Essay 356

Interventions such as anti-viral therapy, caesarean section and avoidance of breastfeeding are shown to reduce the risk of mother-to-child transmission from 30% to less than 1%.

If HAART is started for the woman's own health, it should be continued antenatally. If she does not need HAART for her own health, it should be offered at 20-28 weeks gestation, until delivery. If she does not need HAART for her own health and her viral load is less than 10000 copies/ml with the intention of undergoing caesarean section, zidovudine should be offered at 20-28 weeks gestation until delivery.

At 36 weeks gestation, mode of delivery should be planned. Elective caesarean section should be performed at 38 weeks if the patient is on HAART with viral load more than 50 copies/ml, or if she is on zidovudine monotherapy, or she has hepatitis C co-infection. Elective caesarean section could be postponed to 39 weeks if her viral load is less than 50copies/ml. on the other hand, if she is on HAART with viral load less than 50copies/ml, planned normal vaginal delivery could be considered.

The patient should be advised not to breastfeed post delivery.

PPROM at 28 weeks is associated with risks of prematurity and infection. There should be multidisciplinary management with the obstetrician, neonatologist, infectious disease specialist and midwife to discuss antenatal management plans and mode and timing of delivery.

Investigations include vaginal swab to check for genital infections, urine microscopy and culture, FBC, CRP to monitor for infection, ultrasound for AFI monitoring and daily CTG to check for fetal well being.

Oral erythromycin should be started, keeping in view of IV broad spectrum antibiotics if there are signs of genital infection. Steroids would be given for fetal lung maturity. Maternal anti viral therapy should still be continued. Monitoring of chorioaminitis would include maternal temperature, pulse and blood pressure, signs of uterine tenderness or foul smelling vaginal discharge, as well as twice weekly FBC and CRP for trending.

Delivery should be aimed at 34 weeks gestation, earlier if there are signs or symptoms of chorioaminitis. Viral load and CD4 counts should be taken before delivery.

Planned vaginal delivery with augmentation could be considered if the woman has been on antenatal HAART with viral load less than 50 copies/ml. HAART has to be continued until delivery. IV oxytocin could be used to augment the labour. No invasive procedures such as fetal blood sampling or fetal scalp electrode should be performed. If assisted vaginal delivery is needed, a low cavity forceps could be used.

If the woman is for planned caesarean section, IV zidovudine should be started 4 hours before the caesarean section until the cord is clamped. Surgical field should be kept as haemostatic as possible. If membrane is still seen after uterine incision, it should be kept intact for as long as possible until delivery of the baby's head.

The baby should be bathed immediately after delivery and be reviewed by the neotatologist.

a) Multidiscplinary team involvement including HIV specialist, mid-wife specialist, Obstetrician, counsellor and neonatologist is necessary in this case to optimise management of HIV to reduce complications and vertical transmission. CD4 count and viral load be done to assess the severity of condition. Any genital infection screened and treated. She should be started on Highly active antiretroviral drug therapy. This will not only reduce the progression of condition but will also reduce vertical transmission to baby significantly. There is a risk of pre-term labour and gestational diabetes with HAART and oral glucose tolerance test should be arranged at 24-28 weeks of gestation. Elective cesarean section be advised at 38 weeks gestation to further reduce the risk of vertical transmission. Vaginal delivery be allowed only if viral load is less than 50 copies, patient is on HAART. In case of vaginal delivery avoid rupturing membranes as long as possible. Avoid invasive procedures such as Fetal blood sampling and fetal scalp electrode. Baby should be bathed immediately after delivery. Breast feeding should be avoided completely and bottle feeding advised. All these measures will reduce the rick of vertical transmission from 15-25% to less than 1%.

b) Confirmation of spontaneous rupture of membranes(SROM) is most important. A history of sudden gush of clear fluid with ongoing trickling is most suggestive of rupture of membranes. Enquire about colour, odour of fluid and any bleeding. Examination should include checking of maternal temperature and pulse as pyrexia and tachycardia will make infection likely. Abdominal examination to assess fundal height, presentation and any tenderness. Fetal well being be assessed by CTG. Sterile speculum examination be done to confirm rupture of membranes and assess cervical dilatation. Genital swabs including endo cervical and high vaginal swabs be taken to rule out any infection and treated promptly. Erythromycin 250 mg orally and steroids given for fetal lung maturity. On call consultant Naonatologist, and HIV specialist be informed and advice obtained. Notes should be reviewed and recent viral load and CD4 count checked and repeated. Plan of delivery be discussed again. HAART should be continued. Caesarean section is most beneficial if done within 4 hours of rupture of membranes. However, if viral load is high caesarean section should be done irrespective of duration of SROM. If mother is requesting vaginal delivery, labour can be induced once course of steroids is completed, viral load is less than 50 copies and patient is on HAART. Invasive procedures should be avoided intrapartum and continuous fetal monitoring be done. Episiotomy should be avoided. Baby should be bathed immediately and neonatologist be present at delivery.  

a) Early screening, identification and treatment of HIV positive mothers with antiretroviral therapy will help to reduce mother-to-child transmission of HIV. Advice and antenatal care should be provided by a multidisciplinary team involving a senior obstetrician, HIV physician, specialist midwife, neonatologist and counsellor.

Women who are HIV positive who are considering invasive fetal testing should be counselled in a fetal medicine unit. HAART prior to prenatal invasive procedures should be considered in women not yet on treatment for HIV. On the other hand, the procedure should be delayed until there is no detectable viral load if she is already on treatment.

A decision about mode of delivery should be made by 36 weeks' gestation. An elective Caesarean section at 38weeks should be planned if she is on HAART but viral load is >50 copies/ml, if she is not on HAART, or if she is coinfected with HIV and Hep C. A vaginal delivery can be planned if she is on HAART and has an undetectable viral load (<50copies/ml). In labour, avoid fetal blood sampling and fetal scalp electrode insertion. If assisted delivery is required, a low cavity forceps is preferred.

Advise to avoid breastfeeding post delivery.

All these interventions have been shown to reduce transmission risks from 25-30% to <1%

b) Admit her into hospital for assessment and monitoring. A sterile speculum examination should be done to confirm ruptured membranes and to check for foul smelling discharge/liquor. She should be monitored at least 4-hourly for clinical signs of chorioamnionitis such as maternal pyrexia and offensive vaginal discharge. Investigations - white cell count and CRP and CTG should be done as raised WCC and CRP, fetal tachycardia may suggest chorioamnionitis and fetal infection. High vaginal swabs should also be taken to screen for genital infection. Oral erythromycin and intravenous broad spectrum antibiotics should be given to reduce risk of infection and morbidity. Intramuscular corticosteriods should be given to reduce neonatal morbidity e.g. RDS,IVH due to prematurity. Tocolysis is not recommended. HIV physician advice should be sought regarding choice of anti retroviral therapy, especially if she is not already on HAART. She should be counselled about the higher risk of preterm delivery associated with HAART.

A multidisciplinary team of a senior obstetrician, HIV physician and neonatologist should be involved in the planning of timing and mode of delivery. Expedited delivery is indicated if there is evidence of chorioamnionitis and fetal distress. Otherwise, decision to expedite delivery before 34 weeks of gestation is discussed by the team - risks of prematurity need to be weighed against risks of chorioamnionitis, HIV transmission. Mode of delivery is usually by caesarean section, unless vaginal delivery is imminent and she is on HAART with a viral load of less than 50 copies/ml.

1.The women should be manange in the multidisciplinary team includes obetetrician ,midwife,hiv physician ,neonatologist and social healthworker to have good outcome . she should be advise to have antiretroviral therapy ,delivery by LSCS and avoid breast feeding to reduce the risk of maternal and child transmission.

If she is taking antiretroviral drugs therapy for her own health then she should continue it for the through out the pregnancy and postpartum other wise she should be advise to start antiretroviral therapy  to stop maternal and child transmission from 20 weeks to 28 weeks of gestation. If she is declined such treatment then she should have counseling with the multidisciplinary team and its should be repeated in the later half of the pregnancy and documented in the notes.

If she is started on the antiretroviral drug therapy highly active retroviral drugs should be chosen instead of single agent therapy to avoid drug resistance. once she comes inlabour antiretroviral drugs should be started as soon as possible if she is not on HAART as form on ziduvidine  monotherapy  or if the time is less then she should be started with the drugs which achieve high concentration in the fetus within  short period of time like nevirapine.

She should be followed up with cd4 count and viral load .she should be counseled for the risk of transmission for the prenatal diagnosis like amniocentesis and cordocentesis . if her viral load is high then the procedure should be delayed till her viral load is less than 50 copies /ml.

Risk of transmission increases in presence of other infection like HCV and HBV infection, she should have low threshold for the treatment of any other infection .

Plan of delivery should be decided by 36 weeks of gestation according to her viral load . if her viral load is less than 50 copies /ml then she can be advised for the vaginal delivery as the risk of transmission to the fetus is very less and similar to the caesarian section.

If the viral load is more than 50 copies/ml  and she is coinfected with the HCV then she should be advised for the LSCS .

Once she came in labour her paln of delivery should be followed if she is not on any antiretroviral drugs then iv ziduvidine should be stated and atleast delayed for the 4 hours to deliver and it should continue till the cord is clamped.

During intra-partum rupture of membrane should be avoided as far as possible, invasive fetal monitoring like FBS , fetal scalp electrode should be avoided. Traumatic instrumental vaginal delivery should be avoided . baby should be bathed immediately after birth and handed over to neonatologist and ziduvidine should be started for the neonates for the 6 weeks.

In resourse rich country breast feeding should be avoided to decrease the risk of transmission.

2.she should be asked about the duration of the rupture of membrane ,colour of liquor like clear or meconioum stained  and nature of the liquor whether its foul smelling or not. Any associated feature like fever and not feeling well.she should be admitted as inpatient for the further managementwith the multidisciplinary team include obstetrician,midwife ,HIV physician and neonatologist.she should be examined for her general well being pulse ,BP and temperature .she should be examined per abdomen for the uterine size and tenderness and per speculum examination should be done to see the colour of liquor and dilatation of the cervix .digital examination should be avoided to avoid ascending infection. For the fetal well being CTG should be done.

Investigation should include FBC ,c-reactive protein ,and High vaginal swab along with cd4 count and viral load .since she is HIV positive if she is taking antiretroviral drugs then liver function test ,kidney function test should be reviewed .ultasound for the fetal gestational age ,amount of liquor ,placental localization and presentation should be done.

She should be counseled for the conservative management in view of prematurity and risk of transmission to the fetus as there is two risk factor like premature rupture membrane and prematurity.

She should be started on antibiotic erythromycin for the 10 days and antiretroviral drug should be started .she should be given injection betamethasone 12 mg intramuscular 2 doses 24 hrs apart.

She should be monitored with the temperature 4-6 hrly and ask to report if she feeling not well and any concern about fetal well being. If she is much concern about baby then she should be counselled with the neonatologist .her confidentiality should be maintened and dealt with dignity and respect.

Expectant management should be continued till 34 weeks of gestation or the fetal and maternal wellbeing is with in normal range. After 34 weeks of gestation plan of the delivery should be decided .here mode of delivery will not reduce the risk of maternal to child transmission.

