTERVAL BETWEEN RUPTURE OF THE AMNIOTIC MEMBRANE & DELIVERY DIRECT EXPOSOURE TO MATERNAL BLOOD PRESENCE OF ULCERATIVE GENITAL INFECTION IVDA &cigarette smoking PREMATURITY &LOW BIRTH WEIGHT Vitamin A deficiency Malnutrition CCR5 RECEPTOR Amnionitis

MODE OF DELIVERY ELECTIVE C/S C/S at 38 WEEKS OF GESTATION C/S BE OFFERED TO WOMEN WITH HIV RNA LEVEL >1000copies/ml at 34 to 36 week of gestation ANTIRETROVIRAL THERAPY

INTRAPARTUM CARE Infusion of AZT should be begun after the onset of labor or the rupture of the membrane or at least 3h before c/s.2mg/kg/1h followed by a continuous infusion of 1mg/kg/h until delivery. Use of other antiretroviral agents should be continued during LABOR or PREOPERATIVELY. STAVUDINE may antagonize the effects of AZT. Induced rupture of the membranes should be avoided. Fetal-Scalp electrodes, Scalp blood sampling,Use of instruments to assist delivery,..should be avoided. AVOIDANCE OF EPISIOTOMY. MIDAZOLAM & Ergot preparations should not be used in woman receiving PI (EFAVIRENS OR DELAVIRDINE). Infant should be washed before any blood is drawn or any injections or other invasive procedure are performed.

ANTIRETROVIRAL for PREVENTING PERINATAL TRANSMISSION AZT to mother ANTEPARTUM(100mg oral 5 times/d beginning between weeks 14 &34 ,continuing until onset of labor). INTRAPARTUM 2mg/kg/1hIV,1mg/kg/h during labor until delivery To INFANT (2mg/kg/6h oral for 6 weeks) at 12-24h after birth

ANTIRETROVIRAL for PREVENTING PERINATAL TRANSMISSION Short-course AZT: AZT300mg/BID to mother beginning at 36 weeks until onset of labor, 300mg/3h oral until delivery. AZT& LAMIVUDINE from 38 W, 3TC 150mg/BID AZT300mg/BID through W 1 postpartum,for NEONATE 3TC 4mg/kg/BID+AZT 2mg/kg/6h

ANTIRETROVIRAL for PREVENTING PERINATAL TRANSMISSION NEVIRAPINE: 200mg orally after starting labor & for INFANT 2mg/kg at 48-72

POSTPARTUM CARE WOMAN CONTINUATION OF THERAPY PSYCHOSOCIAL SUPPORT NO BREAST-FEEDING CONTRACEPTION

POSTPARTUM CARE AZT FOR 6 W. INFANT INITIATION OF PCP PROPHILAXIS AT 4-6W. DETERMINATION OF HIV INFECTION STATUS WITH TESTING AT 1-2D,2W,1-2M,3-6M OF AGE

CONCLUSIONS Antiretroviral therapy during PREGNANCY Antiretroviral therapy during LABOR Elective Cesarean Section Antiretroviral therapy for INFANT Avoiding from BREAST-FEEDING