If she delivers vaginally the precaution should be taken to avoid fetal trauma. neonates should be given antiretroviral therapy and breast feeding should be avoided.

Interventions

Antepartum:

Multidisciplinary team approach is needed for her management including HIV physician,GUM medicine,obstetrician,GP,midwife.Viral load and CD4+T lymphocyte isto be checked.If she has viral load <10000-20000 copies/ml,CD4+T lymphocytes>250/cumm she doesn"t need antiretroviral therapy for her own but needs it to reduce MTCT transmission.She will take oral ZDV antenetally plus during labor in IV form 2mg/kg loading followed by 1mg/kg until delivery.Baby will have oral ZDV until 6weeks of age.

If viral load >10000-20000copies /ml and CD4+Tlymphocytes<250 /cumm blood,she will need antiretroviral therapy for her own as well as to reduce MTCT.She will take HAART antenatally plus ZDV in IV form during labor

If patient is taking HAART frm beginnig it should be continued as it effectively reduces viremia.

Intrapartum:

If patient received HAART and undetectable viral load she may allowed to deliver vaginally.Induction should be given at 38 -39 weeks to prevent spontaneous rupture of membrane.IV ZDV will cover intrapartum period.cord should be clumped immediately after birth and baby should be bathed immediately.Invasive procedures lika SBS,instrumental deliveries should be avoided.

If patient has detectable viral load or taking oral ZDV she shoud opt for elective C/S at 38 weeks.Iv ZDV will b started 4 hours before OT and cover intraoperative period.cord should b clumped immediately and baby shud b bathed immediately.

Postpartum:

Artificial feeding when found feasible and safe,it should be offered becoz breast feeding transmits infection.

Together with antiretroviral therapy,electiveC/S,avoidance of breast feeding MTCT is reduced from 25-30% to less than 2%.

She presents at 28 wks with SROM with no pain:

She shud be admit for assesment.History is taken for duration,amount,color of liqor and any cord prolapse to find out whether the condition is an emergency one or not.Enquiry about UTI and DM.Physical examination will include Vitals,temperature,anaemia,SFH,lie ,presentation,abdominal tenderness,contractions.Speculum examination is done to confirm SROM and taking HVS for c/s,exclusion of cord prolapse,any cervical dilatation,color of liqor.

Investigation shud be undertaken CBC,CRP although nonspecific but rising level is of value.HVS for c/s,urine R/M/E and c/s, NST,BPP,screening for BV .

She shud b counsel about risk of remaining baby in utero of transmitting infection and side by side fate of delivery at this early gestation is at risk of prematurity and made her to have a informed choice.neonatologist view shud b taken and NICU facility of the hospital also a important issue lacking of which warrants in utero transfer to tertiary centre.

Steroid dose shud b given.If she opts for conservative mx regular fetomaternal monitoring to identify chorioamnionitis,fetal wellbeing both clinically and by investigation.Delivery at weeks best for both mom n baby but at least 24hrs later of last steroid dose.Broad spectrum antibiotics is given.

If she wants to deliver C/S will b appropriate at this gestation as lower segment is not formed and there is increasd rate of induction failure.Lower segment vertical or J incision is needed to deliver the fetus.neonatologist shud b present and baby incubator shud b available.Iv ZDV shud cover intraot period,baby is bathed immediately after cutting cord.strict asepsis is maintained and staff shud maintain universal precaution of infection prevention.

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a) Appropriate interventions in the antenatal, intrapartum & postnatal period in a HIV positive patient, significantly reduces the risk of disease transmission to the fetus, from 25-30 % to as low as 1-2 %.

In the above patient with 14 weeks pregnancy & HIV positive result, a multidisciplinary approach should be taken. This should involve HIV specialist, Obstetrician, paediatrician & speciality midwife. A help from psychologist or counsellor will be of special benefit in this woman to assist for overcoming the possible mental trauma caused due to unexpected result.

Antenatal interventions- Maternal blood should be checked for plasma viral load for HIV & CD4 count. Repeat tests might be necessary during the course of pregnancy. Detailed & sympathetic discussion must be done with the patient about the benefits & side-effects of ART emphasizing the significant reduction in the risk of transmission to fetus if ART is taken.HAART with zidovudine, lamovudine & protease inhibitor is preferable provided there is no contraindication. If woman refuses HAART or does not tolerate, monotherapy with zidovudine should be started. Screening for STI should be done at 28 weeks. Infection should be treated even if the pt. is asymptomatic. Plan for the mode of delivery should be made at 36 weeks with consideration of viral load, obstetric complications, opinion of HIV specialist & woman's wishes.                                                                                                                                                                                              Intranatal interventions - If the decision of caesarean section is taken, zidovudine infusion should be started. This should be timed 4 hours before the surgical incision & to be continued till the umbilical cord is clamped. Surgical field is kept as bloodless as possible. The membranes should be kept intact till the head of the fetus is delivered through the surgical incision.                                                                   If the decision taken for vaginal delivery, HAART should be continued throughout the labour.Membranes should be kept intact as long as possible. If needed, low cavity forceps should be used instead of ventouse. Invasive procedures like fetal blood sampling, scalp electrodes should be avoided.                                                                                                                                                                        Postnatal interventions -  Breasfeeding should be discouraged. The neonate should receive ART in the form of HAART or zidovudine monotherapy.    

b)  When the woman presents at 28 weeks with SROM, delivery should be expedited. All possible measures should be undertaken to reduce the transmission of the disease from mother to fetus. Maternal blood should be tested for viral load, CD4 count alongwith the baseline investigations like complete blood count. Woman's antenatal records & ART should be reviewed. Team approach with HIV specialist, Neonatalogist & specialist midwife is necessary. Fetal wellbeing should be assessed by USG & electronic fetal heart monitoting. Corticosteroids for the lung maturity should be administered. Screening for STIs should be done & infection treated even if woman is asymptomatic. Oral erythromycin with intravenous broad spectrum antibiotics should be started. Cervical assessment should be done to decide the prospects for vaginal delivery.                                                                                                                                          Detailed discussion should be done with woman & her partner about the status & mode of delivery should be decided mainly based on the plasma viral load & the type of ART that the woman was taking. If woman was on HAART & the viral load is less than 50 copies/ml, vaginal delivery may be attempted provide there is no obstetric contraindication. If the woman was on zidovudine monotherapy or if the plasma viral load is > 50 copies/ml, caesarean section will be the safer option in view of the risk of disease transmission. In this case the zidovudine infusion should be started 4 hours prior to taking surgical incision 7 to be continued till the cord is clamped. This will be of special benefit to baby, as after birth this preterm baby may not tolerate the oral ART well. Woman should be counselled to avoid breastfeeding.

A) he risk of HIV mother to child transmission can be reduced to less than 1%.knowing the patient  immunity status CD4 counts and the viral load is corestone .if her viral load is high and CD4 count is low she will need intravenous anti retrovial drugs.patient should be referred to HIV  physician for her care in conjunction with the obstetric consultant led care as this pt is a high risk pregnancy .anomaly scan should be booked at 20 wks gest to rule out any cong anomalies.

Avoidance of any invasive technique for pre natal diagnosis is recommended eg avoidance of amniocentesis and chorionic villous sampling. prophylactic antibiotic can be given to prevent against pneumocytis cranii pneumonia.As she is vulernable to other STDs(sexually transmitted dis) she should be screened for other STDs and treated e.g HSV for culture/sensitivity and endocervical swabs for c.trachomatic and N.gonorrhea. sexual contact should be traced ,screened and referred to GUM clinic to be trated.

c) @ 28 wks ,pt.  should  be admitted to the hospital.assessment of her status of CD4 and viral load should be checked . full blood count .C reactive protein ,and high vaginal swab should be obtained

Steroid injection to promote lung maturity and oral antibiotic Erythromycin 250 mg ,QDS should be given. The aim is to expedit delivery and to decrease the time of exposure of the foetus to the mother blood stream "fluid" while in utero while buying time for the stroid and the antibiotic to kick in.The risk of retaining in utero "foetal infection"should be balanced againt the risk of prematurity and it's complications.

Multi desciplinary approch including HIV p-hyscian .obstetric counsultant ,neonatalogist .their input should be sought for the care of this patient .

Foetal wellbeing should be assessed ,Biop-hysical profile and estimated foetal weight should be obtained as well as CTG/

the safest and best mode of delivery is by elective lower segment cesrean section after comp-lteing the course of steroid baby should be handled to the neonatlogist to take safe measures.

a) The transmission in treated women is less than 2%. Check maternal viral load and lymphocyte CD4 count. If her CD4 count is less than 200x 10^6/L or if she is symptomatic then she will need initiation of HAART regime to reduce the risk of transmission to the fetus. It is important she has a multidisciplinary input to her management from a HIV specialist, specialist midwife, obstetrician with a special interest and neonatologist. She will need as a minimum checking of her viral load and CD4 count in every trimester, at 36 weeks and at delivery in order to start treatment if necessary. If at 36 weeks or at delivery her viral load is more than 50 copies then vaginal delievery should be discouraged to reduce the risk of transmission. If caesarean section (LSCS) is to take place and the woman is not on HAART then IV Zidovudin should be started 4 hours prior to the caesarean section and continued until the cord is clamped to reduce risk of transmission. If the viral load is more than 50 copies then elective LSCS should be planned for 38 weeks to avoid risk of spontaneous labour, otherwise if the viral load is less than 50 copies and there are obstetric indications for LSCS, then it can be planned for 39 weeks. During the caesarean section the fetal membranes should be kept intact whilst delivering the baby to reduce risk of transmission. If she was to have a vaginal delivery then an intrapartum care plan should be documented to avoid artificial rupture of membranes,fetal scalp electrode, fetal blood sampling, ventouse or mid cavity instrumental delivery in order to avoid transmission.The baby should be washed immediatly to reduce risk of transmission. Breastfeeding should be discouraged as it has been shown to increase transmission by double the rate.

If the woman requires an amniocentesis after 15 weeks then the viral load should be checked and if more then 50 copies the procedure should be delayed until the viral load is less that 50 copies. IV zidovudin should also be started if not on HAART to cover the amniocentesis.

b)At 28 weeks the risks of prematurity need to be weighed against the risks of HIV transmission to the fetus. The parents need to be counselled with the HIV specialist, neonatologist and obstetrician and written information should be provided where possible. The parents need to be counselled regarding the risks of immediate delivery and the neonatal outcome or delaying delivery and the increased risk of HIV transmission. The risks of premaurity such as necrotising enterecoliitis, encephalopathic leucomalacia leading to cerebral palsy, respiratory morbidity and neonatal mortality can be reduced with the administration of corticosteroids, preferably Betamethasone 12mg IM 24 hours apart. Magnesium sulphate infusion if given within 24hours of delivery has been shown to reduce the risk of cerebral palsy. If the parents opt to delay delivery in order to either have the opportunity to administer the corticosteroids and avoid the consequences of premaurity and be induced at 34-36 weeks then risk of HIV tranmission is increased. After 4 hours of ruptured membranes the risk is increased and there's an incremental risk of transmission of 2% for every hour up to 24 hours. There is not enough evidence regarding administering antiretrovirals IV to reduce the risk of transmission if delivery is going to be delayed in premature fetuses at they lack hepatic enzymes and these may not be effective. Erythromycin 250mg QDS should be administered for 10days to reduce the risk of chorioamnionitis. If the parents want immediate delivery then IV Zidovudin should be administerd prior to caesarean section (this is the most likely mode of delivery at 28 weeks when not labouring) and continued until the cord is clamped. If maternal viral load is less than 50 copies then induction of labour is advocated at 34-36 weeks and fetal scalp electrode, fetal blood sampling, ventouse delivery and mid cavity instrumental deliveries should be avoided to reduce risk of transmission. If the viral load is more than 50 copies then LSCS should be performed.

a)

Women given evidence based information of different options to reduce the rate of transmission. Parent to child transmission rate is 25-30% without treatment. Higly active anti retroviral treatment , cesarean section and avoidance of breast feeding decreases the rate to less than 2%. Cesarean section prior to labour onset and rupture of membranes, less spillage of blood during labour and delivery with intact membranes is effective. 

Zidovudine monotherapy alone through out antenatal period and infusion durnig delivery reduces rate to 8 - 12%, Avoidance of breast feeding alone brings down rate to 12- 15% in resource rich countries. Tablet nevirapine treatment alone during labour 4 hrs prior to delivery is also effective.

During labour to avoid instrumental deliveries and use of fetal scalp and fetal blood sampling.

b) 

Initial management includes History of vaginal loss and bleeding, frequency and regularity of contractions assessed. Abdominal examination done, fetal pole palpated since high chance of breech at preterm age. Speculum examination done to confirm leakage and to rule out cord prolapse or abnormal presentation. Vaginal examination deferred. Continous CTG for 30 mins done to assess fetal conditions.

Blood investigations to check viral copies ( if less than 50 than vaginal delivery can take place) white cell count to assess infection , CD 4 counts recent one assessed and vaginal swab taken.

Multidisciplinary care involving HIV physician, obstetrician, neonatologist and anesthetist if need arises for cesarean section. Delivery should take place in hospital and under consultant led care. Women given information of increased chance of infection to baby in case of remature rupture of membranes with high viral copies.

Antibiotic treatment with erythromycin given , tocolysis considered if transfer to unit with special baby care, steriod therau with inj betamethasone 12mg 2 doses 24 hrs apart. It is useful even after single dose against respiratory distress syndome.

Vaginal delivery considered in case of low viral copies and since membranes are already ruptured under consultant care. Neonatologist informed. Effective analgesia options given with no contrindication for epidural. Continous electronic fetal monitoring and partographic assessment of labour.To avoid invasive testing on baby like fetal scalp and fetal blood sampling during labour and to allow spontaneous progress of labour. To avoid if possible instrumental deliveries if required than to use forceps as compared to vaccum, and episiotomy. To continue zidovudine infusion during labour or tablet nevirapine prior to delivery.

In case of cesarean section to deliver baby with membrane intact, to avoid blade injury to baby, avoid spillage of blood.

Post delivery baby to be assessed by neonatologist and admitted in special baby care unit if required. Baby checked for HIV at birth at 4 weeks 6 months and 18 months of age. To avoid breast feeding, to give esternal feeds. Options of contraception like barrier, hormonal or coils discussed, regarding treatment of HIV with HIV physician considered. Implication for future pregnancy explained with nedd to bring hiv viral loads to low levels with traetment. 

a) The three main interventions  to prevent MTCT of HIV are avoidance of breast feeding,the use of Antiretroviral therapy  and prelabour  caesarean section.

Use of ART helps in reducing viral load and maternal CD4 cell count which are associated with increased risk of transmission and provide pre and postexposure prophylaxis to baby.

If untreated, vaginal delivery is associated with increased risk.Preterm delivery before 34 weeks  is  associated with an increased risk.

 Maternal screening enables appropriate interventions to reduce MTCT of HIV infection.High risk women who are HIV negative at booking should be retested later in third trimester .Provide rapid HIV testing to all women who arrive unbooked at a delivey suite,so that PEP  can be properly instituted. One of the key strategies to prevent perinatal HIV infection in UK has been the DH policy of ‘opt out HIV ‘testing for every pregnant woman.

Women infected with HIV should be under care of MDT. All should be screened for hepatitis and other sexually transmitted infections and treated accordingly. The administration of HAART reduces the risk of vertical transmission by 2/3^rds.For those not receiving HAART,LSCS  and 4 hrs  preop  Zidovudine infusion reduces the risk by 50-70%.The effect on MTCT and maternal health of planned LSCS for women on HAART or who have very low viral loads is likely to be minimal.Vaginal delivery without interventions like fetal blood sampling and FSE ,delayed amniotomy and early clamping of the cord can be accepted in selected cases. Avoidance of breast feeding reduced the risk further.

All above interventions can reduce the risk of MTCT from 25-30% to less than 2%.

Non breastfed babies should have a viral culture taken and PCR to determine infection in the baby.All  infants born to HIV positive women should be treated with ART from birth.

All women with HIV during pregnancy should be reported to the National Study of HIV in pregnancy and childhood Registry  at RCOG.

b)Initial assessment should be in accordance to guidelines for the general population.

Multidisiplinary team is involved so that a clear plan is in place.

A  vaginal swab should be taken for bacteriology and infection treated ,even if asymptomatic ,according to national guidelines.

I/M steroids should be started, aiming for 2 doses 24 hour apart for fetal lung maturation.

If untreated  ,take baseline bloods for CD4 cell count and viral load if not known and commence HAART.

Nevirapine should be included in the regimen as it crosses the placenta rapidly.

If already taking HAART and Viral load is more than 50 copies /ml, review and optimize HAART and single dose NVP .

For the woman on HAART and Viral load less than 50 copies /ml,continue HAART ,but consider single dose NVP,If she is not on NNRTI.

Oral Eryromycin and parenteral antibiotic should be instituted as indicated.

The decision whether to perform LSCS should be taken. Chorioamnionitis and fetal distress are indications for prompt delivery.

The timing for  delivery  will involve balancing the risk of MTCT of HIV with the risks of severe prematurity.

This should involve multidisciplinary team discussion with the obstetricians, neonatologists and  HIV physicians to consider the adequacy of maternal HAART ,plasma viraemia and the presence of any other pregnancy or HIV related comorbidities.

The decision to deliver will balance HIV transmission risk with fetal age and size and neonatal facilities.

Expert advice from outside the host institution may be helpful.

If not yet on HAART ,and with a viral load of more than 50 copies/ml, IV  Zidovudine should be continued in addition to above measures. In untreated, ROM more than 4 hrs is associated with a doubling of the risk of HIV transmission .Risk also increased  if duration of HAART is short.

In selected cases expectant management is appropriate.

Contact HIV physician for choice of ART as preterm neonate may be unable to tolerate oral medication; administering ART to the mother will provide prophylaxis to neonate.

Neonatologist present at delivery. Neonatal  treatment  and follow up essential.

Provide supportive advice about formula feeding and cabergoline to suppress lactation.

Patient should be provided written information, counseling,support and support groups.

Patient should be notified according to local guidelines.

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1. Management of this pt.with hiv by multidiscipilinary team including obstetrician ,HIV physician,paediatrician  ,specialist nurse and social worker will lead to adequate control  of disease and ultimately vertical transmission to child.

    Combination of antiretroviral therapy,appropriate management of delivery  and avoidance of breast feeding  reduces the mother to child transmission from 25-30% to less than   1%.she should be  started haart if sympyomatic or CD4count is less than 350x106/l,should continue throughout pregnancy and postpartum.if she does not want treatment for her own ,HAART can be started from 20-28 wks and stopped at delivery.if her viral load is less than 10,000 copies/ml and she is planning to deliver by elective caesarean section then Ziduvudine as monotherapy may be commenced from 20-28 wks ,orally twice daily during pregnancy and intravenously at delivery and discontinue after delivery.

     Elective caesarean section at 38 wks to avoid labour and rupture membranes ,if viral load is more than 400 copies /ml or not on any  ART, will reduce the maternal to child transmission .

During vaginal delivery membranes should be kept intact as long as possible .invasive procedures  such as episiotomy, fetal blood sampling, use of fetal scalp electrode should be avoided. Low cavity forceps should be used in preference of ventouse   if deemed necessary.

Woman should be advised to unprotected intercourse during pregnancy to prvent  increase in viral load.

Avoidance of breast feeding will reduce the vertical transmission from 28% to14%. Woman should be provided information and support about formula feeding and lactation suppression strategies such as cabergolin and use of firm bra.

1. She will be admitted  in hospital  at least for 48 hours for assessment, management and in patient monitoring   and would be informed  that there is  risk of infection and preterm labour .

She   should be managed by multidisciplinary team including HIV physician ,obstetrician ,specialist midwife ,pediatricians and social worker.

Diagnosis is confirmed by maternal history  and evidence of pooling of fluid in vagina on sterile  speculum examination .measurement of temperature (high) and pulse (tachycardia)to exclude infection will be performed. Abdominal examination to assess lie ,presenting part ,uterine tenderness ,and fetal heart  status would be done  as she may go into labour .ultrasound may be useful to reveal fetal size, growth, presentation and amount of liquor. cardiotocogram will provide fetal  heart  rate status  in detail .Full blood count ,Creative protein and high vaginal swab will be  performed to  exclude infection.Viral load and CD4 count  will be checked as base line  .

If infection is identified ,should be treated  even asymptomatic.she should be give oral erythromycin 250 mg thrice daily for 10 days to prevent from infection.consideration should be given to to commence broad spectrum antibiotics .

Corticosteroid should be give in the form of inj,Betamethasone 12 mg  ,intramuscularly,in  2 doses, ,24 hours apart to promote lung maturity  as there  is risk of preterm delivery.

She will be monitored  for signs of chorioamnionitis  which includes pyrexia,tachycardia,uterinen tenderness,foul smelling vaginal discharge.fetal tachycardia ,every 4-8 hours.

Viral load  and CD4 count will be monitored at 36 wks  and at deliver.Full blood count ,urea,electrolytes  and liver function test  is undertaken regularly to assess toxicity of HHART.

Serial growth scans will be  arranged ,fortnightly to monitor growth as there is risk of fetal growth restriction .

Decision about delivery  would be undertaken by multidisciplinary team involving HIV physician,obstetrician,and paediatrician  and woman and family.Time and mode of delivery would be planned and documented in notes.

Evidence  of infection or  fetal distress will   lead to  decision of immediate delivery.In the absence of them delivery  should be planned at 34  weeks to prevent fro infection  ,after counseling the woman.Mode of delivery will depend up on  viral load ,vaginal delivery may be appropriate if she is on HAART and viral load is less than 400 copies/ml,OR if she is on other ART

And viral load is less than 50 copies/ml.Elective caesarean section should be performed if she is not on any ART or receiving any retroviral therapy and viral load is 400 or more copies /ml.In

Case she is on ART and viral load is between 50-400 copies /ml ,vaginal birth or caesarean section may be considered as there is insufficient evidence to recommend caesarean section

to prvent mother to child transmission.Neccesary measures to control transmission of infection

to baby and staff such as delayed rupture of membranes,avoid invasive procedure, use of ART ,

double gloving would be  taken and documented in plan. 

 1.The women should be manange in the multidisciplinary team includes obetetrician ,midwife,hiv physician ,neonatologist and social healthworker to have good outcome . she should be advise to have antiretroviral therapy ,delivery by LSCS and avoid breast feeding to reduce the risk of maternal and child transmission.

She need appropriate post screening counselling in sensitive manner and she should be reassured that her confidentiality will be maintained and counselling to reveal her status to her sexual partner.

If she is taking antiretroviral drugs therapy for her own health then she should continue it for the through out the pregnancy and postpartum other wise she should be advise to start antiretroviral therapy  to stop maternal and child transmission from 20 weeks to 28 weeks of gestation. If she is declined such treatment then she should have counseling with the multidisciplinary team and its  should be repeated in the later half of the pregnancy and documented in the notes.

If she is started on the antiretroviral drug therapy highly active retroviral drugs should be chosen instead of single agent therapy to avoid drug resistance. once she comes in labour antiretroviral drugs should be started as soon as possible if she is not on HAART as form on ziduvidine  monotherapy  or if the time is less then she should be started with the drugs which achieve high concentration in the fetus within  short period of time like nevirapine.

She should be followed up with cd4 count and viral load .she should be counseled for the risk of transmission for the prenatal diagnosis like amniocentesis and cordocentesis . if her viral load is high then the procedure should be delayed till her viral load is less than 50 copies /ml.

Risk of transmission increases in presence of other infection like HCV and HBV infection, she should have low threshold for the treatment of any other infection .

Plan of delivery should be decided by 36 weeks of gestation according to her viral load . if her viral load is less than 50 copies /ml then she can be advised for the vaginal delivery as the risk of transmission to the fetus is very less and similar to the caesarian section.

If the viral load is more than 50 copies/ml  and she is coinfected with the HCV then she should be advised for the LSCS .

Once she came in labour her paln of delivery should be followed if she is not on any antiretroviral drugs then iv ziduvidine should be stated and atleast delayed for the 4 hours to deliver and it should continue till the cord is clamped.

During intra-partum rupture of membrane should be avoided as far as possible, invasive fetal monitoring like FBS , fetal scalp electrode should be avoided. Traumatic instrumental vaginal delivery should be avoided .early cord clamping and  baby should be bathed immediately after birth and handed over to neonatologist and ziduvidine should be started for the neonates for the 6 weeks.

In resourse rich country breast feeding should be avoided to decrease the risk of transmission.instruction about the bottle feeding and breat milk suppression should be given.

2.she should be asked about the duration of the rupture of membrane ,colour of liquor like clear or meconioum stained  and nature of the liquor whether its foul smelling or not. Any associated feature like fever and not feeling well.she should be admitted as inpatient for the further management with the multidisciplinary team include obstetrician,midwife ,HIV physician and neonatologist.she should be examined for her general well being pulse ,BP and temperature .she should be examined per abdomen for the uterine size and tenderness and per speculum examination should be done to see the colour of liquor and dilatation of the cervix .digital examination should be avoided to avoid ascending infection. For the fetal well being CTG should be done.

Investigation should include FBC ,c-reactive protein ,and High vaginal swab along with cd4 count and viral load .since she is HIV positive if she is taking antiretroviral drugs then liver function test ,kidney function test should be reviewed .ultasound for the fetal gestational age ,amount of liquor ,placental localization and presentation should be done.

She should be counseled for the conservative management in view of prematurity and risk of transmission to the fetus as there is two risk factor like premature rupture membrane and prematurity.

She should be started on antibiotic erythromycin for the 10 days and antiretroviral drug should be started .she should be given injection betamethasone 12 mg intramuscular 2 doses 24 hrs apart.

She should be monitored with the temperature 4-6 hrly and ask to report if she feeling not well and any concern about fetal well being. If she is much concern about baby then she should be counselled with the neonatologist .her confidentiality should be maintened and dealt with dignity and respect.

Expectant management should be continued till 34 weeks of gestation or the fetal and maternal wellbeing is with in normal range. After 34 weeks of gestation plan of the delivery should be decided .here mode of delivery will not reduce the risk of maternal to child transmission,so caesarian section for the obstetric indication and vaginal delivery should expect .unversal precaution for the health care professional .

If she delivers vaginally the precaution should be taken to avoid fetal trauma. neonates should be given antiretroviral therapy and breast feeding should be avoided.

It should be registered to british registration of pregnancy and hiv.

Neonates should be followed for the antibody test for 6 weeks,12 week and 18 monyh.

Factors associated with increased risk of  HIV transmission from mother to child are high viral load, low CD4 count,vaginal delivery, preterm labour, chorioamnionitis and breast feeding. 80% transmissions take place after 36 weeks of gestation including labour and delivery.The 3 major interventions to reduce the transmission risk are

Avoidance of breast feeding

Antiretroviral  therapy and

Appropriate management of delivery.

Avoiding breast feeding and advising formula feed in resource rich countries reduces the transmission of HIV from25-40% to 15-20%.

Regarding antiretroviral therapy, the HIV physician should be consulted for the appropriate gestation and the optimum antiretroviral for the situation. This will depend upon the plasma viral load, CD4 count and the need of the therapy for mother’s own health. If the plasma viral load is high combination therapy with Highly Active Anti Retroviral Therapy(HAART) is recommended as compared to monotherapy with Zidovudine. If CD4 count is less than 200 million/Litre ,Pneumocystis carinii prophylaxis with Cotrimoxazole preferably should be offered .Regarding gestation and duration of therapy, if woman requires antiretroviral for her own health, she should be given HAART during pregnancy and continued postpartum. Those who do not need for their own health will start HAART between 20-28 weeks gestation and discontinue following clamping of the cord at delivery. Those with plasma viral load less than 10,000 copies/ml can have monotherapy with oral zidovudine 250 mg twice daily started between 20-28 weeks gestation with  intravenous infusion started 4 hours before elective cesarean section and to be discontinued following delivery. The neonate should be given a bath immediately following delivery. Antiretroviral should be started within 4 hours of delivery and continued for atleast 6 weeks. Those at high risk of HIV should be given Pneumocystis carinii prophylaxis in addition.

Viral load and CD4 count estimation should be done prior to delivery. If the viral load is more than 50 copies/ml and the woman is on HAART or if the load is less than 50 copies/ml and she is on single agent zidovudine , elective cesarean section at 38 weeks of gestation should be offered. Cesarean section can be delayed to 39+ weeks if the viral load is less than 50 copies/ml to reduce the risk of transient tachypnoea of newborn. Durng cesarean section care should be taken to minimize transmission by maintaining good haemostasis and keeping the membrane intact till just before delivery of the presentation. If the viral load is less than 50 copies/ml  and the woman is on HAART, vaginal delivery may be permitted since there is no increase in transmission risk with these low counts. However, care should be taken during vanal delivery to avoid foetal scalp electrode and foetal blood sampling in labour. Membranes should be kept intact as long as possible. Oxytocin may be used to augment labour. If instrumental delivery is required ,low forceps is preferable to ventouse extraction.

Combination of these 3 factors reduces the risk of transmission from mother tp baby from 25-30% to less than 1%.

B) A multidisciplinary management should be planned and include a senior obstetrician, experienced midwife,HIV physician, neonatologist and a social support group. Delivery should be planned in a high risk unit with 24 hours emergency cesarean section and advanced neonatal resuscitation facilities.

In this woman with ruptured membranes at 28 weeks of gestation, screening for other genital tract infections should be done with appropriate swabs for culture/sensitivity. Screening for Hepatitis B,C and syphilis should also be done if not done earlier. Partner should be referred to genitor-urinary clinin for screening. Screen positive cases should be treated with appropriate antibiotics even if asymptomatic. The couple should be counseled regarding use og condom if the partner is sero-negative.

Corticosteroid as injection betamethasone 12mg intramuscular 2 doses 24 hours apart is given to enhance lung maturity.

Antibiotic, oral Erythromycin 250 mg qid is started to reduce viraemia and prolong pregnancy.

HIV physician is consulted regarding optimum  antiretroviral therapy. If the delivery occurs before 32 weeks the baby may not be able to tolerate oral medications. In this situation, antiretroviral will be given to mother just before and during labour to provide prophylaxis to the neonate.

If the woman is on HAART,monitoring for drug toxicity should be done—full blood count, urea& electrolytes, liver function tests, serum lactate and glucose.

Woman is at increased risk of chorioamnionitis in view of ruptured membranes. Monitoring is done with regular assessment of temperature, lower abdominal tenderness ,offensive vaginal discharge and foetal tachycardia on cardiotocography.

Foetus is at risk of prematurity and sepsis. Accurate counselling and the increased risk of morbidity along with prognosis should be provided to the woman and family by the senior neonatologist.

Foetal growth and well being should be monitored with regular growth scans and amniotic fluid index and umbilical artery Doppler.

Delivery is planned at 34 weeks gestation to reduce the risk of respiratory distress syndrome. Earlier delivery will be undertaken if chorioamnionitis sets in or there is evidence of foetal compromise. The mode of delivery will depend on the fetal presentation and maternal viral load and CD4 count. All precautions to reduce transmission should be followed at delivery. Senior neonatologist with experience in advanced resuscitation skills should be present during delivery.

Following delivery, oral cabergoline 1 mg should be prescribed for mother to suppress lactation. Formula feed is advised.

Effective contraceptive  with additional barrier contraception should be advised.

Contact details of HIV support groups should be provided.

Registration of birth in National HIV register and Antiretroviral register should be done.

a)    It is of paramount importance to explain to the patient the implications of her diagnosis in order to achieve maximum compliance from her. The most important intervention to minimise the risk of transmission in to organise a multidisciplinary team for this patent's antenatal intrapartum and postnatal care that would include an HIV physician, an obstetrician a sepcialist midwife and paediatrician. The viral load and CD4 count should be checked as a baseline value and the patient should be advised to start anteretroviral therapy if the CD4 count is low <350x10^6/L or if she is symptomatic of HIV infection. If there is no such indication, then antiretroviral treatment should be initiated between 20-28 weeks of gestation. The highly active antiretroviral therapy should be the treatment of choice unless the patient's viral load is <10000copies/ml and the patient is prepared to have caesarean section; in this case she could be treated only with zidovudine. If the viral load is <50 copies/ml and the patient is on HAART she could have a normal delivery however, it FSE and FBS should be avoided. Moreover, membranes should remain intact as long as labour is progressing satisfactorily. In case of the need of instrumental delivery, forceps should be the prefered instrument than ventouse. If on the other hand the patient's viral load is high or if she is on ziduvudine then an elective caesarean section should be performed during which good haemostasis should be ensured and the membranes should not be ruptured until the head is delivered from the abdomen. Finally the ziduvudine infusion should be continued until the delivery. The umbilical cord should be clamped immediately for both vaginal and caesarean delivery. In the postpartum period breastfeeding should be avoided as this can double the risk of HIV transmission.

b) When the patient presents with ruptured of membranes at 28 weeks an individualised plan according to the multidisciplinary team should be made taking into consideration the risks of prematurity and the risks of transmission of HIV. Steroids should be administered for lung maturation and erythromycin should be initiated to prevent any infection. The patient's care should be as an inpatient in order to closely monitor her for signs of chorioamnionitis. The patient should have her pulse and temperature checked regularly (ideally every 4 hours), she should have her WCC and CRP checked at least twice a week and on admission and then weekly genital swabs should be obtained. The CD4 count and viral load should also be checked on admission and the patient's compliance with the anteretroviral therapy that should have been started by this gestation should be confirmed. A CTG should be perfmormed daily to assess fetal well being.  If there are any signs of chorioamnionitis the delivery should be expedited. The mode of delivery will depend on the fetal lie and presentation as well as the viral load and of course any fetal cmpromise.If there is fetal compromise or signs of chorioamnionitis and the cervix is unfavourable then a caesarean section may be more appropriate and in this case a classical C/S may be the only option. Moreover, the risk of HIV transmission should be considered according the advice of the HIV physician. Finally the patient should also be reviewed by a neonatologist who should explain the risks of prematurity.

ncidence of HIV has increased worldwide but the Neonatal tranmission is reducing by various measures taken antenatly, intrapartum and postpartum.

The antiretroviral have shown to decrease the transmission. As patien has been diagnosed on routine screening so will not be on any antiretrovirals. If she require HAART for her own heath it can be started at any gestation however if she doesnot require it , it is started at 28 weeks gestation.If her viral load is undetectable and she is willing to deliver by cesrean section Zidovidine is an alternative to HAART to be started from 28 weeks till delivery.

Mode of delivery is the other confounding factor in reducing the mother to child transmission. If patient viral load is higher than 50, or she is on montherapy, or co infection wth HCV she will need delivery by cesarean section at 38 weeks. If she has low viral count <50 & is on HAART from 28 weeks or atleast 6 weeks before delivery she can try for vaginal delivery..

If vaginal delivery is allowed invasive procedures like FBS, fetal scalp electrode should be avoided. Also difficult instrumental delivery should not be performed and if a low cavity delivery is required forceps id preferred over ventouse.

For elective cesarean section I/V Zidovudine should be started 4 hours before the c/s, avoiding rupture of memebrane until head is out of the incsion and keep surgical field as haemostatic as possible.

Women should be advised not to breast feed as it has shown decrease the transmission rates.

Baby should be bath immediately afer delivery.

Neonatal antiretoviral are indicated . Baby should be commenced on HAART and HIv status checked at 6 months, 12 months and finally at 18 months.

B)

Prolonged SROM increases risk of tramission of HIv from mther to child.This risk should be weiht against the risk of premature delivery. It is therefore important the history of SROM is confirmed by speculum exmination to check for liquor drainage or pooling in posterior fornix.

Patient should be managed ideally by a MDT involving Obstetrics consultant, HIV physcian, specailist nurse and neonatologist. Patient notes should be checked for any plan from the MDT in the antenatal period.

A history regarding her HIv also need to be obtained, her disease status, recent viral load and CD4 count, any antiretroviral treatment she is on.

The decision for conservative mangement or delivery will depend on the dicussion with the MDT after reviwing her CD4 count and viral load.

She will need inpatient monitoring for atleast 24-48 hours after which decision for outpatient monitring should be made by a consultant Obstetrician.

She will need a FBC/ CRP and genital swabs to check for any infection.

She will need steroids either betamethasone or dexamethasone depending on availabilty.

She also need eythromycin for 10 days orally however if signs of infection parental antibiotics hsould be considered.

If she is on Antiretroviral she should continue till delivery if it not for her health in which she continues after that also.

For outpatient mangement she need to be informed about signs of chorioaminitis an dto report immediately if they appear.

She needs to check her temp daily, and check for colour of the liquor.

She will also need regulary outpatient appointments atleast weekly to check for mother and baby well being. She will require scan for growth and liquor.

FBC /CRP are done routinely (weekly) also have poor senstivity/ specificity to detect infection.

Timing and mode of delivery are made at the MDT meeting roughly after 32-34 weeks.

If delivery is allowed vaginal all efforts should be taken to reduce transmission to baby (eg avoid FBS, FSE etc)

Special care unit should be made aware of the delivery of the baby and availabilty of cots checked before hand as baby will likely to require SCBU admission after delivery.

a)  antenatal HAART  treament,planned cs combined with avoidance of breast feeding decreases the MTCT of hiv  from 20-30% to

< 1-2%.

HAART TREATMENT

in women who do not require treatment for their own health HAART must be started at 20-28 weeks and discontinued at delivery.

women with high baseline titres of viral load and who intend to achieve undetectable viral load by 36 weeks, so as to proceed with vaginal delivery  will need to start HAART earlier at 20-24 weeks .

aim of treatment is to achieve undetectable viral load --<50copies/ml before delivery.

ART should contain   zidovudine,lamovudine  and boosted protease inhibitor unless they are contraindicated.

alternatively women who repeatedly have a viral load of less than 10000 copies/ml  can be treated with zidovudine mono therapy combined with elective CS at 38 weeks. iv infusion to be started 4 hrs before cs. monotherapy must commence by 28 weeks. this regimen reduces the fetal exposure to ART. minimises maternal and fetal  toxicity. also minimises the risk of pre term delivery associated with HAART. development of resistance in the mother is also minimum with monotherapy.

women who need HAART for their own health need treatment throughout pregnancy and postpartum. delay starting treatment until after the first trimester.

women who conceive when on HAART and has undetectable viral loads should be encouraged to continue the treatment after a discussion of risks and benefits.

mode of delivery must be decided  by 36 weeks

delivery by elective CS at 38 weeks recommended in  women taking HAART with a viral load of >50copies/ml

women on ZDV monotherapy as an alternative to HAART

women with HIV and hepatitis C -- co infection

otherwise delivery by CS can be delayed till 39 weeks to avoid respiratory distress in the new born.

a planned vaginal delivery can be allowed in women on HAART with a plasma viral load < 50 copies /ml.

continue HAART throughout labour.

avoid invasive procedures like FBS and FSE. keep membranes intact as long as possible. amniotomy and augmentation with syntocinon can be considered .

if instrumental delivery is needed low cavity forceps is preferred to ventouse.

postpartum--  all women in resource rich countries should be advised not to breast feed.

neonatal --all neonates should be treated with anti retrovial therapy within 4 hours of birth, either HAART or zdv monotherapy.

b)

women receiving HAART must be adequately couselled about the risks of pre term labour

 must be screened for genital tract infections and treated even if asymptomatic.

corticosteroids  are given for fetal lung maturity. 2 doses of betamethasone 12 mgms 24 hrs apart.

a full multidisciplinary plan including hiv physician and paeditrician to be formulated in case pre term labour supervenes.

discussion with hiv physician to decide about ART regimen if delivery happens before 32 weeks. the neonate may not tolerate oral medication and intrapartum prophylaxis to the mother in such cases would benefit the neonate.

for PPROM  after 34 weeks delivery must be expedited and augmentation considered if viral load is <50 copies/ml.

oral erythromycin is prescribed and intravenous broad spectrum antibiotics to be considered.

Ni

1. There is risk of transmission of HIV about 25 -30% without any intervention in developed countries like UK. It has been found that with certain measures like elective LSCS (before onset of labour)reduces the risk as in most of the cases transmission occurs at the time of delivery. Similarly transmission risk increases by breast feeding so stopping the breast feeding quite significantly reduces the risk . Similarly starting retroviral therapy (HAART) during 20-28 weeks and continuing upto deliveryof the infant, including zidovudine intravenous , which reduces the risk significantly, if mother does not require HAART for herself. Similarly if patient requires HIV therapy for heself or already on HAART , should be continued throughout pregnancy & during labour . Intravenous zidovudine reduces the risk . It has been found that by following the above measures , the risk has been reduced to 1%. During neonatal & infancy , baby should be under surveillance with antiretroviral therapy& regular monitoring of HIV status, reduces the risk significantly.
2. When PPOM occurs , what is the scenario here , main dilemma here is how to manage , as risk of HIV transmission increases as pregnancy advances after rupture of membranes. Other problem is risk of prematurity. So there should be a balance to have an optimum management & multidisciplinary care should be sought & case should be referred to HIV physician for retroviral drugs administration. As already it is 28 weeks & PROM , the advantage of elective LSCS is is reduced. I will see her record of recent viral load, if viral copies less than 50 copies/ml, CD4 count more than 400 & if patient on HAART , the risk to the fetus is significantly low. In this scenario conservative management can be considered with proper discussion & information to the patient. She can be provided with Inj Betamethasone 12 mg IM 24 hours apart for fetal lung maturity & single dose of corticosteroids does not have any significant adverse effect on mother & baby & delivery can be planned after 48 hours as already in 28 wks & survival rate is 70 to 80 % at this gest age though the baby has to be managed in NICU.So neonatologist should be before planning for delivery & availability of NICU beds.She should be advised to take Eritromycin 250mg qid if decided to prolong the pregnancy to prevent infection.If signs of chorioamnionitis found ,delivery should be expedited & even a single dose of corticosteroid helps in reducing RDS so it should be given.

                              If the viral load is high>50/ml,CD4 count <400,the risk of transmission  to fetus increases.So at the time of delivery,IV zidovudin shold be given along with HART to reduce neonatal infection.She should be planned for delivery in a centre where where NICU facilities available.

A 23 year old woman has been referred to the antenatal clinic at 14 weeks gestation. She has been found to be HIV positive on routine screening. (a) Discuss the interventions that would minimise the risk of mother-to-child transmission of HIV [8 marks]. (c) She presents at 28 weeks gestation with spontaneous rupture of the membranes but no contractions. Discuss your subsequent antenatal management including planning for delivery [12 marks].

a) Discuss the interventions that would minimise the risk of mother-to-child transmission of HIV [8 marks].

The antenatal interventions include antiretroviral therapy consisting of zidovudine, Lamivudine (3TC) and a boosted Protease inhibitor. If the woman doesnot require treatment for their own health , HAART should be started between 20 – 28 weeks and and discontinued at the delivery. If the woman requires HAART for their own health, HAART should be continued till delivery and post partum. The aim is to keep the viral loads undetectable.

The intervention regarding delivery is by recommending caesarean section at 38 weeks if the woman is taking HAART with plasma viral loads more than 50 copies / ml. Delivery by CS is advised if the woman is taking zidovudine monotherapy instead of HAART. CS is advised if the woman is coinfected with hepatitis C. Planned vaginal delivery can be allowed if the woman has received HAART with viral load below 50 copies/ ml.

Intrapartum interventions include keeping the membranes intact as long as possible. Invasive procedures are avoided such as scalp electrodes, and scalp blood sampling. If instrumental delivery is required low forceps is preferable of ventouse.

In the post partum period, breast feeding is avoided in resource rich countries. Neonate should be treated with antiretroviral therapy with in 4 hours of birth.

B) She presents at 28 weeks gestation with spontaneous rupture of the membranes but no contractions. Discuss your subsequent antenatal management including planning for delivery [12 marks].

History is taken regarding the time since leaking and nature of leaking ( colour, foul smelling discharge and blood stained) Enquiry is made about pain abdomen, fever with chills. Vaginal discharge or urinary incontinence is excluded.

clinical examination is performed to record pulse and temp.

Assessment is made to detect uterine height, uterine tenderness along with fetal lie & presentation.

CTG done to assess the fetal heart rate.

Sterile speculum examination is done to confirm liquor pool in vagina, and for obtaining swabs to screen for genital infection. FBC ,CRP, are done to exclude infection viral load and CD4 count for base line values.

Discussion with multidisciplinary team including HIV physician, obstetrician and paediatrician should be arranged to discuss about the adequacy of maternal HAART, plan of care during antenatal period and timing of delivery.

Risks are explained to the woman and family regarding prematurity ( due to PPROM and due to HAART) and ascending infection.

Erythromycin should be prescribed to prevent infection. She should be explained delivery would be expedited in case of chorioamniotis or fetal compromise. Steroids are prescribed for the fetal lung maturity.

Monitoring is done every 4- 8 hours for the signs of chorioamniotis such as fever, tachycardia, uterine tenderness, fetal tachycardia and foul smelling vaginal discharge.

Serial growth scans should be arranged to monitor fetal growth every 2 weeks.

If spontaneous delivery sets in opinion should be sought from HIV physician regarding the choice of anti-retroviral therapy. Infants born below 32 weeks of gestation may be unable to tolerate oral medication, so administering anti-retroviral therapy to the mother during labour will provide prophylaxis to the neonate.

If the pregnancy has progressed beyond 34 weeks, delivery should be expedited.

Augmentation and Vaginal delivery is considered if the viral load is below 50 copies/ml.

Elective CS is considered if the viral load is more than 50 copies/ ml.

[a]

Mother to child transmission of HIV can be reduced by start HAART to mother and by offering the elective CS and avoidance of breast feeding. In resource rich countries formula milk can be used. Patient who wants anti-retroviral therapy for her own health will start in the pregnancy and continue after delivery with collaboration of HIV physician. If patient wants HAART only for her baby then it will be started 20-28 weeks of gestation and stopped after delivery. Mode of delivery will be planned according to plasma viral load. Patient can undergo vagial delivery if her plasma viral load is < 50 copies/ml with HAART.  She will be planned for elective CS if viral load is more than 50 copies/ml on HAART, if she is on monotherapy or she is hepatitis C +ve. Zidovidine will be started 4 hours before CS and will be continued until the clamping of the umbilical cord. Bloodless surgery will be considered and try to deliver the baby with intact membranes. During vaginal delivery HAART will be continued and avoid early rupture of membranes. Avoid all invasive monitoring. Avoid difficult instrument delivery. Give neonate anti-retroviral therapy within four hour of birth according to risk level.

[b]

She will be dealt same as PPROM of HIV –ve patient. She will be asked about the vaginal bleeding, colour of liquor and history of fever. On examination her pulse and temperature will be taken, abdominal examination will be done to exclude the tenderness and check fetal heart rate. Sterile speculum examination will be done. Swabs will be taken for genital infections. Blood will be taken for FBC, CRP and ESR. Fetus will be assessed by CTG and USG. She will be monitored for chorio-amnioitis by observing pulse and temperature. If there is no signs of chorio-amnioitis, she will be managed expectantly until 34 weeks and antibiotics will be started. Erythromycin is the drug of choice. Broad spectrum antibiotic is considered if genital infection is suspected. Steroids will be given to enhance lung maturity of the baby. HIV physician will be involved to start HAART to the mother as premature baby cannot oral drug if delivery occurs. Her care plan will be reviewed, if she is for vaginal delivery she will be induced at 34 weeks if no contra-indication to vaginal delivery. She can be delivered early if there is any sign of fetal distress or chorio-amnioitis. Pediatrician will be involved and HAART will be given to new born if mother is at high risk. Pneumococal vaccination will be given to baby. Breast feeding will be avoided and formula milk will be started. Rubella and Vericella vaccinations will be given for mother.

           A) Management should be multidisciplinary including, obstetrician, HIV physician, specialist midwife, paediatrician, support groups, psychiatrist, drug dependency specialist if necessary and health advisor.

             I’ll counsel her about the risk of vertical transmission and need of interventions. I’ll document the plan of care.

            I’ll advice her screening for other sexually transmitted infections and genital tract infections, co infection with hepatitis C increase the risk of vertical transmission, and genital tract infection increase the viral load in genital tract as compared to plasma and increase the risk of ascending infection. Screening for genital tract infections is again offered at 28 weeks.

           She should be advised against cigarette smoking and illicit drug use as it increases MTCT. Use of illicit drugs is also associated with increased risk of preterm delivery.

           If invasive procedures are required she should be referred to fetal specialist unit where advice o HIV physician should be sought. Nutritional deficiency should also be taken care of as there is evidence that deficiency of vitamin A increases the risk of MTCT.

           High plasma viral load and low CD4 lymphocyte count is associated with increased MTCT therefore advice should be sought from HIV physician to start antiretroviral therapy. If she needs ART for her own health she should be commenced on highly active antiretroviral therapy (HAART) which includes zidovudine (ZDV). Criteria for commencing HAART are the same as for non pregnant individuals that is <200/mm3, or plasma RNA levels more than 55,000copies/ml. if she does not need treatment for herself the HAART should be started between 20 to 28 weeks and continue till delivery. If the viral load is less than 10,000, and she is prepared to be delivered by elective caesarean section zidovudine monotherapy is an alternative.  

            A decision about mode of delivery should be made by 36 weeks. An elective C/S is recommended at 38 weeks if she is on HAART and plasma viral load is greater than 50 copies, if she is on zidovudine  monotherapy or if she has HIV with hepatitis C coinfection. Delivery by c/s on maternal request or due to obstetric indication should be delayed till 39 weeks in women who have plasma viral load more than 50 copies /ml to reduce the risk of transient tachypnoea.

           Avoidance of breast feeding reduces the risk of MTCT  from 25 to 30% to less than 1%.

B)    I’ll inquire the details of other symptoms that is abdominal pain bleeding, the duration of rupture of membranes, colour of liquor, any offensive smell or fever.

               I’ll ask about urinary and bowel symptoms also, that is frequency and burning of micturation suprapubic or loin pain and diarrhea or colicky abdominal pain.

               I’ll ask details of obstetric history including her LMP regularity of cycles, number of children and their mode of deliveries and any history of preterm labour.

                Medical history should also be elicited like diabetes, hypertension UTI or autoimmune disease.                       

                Social history is also very important in her case as smoking and illicit drug abuse can lead to preterm labour. Stress and social deprivation and malnutrition are other factors which can contribute.

              I’ll assess her weight and height, note pallor, fever, tachycardia and hypotension . Abdominal examination should be performed for fundal height, lie, presentation, amount of liquor and tenderness.

              Speculum examination is required to note the colour of liquor, and tale low and high vaginal swabs, for BV and GBS, endocervical swab should be taken for Chlamydia.

            Investigations required are FBC, to check Hb level to detect anemia, WBCs and platelet counts. CRP for risk of infection.  CD4 count and viral load for the severity of HIV. MSU for microscopy and culture sensitivity. USG is advised for gestational age, fetal well being, and amount of liqour.

          Management is multidisciplinary including senior obstetrician, HIV physician, specialist nurse, paediatrician, health advisor and psychologist if indicated.

          She should be admitted and should be counseled about the increased risk of preterm delivery with HAART.

          Oral erythromycin should be started. If there is risk of chorioamnionitis broad spectrum intravenous should be started.

         Steroids should be given for fetal lung maturity.

          If there is indication of fetal compromise or chorioamnionitis advice from HIV physician should be sought to expedite delivery.

          If expectant management is planned regular monitoring of pulse, BP, temperature and uterine tenderness is performed at least 3 to 4 times per day.

         Serial growth scans for fetal growth and well being should be performed every 2 to 3 weeks. FBC and CRP are required twice a week to assess risk of infection and HVS is required weekly for the assessment of genital tract infection.

        If gestation is progressed to 34 weeks, delivery should be planned with advice from HIV physician. If the viral load is less than 50 copies/ml, she can have augmentation for vaginal delivery and if viral load is more than 50 copies /ml, she should have delivery by C/s

           A) Management should be multidisciplinary including, obstetrician, HIV physician, specialist midwife, paediatrician, support groups, psychiatrist, drug dependency specialist if necessary and health advisor.

             I’ll counsel her about the risk of vertical transmission and need of interventions. I’ll document the plan of care.

            I’ll advice her screening for other sexually transmitted infections and genital tract infections, co infection with hepatitis C increase the risk of vertical transmission, and genital tract infection increase the viral load in genital tract as compared to plasma and increase the risk of ascending infection. Screening for genital tract infections is again offered at 28 weeks.

           She should be advised against cigarette smoking and illicit drug use as it increases MTCT. Use of illicit drugs is also associated with increased risk of preterm delivery.

           If invasive procedures are required she should be referred to fetal specialist unit where advice o HIV physician should be sought. Nutritional deficiency should also be taken care of as there is evidence that deficiency of vitamin A increases the risk of MTCT.

           High plasma viral load and low CD4 lymphocyte count is associated with increased MTCT therefore advice should be sought from HIV physician to start antiretroviral therapy. If she needs ART for her own health she should be commenced on highly active antiretroviral therapy (HAART) which includes zidovudine (ZDV). Criteria for commencing HAART are the same as for non pregnant individuals that is <200/mm3, or plasma RNA levels more than 55,000copies/ml. if she does not need treatment for herself the HAART should be started between 20 to 28 weeks and continue till delivery. If the viral load is less than 10,000, and she is prepared to be delivered by elective caesarean section zidovudine monotherapy is an alternative.  

            A decision about mode of delivery should be made by 36 weeks. An elective C/S is recommended at 38 weeks if she is on HAART and plasma viral load is greater than 50 copies, if she is on zidovudine  monotherapy or if she has HIV with hepatitis C coinfection. Delivery by c/s on maternal request or due to obstetric indication should be delayed till 39 weeks in women who have plasma viral load more than 50 copies /ml to reduce the risk of transient tachypnoea.

           Avoidance of breast feeding reduces the risk of MTCT  from 25 to 30% to less than 1%.

B)    I’ll inquire the details of other symptoms that is abdominal pain bleeding, the duration of rupture of membranes, colour of liquor, any offensive smell or fever.

               I’ll ask about urinary and bowel symptoms also, that is frequency and burning of micturation suprapubic or loin pain and diarrhea or colicky abdominal pain.

               I’ll ask details of obstetric history including her LMP regularity of cycles, number of children and their mode of deliveries and any history of preterm labour.

                Medical history should also be elicited like diabetes, hypertension UTI or autoimmune disease.                       

                Social history is also very important in her case as smoking and illicit drug abuse can lead to preterm labour. Stress and social deprivation and malnutrition are other factors which can contribute.

              I’ll assess her weight and height, note pallor, fever, tachycardia and hypotension . Abdominal examination should be performed for fundal height, lie, presentation, amount of liquor and tenderness.

              Speculum examination is required to note the colour of liquor, and tale low and high vaginal swabs, for BV and GBS, endocervical swab should be taken for Chlamydia.

            Investigations required are FBC, to check Hb level to detect anemia, WBCs and platelet counts. CRP for risk of infection.  CD4 count and viral load for the severity of HIV. MSU for microscopy and culture sensitivity. USG is advised for gestational age, fetal well being, and amount of liqour.

          Management is multidisciplinary including senior obstetrician, HIV physician, specialist nurse, paediatrician, health advisor and psychologist if indicated.

          She should be admitted and should be counseled about the increased risk of preterm delivery with HAART.

          Oral erythromycin should be started. If there is risk of chorioamnionitis broad spectrum intravenous should be started.

         Steroids should be given for fetal lung maturity.

          If there is indication of fetal compromise or chorioamnionitis advice from HIV physician should be sought to expedite delivery.

          If expectant management is planned regular monitoring of pulse, BP, temperature and uterine tenderness is performed at least 3 to 4 times per day.

         Serial growth scans for fetal growth and well being should be performed every 2 to 3 weeks. FBC and CRP are required twice a week to assess risk of infection and HVS is required weekly for the assessment of genital tract infection.

        If gestation is progressed to 34 weeks, delivery should be planned with advice from HIV physician. If the viral load is less than 50 copies/ml, she can have augmentation for vaginal delivery and if viral load is more than 50 copies /ml, she should have delivery by C/s

           A) Management should be multidisciplinary including, obstetrician, HIV physician, specialist midwife, paediatrician, support groups, psychiatrist, drug dependency specialist if necessary and health advisor.

             I’ll counsel her about the risk of vertical transmission and need of interventions. I’ll document the plan of care.

            I’ll advice her screening for other sexually transmitted infections and genital tract infections, co infection with hepatitis C increase the risk of vertical transmission, and genital tract infection increase the viral load in genital tract as compared to plasma and increase the risk of ascending infection. Screening for genital tract infections is again offered at 28 weeks.

           She should be advised against cigarette smoking and illicit drug use as it increases MTCT. Use of illicit drugs is also associated with increased risk of preterm delivery.

           If invasive procedures are required she should be referred to fetal specialist unit where advice o HIV physician should be sought. Nutritional deficiency should also be taken care of as there is evidence that deficiency of vitamin A increases the risk of MTCT.

           High plasma viral load and low CD4 lymphocyte count is associated with increased MTCT therefore advice should be sought from HIV physician to start antiretroviral therapy. If she needs ART for her own health she should be commenced on highly active antiretroviral therapy (HAART) which includes zidovudine (ZDV). Criteria for commencing HAART are the same as for non pregnant individuals that is <200/mm3, or plasma RNA levels more than 55,000copies/ml. if she does not need treatment for herself the HAART should be started between 20 to 28 weeks and continue till delivery. If the viral load is less than 10,000, and she is prepared to be delivered by elective caesarean section zidovudine monotherapy is an alternative.  

            A decision about mode of delivery should be made by 36 weeks. An elective C/S is recommended at 38 weeks if she is on HAART and plasma viral load is greater than 50 copies, if she is on zidovudine  monotherapy or if she has HIV with hepatitis C coinfection. Delivery by c/s on maternal request or due to obstetric indication should be delayed till 39 weeks in women who have plasma viral load more than 50 copies /ml to reduce the risk of transient tachypnoea.

           Avoidance of breast feeding reduces the risk of MTCT  from 25 to 30% to less than 1%.

B)    I’ll inquire the details of other symptoms that is abdominal pain bleeding, the duration of rupture of membranes, colour of liquor, any offensive smell or fever.

               I’ll ask about urinary and bowel symptoms also, that is frequency and burning of micturation suprapubic or loin pain and diarrhea or colicky abdominal pain.

               I’ll ask details of obstetric history including her LMP regularity of cycles, number of children and their mode of deliveries and any history of preterm labour.

                Medical history should also be elicited like diabetes, hypertension UTI or autoimmune disease.                       

                Social history is also very important in her case as smoking and illicit drug abuse can lead to preterm labour. Stress and social deprivation and malnutrition are other factors which can contribute.

              I’ll assess her weight and height, note pallor, fever, tachycardia and hypotension . Abdominal examination should be performed for fundal height, lie, presentation, amount of liquor and tenderness.

              Speculum examination is required to note the colour of liquor, and tale low and high vaginal swabs, for BV and GBS, endocervical swab should be taken for Chlamydia.

            Investigations required are FBC, to check Hb level to detect anemia, WBCs and platelet counts. CRP for risk of infection.  CD4 count and viral load for the severity of HIV. MSU for microscopy and culture sensitivity. USG is advised for gestational age, fetal well being, and amount of liqour.

          Management is multidisciplinary including senior obstetrician, HIV physician, specialist nurse, paediatrician, health advisor and psychologist if indicated.

          She should be admitted and should be counseled about the increased risk of preterm delivery with HAART.

          Oral erythromycin should be started. If there is risk of chorioamnionitis broad spectrum intravenous should be started.

         Steroids should be given for fetal lung maturity.

          If there is indication of fetal compromise or chorioamnionitis advice from HIV physician should be sought to expedite delivery.

          If expectant management is planned regular monitoring of pulse, BP, temperature and uterine tenderness is performed at least 3 to 4 times per day.

         Serial growth scans for fetal growth and well being should be performed every 2 to 3 weeks. FBC and CRP are required twice a week to assess risk of infection and HVS is required weekly for the assessment of genital tract infection.

        If gestation is progressed to 34 weeks, delivery should be planned with advice from HIV physician. If the viral load is less than 50 copies/ml, she can have augmentation for vaginal delivery and if viral load is more than 50 copies /ml, she should have delivery by C/s

           A) Management should be multidisciplinary including, obstetrician, HIV physician, specialist midwife, paediatrician, support groups, psychiatrist, drug dependency specialist if necessary and health advisor.

             I’ll counsel her about the risk of vertical transmission and need of interventions. I’ll document the plan of care.

            I’ll advice her screening for other sexually transmitted infections and genital tract infections, co infection with hepatitis C increase the risk of vertical transmission, and genital tract infection increase the viral load in genital tract as compared to plasma and increase the risk of ascending infection. Screening for genital tract infections is again offered at 28 weeks.

           She should be advised against cigarette smoking and illicit drug use as it increases MTCT. Use of illicit drugs is also associated with increased risk of preterm delivery.

           If invasive procedures are required she should be referred to fetal specialist unit where advice o HIV physician should be sought. Nutritional deficiency should also be taken care of as there is evidence that deficiency of vitamin A increases the risk of MTCT.

           High plasma viral load and low CD4 lymphocyte count is associated with increased MTCT therefore advice should be sought from HIV physician to start antiretroviral therapy. If she needs ART for her own health she should be commenced on highly active antiretroviral therapy (HAART) which includes zidovudine (ZDV). Criteria for commencing HAART are the same as for non pregnant individuals that is <200/mm3, or plasma RNA levels more than 55,000copies/ml. if she does not need treatment for herself the HAART should be started between 20 to 28 weeks and continue till delivery. If the viral load is less than 10,000, and she is prepared to be delivered by elective caesarean section zidovudine monotherapy is an alternative.  

            A decision about mode of delivery should be made by 36 weeks. An elective C/S is recommended at 38 weeks if she is on HAART and plasma viral load is greater than 50 copies, if she is on zidovudine  monotherapy or if she has HIV with hepatitis C coinfection. Delivery by c/s on maternal request or due to obstetric indication should be delayed till 39 weeks in women who have plasma viral load more than 50 copies /ml to reduce the risk of transient tachypnoea.

           Avoidance of breast feeding reduces the risk of MTCT  from 25 to 30% to less than 1%.

B)    I’ll inquire the details of other symptoms that is abdominal pain bleeding, the duration of rupture of membranes, colour of liquor, any offensive smell or fever.

               I’ll ask about urinary and bowel symptoms also, that is frequency and burning of micturation suprapubic or loin pain and diarrhea or colicky abdominal pain.

               I’ll ask details of obstetric history including her LMP regularity of cycles, number of children and their mode of deliveries and any history of preterm labour.

                Medical history should also be elicited like diabetes, hypertension UTI or autoimmune disease.                       

                Social history is also very important in her case as smoking and illicit drug abuse can lead to preterm labour. Stress and social deprivation and malnutrition are other factors which can contribute.

              I’ll assess her weight and height, note pallor, fever, tachycardia and hypotension . Abdominal examination should be performed for fundal height, lie, presentation, amount of liquor and tenderness.

              Speculum examination is required to note the colour of liquor, and tale low and high vaginal swabs, for BV and GBS, endocervical swab should be taken for Chlamydia.

            Investigations required are FBC, to check Hb level to detect anemia, WBCs and platelet counts. CRP for risk of infection.  CD4 count and viral load for the severity of HIV. MSU for microscopy and culture sensitivity. USG is advised for gestational age, fetal well being, and amount of liqour.

          Management is multidisciplinary including senior obstetrician, HIV physician, specialist nurse, paediatrician, health advisor and psychologist if indicated.

          She should be admitted and should be counseled about the increased risk of preterm delivery with HAART.

          Oral erythromycin should be started. If there is risk of chorioamnionitis broad spectrum intravenous should be started.

         Steroids should be given for fetal lung maturity.

          If there is indication of fetal compromise or chorioamnionitis advice from HIV physician should be sought to expedite delivery.

          If expectant management is planned regular monitoring of pulse, BP, temperature and uterine tenderness is performed at least 3 to 4 times per day.

         Serial growth scans for fetal growth and well being should be performed every 2 to 3 weeks. FBC and CRP are required twice a week to assess risk of infection and HVS is required weekly for the assessment of genital tract infection.

        If gestation is progressed to 34 weeks, delivery should be planned with advice from HIV physician. If the viral load is less than 50 copies/ml, she can have augmentation for vaginal delivery and if viral load is more than 50 copies /ml, she should have delivery by C/s

           A) Management should be multidisciplinary including, obstetrician, HIV physician, specialist midwife, paediatrician, support groups, psychiatrist, drug dependency specialist if necessary and health advisor.

             I’ll counsel her about the risk of vertical transmission and need of interventions. I’ll document the plan of care.

            I’ll advice her screening for other sexually transmitted infections and genital tract infections, co infection with hepatitis C increase the risk of vertical transmission, and genital tract infection increase the viral load in genital tract as compared to plasma and increase the risk of ascending infection. Screening for genital tract infections is again offered at 28 weeks.

           She should be advised against cigarette smoking and illicit drug use as it increases MTCT. Use of illicit drugs is also associated with increased risk of preterm delivery.

           If invasive procedures are required she should be referred to fetal specialist unit where advice o HIV physician should be sought. Nutritional deficiency should also be taken care of as there is evidence that deficiency of vitamin A increases the risk of MTCT.

           High plasma viral load and low CD4 lymphocyte count is associated with increased MTCT therefore advice should be sought from HIV physician to start antiretroviral therapy. If she needs ART for her own health she should be commenced on highly active antiretroviral therapy (HAART) which includes zidovudine (ZDV). Criteria for commencing HAART are the same as for non pregnant individuals that is <200/mm3, or plasma RNA levels more than 55,000copies/ml. if she does not need treatment for herself the HAART should be started between 20 to 28 weeks and continue till delivery. If the viral load is less than 10,000, and she is prepared to be delivered by elective caesarean section zidovudine monotherapy is an alternative.  

            A decision about mode of delivery should be made by 36 weeks. An elective C/S is recommended at 38 weeks if she is on HAART and plasma viral load is greater than 50 copies, if she is on zidovudine  monotherapy or if she has HIV with hepatitis C coinfection. Delivery by c/s on maternal request or due to obstetric indication should be delayed till 39 weeks in women who have plasma viral load more than 50 copies /ml to reduce the risk of transient tachypnoea.

           Avoidance of breast feeding reduces the risk of MTCT  from 25 to 30% to less than 1%.

B)    I’ll inquire the details of other symptoms that is abdominal pain bleeding, the duration of rupture of membranes, colour of liquor, any offensive smell or fever.

               I’ll ask about urinary and bowel symptoms also, that is frequency and burning of micturation suprapubic or loin pain and diarrhea or colicky abdominal pain.

               I’ll ask details of obstetric history including her LMP regularity of cycles, number of children and their mode of deliveries and any history of preterm labour.

                Medical history should also be elicited like diabetes, hypertension UTI or autoimmune disease.                       

                Social history is also very important in her case as smoking and illicit drug abuse can lead to preterm labour. Stress and social deprivation and malnutrition are other factors which can contribute.

              I’ll assess her weight and height, note pallor, fever, tachycardia and hypotension . Abdominal examination should be performed for fundal height, lie, presentation, amount of liquor and tenderness.

              Speculum examination is required to note the colour of liquor, and tale low and high vaginal swabs, for BV and GBS, endocervical swab should be taken for Chlamydia.

            Investigations required are FBC, to check Hb level to detect anemia, WBCs and platelet counts. CRP for risk of infection.  CD4 count and viral load for the severity of HIV. MSU for microscopy and culture sensitivity. USG is advised for gestational age, fetal well being, and amount of liqour.

          Management is multidisciplinary including senior obstetrician, HIV physician, specialist nurse, paediatrician, health advisor and psychologist if indicated.

          She should be admitted and should be counseled about the increased risk of preterm delivery with HAART.

          Oral erythromycin should be started. If there is risk of chorioamnionitis broad spectrum intravenous should be started.

         Steroids should be given for fetal lung maturity.

          If there is indication of fetal compromise or chorioamnionitis advice from HIV physician should be sought to expedite delivery.

          If expectant management is planned regular monitoring of pulse, BP, temperature and uterine tenderness is performed at least 3 to 4 times per day.

         Serial growth scans for fetal growth and well being should be performed every 2 to 3 weeks. FBC and CRP are required twice a week to assess risk of infection and HVS is required weekly for the assessment of genital tract infection.

        If gestation is progressed to 34 weeks, delivery should be planned with advice from HIV physician. If the viral load is less than 50 copies/ml, she can have augmentation for vaginal delivery and if viral load is more than 50 copies /ml, she should have delivery by C/s

           A) Management should be multidisciplinary including, obstetrician, HIV physician, specialist midwife, paediatrician, support groups, psychiatrist, drug dependency specialist if necessary and health advisor.

             I’ll counsel her about the risk of vertical transmission and need of interventions. I’ll document the plan of care.

            I’ll advice her screening for other sexually transmitted infections and genital tract infections, co infection with hepatitis C increase the risk of vertical transmission, and genital tract infection increase the viral load in genital tract as compared to plasma and increase the risk of ascending infection. Screening for genital tract infections is again offered at 28 weeks.

           She should be advised against cigarette smoking and illicit drug use as it increases MTCT. Use of illicit drugs is also associated with increased risk of preterm delivery.

           If invasive procedures are required she should be referred to fetal specialist unit where advice o HIV physician should be sought. Nutritional deficiency should also be taken care of as there is evidence that deficiency of vitamin A increases the risk of MTCT.

           High plasma viral load and low CD4 lymphocyte count is associated with increased MTCT therefore advice should be sought from HIV physician to start antiretroviral therapy. If she needs ART for her own health she should be commenced on highly active antiretroviral therapy (HAART) which includes zidovudine (ZDV). Criteria for commencing HAART are the same as for non pregnant individuals that is <200/mm3, or plasma RNA levels more than 55,000copies/ml. if she does not need treatment for herself the HAART should be started between 20 to 28 weeks and continue till delivery. If the viral load is less than 10,000, and she is prepared to be delivered by elective caesarean section zidovudine monotherapy is an alternative.  

            A decision about mode of delivery should be made by 36 weeks. An elective C/S is recommended at 38 weeks if she is on HAART and plasma viral load is greater than 50 copies, if she is on zidovudine  monotherapy or if she has HIV with hepatitis C coinfection. Delivery by c/s on maternal request or due to obstetric indication should be delayed till 39 weeks in women who have plasma viral load more than 50 copies /ml to reduce the risk of transient tachypnoea.

           Avoidance of breast feeding reduces the risk of MTCT  from 25 to 30% to less than 1%.

B)    I’ll inquire the details of other symptoms that is abdominal pain bleeding, the duration of rupture of membranes, colour of liquor, any offensive smell or fever.

               I’ll ask about urinary and bowel symptoms also, that is frequency and burning of micturation suprapubic or loin pain and diarrhea or colicky abdominal pain.

               I’ll ask details of obstetric history including her LMP regularity of cycles, number of children and their mode of deliveries and any history of preterm labour.

                Medical history should also be elicited like diabetes, hypertension UTI or autoimmune disease.                       

                Social history is also very important in her case as smoking and illicit drug abuse can lead to preterm labour. Stress and social deprivation and malnutrition are other factors which can contribute.

              I’ll assess her weight and height, note pallor, fever, tachycardia and hypotension . Abdominal examination should be performed for fundal height, lie, presentation, amount of liquor and tenderness.

              Speculum examination is required to note the colour of liquor, and tale low and high vaginal swabs, for BV and GBS, endocervical swab should be taken for Chlamydia.

            Investigations required are FBC, to check Hb level to detect anemia, WBCs and platelet counts. CRP for risk of infection.  CD4 count and viral load for the severity of HIV. MSU for microscopy and culture sensitivity. USG is advised for gestational age, fetal well being, and amount of liqour.

          Management is multidisciplinary including senior obstetrician, HIV physician, specialist nurse, paediatrician, health advisor and psychologist if indicated.

          She should be admitted and should be counseled about the increased risk of preterm delivery with HAART.

          Oral erythromycin should be started. If there is risk of chorioamnionitis broad spectrum intravenous should be started.

         Steroids should be given for fetal lung maturity.

          If there is indication of fetal compromise or chorioamnionitis advice from HIV physician should be sought to expedite delivery.

          If expectant management is planned regular monitoring of pulse, BP, temperature and uterine tenderness is performed at least 3 to 4 times per day.

         Serial growth scans for fetal growth and well being should be performed every 2 to 3 weeks. FBC and CRP are required twice a week to assess risk of infection and HVS is required weekly for the assessment of genital tract infection.

        If gestation is progressed to 34 weeks, delivery should be planned with advice from HIV physician. If the viral load is less than 50 copies/ml, she can have augmentation for vaginal delivery and if viral load is more than 50 copies /ml, she should have delivery by C/s

           A) Management should be multidisciplinary including, obstetrician, HIV physician, specialist midwife, paediatrician, support groups, psychiatrist, drug dependency specialist if necessary and health advisor.

             I’ll counsel her about the risk of vertical transmission and need of interventions. I’ll document the plan of care.

            I’ll advice her screening for other sexually transmitted infections and genital tract infections, co infection with hepatitis C increase the risk of vertical transmission, and genital tract infection increase the viral load in genital tract as compared to plasma and increase the risk of ascending infection. Screening for genital tract infections is again offered at 28 weeks.

           She should be advised against cigarette smoking and illicit drug use as it increases MTCT. Use of illicit drugs is also associated with increased risk of preterm delivery.

           If invasive procedures are required she should be referred to fetal specialist unit where advice o HIV physician should be sought. Nutritional deficiency should also be taken care of as there is evidence that deficiency of vitamin A increases the risk of MTCT.

           High plasma viral load and low CD4 lymphocyte count is associated with increased MTCT therefore advice should be sought from HIV physician to start antiretroviral therapy. If she needs ART for her own health she should be commenced on highly active antiretroviral therapy (HAART) which includes zidovudine (ZDV). Criteria for commencing HAART are the same as for non pregnant individuals that is <200/mm3, or plasma RNA levels more than 55,000copies/ml. if she does not need treatment for herself the HAART should be started between 20 to 28 weeks and continue till delivery. If the viral load is less than 10,000, and she is prepared to be delivered by elective caesarean section zidovudine monotherapy is an alternative.  

            A decision about mode of delivery should be made by 36 weeks. An elective C/S is recommended at 38 weeks if she is on HAART and plasma viral load is greater than 50 copies, if she is on zidovudine  monotherapy or if she has HIV with hepatitis C coinfection. Delivery by c/s on maternal request or due to obstetric indication should be delayed till 39 weeks in women who have plasma viral load more than 50 copies /ml to reduce the risk of transient tachypnoea.

           Avoidance of breast feeding reduces the risk of MTCT  from 25 to 30% to less than 1%.

B)    I’ll inquire the details of other symptoms that is abdominal pain bleeding, the duration of rupture of membranes, colour of liquor, any offensive smell or fever.

               I’ll ask about urinary and bowel symptoms also, that is frequency and burning of micturation suprapubic or loin pain and diarrhea or colicky abdominal pain.

               I’ll ask details of obstetric history including her LMP regularity of cycles, number of children and their mode of deliveries and any history of preterm labour.

                Medical history should also be elicited like diabetes, hypertension UTI or autoimmune disease.                       

                Social history is also very important in her case as smoking and illicit drug abuse can lead to preterm labour. Stress and social deprivation and malnutrition are other factors which can contribute.

              I’ll assess her weight and height, note pallor, fever, tachycardia and hypotension . Abdominal examination should be performed for fundal height, lie, presentation, amount of liquor and tenderness.

              Speculum examination is required to note the colour of liquor, and tale low and high vaginal swabs, for BV and GBS, endocervical swab should be taken for Chlamydia.

            Investigations required are FBC, to check Hb level to detect anemia, WBCs and platelet counts. CRP for risk of infection.  CD4 count and viral load for the severity of HIV. MSU for microscopy and culture sensitivity. USG is advised for gestational age, fetal well being, and amount of liqour.

          Management is multidisciplinary including senior obstetrician, HIV physician, specialist nurse, paediatrician, health advisor and psychologist if indicated.

          She should be admitted and should be counseled about the increased risk of preterm delivery with HAART.

          Oral erythromycin should be started. If there is risk of chorioamnionitis broad spectrum intravenous should be started.

         Steroids should be given for fetal lung maturity.

          If there is indication of fetal compromise or chorioamnionitis advice from HIV physician should be sought to expedite delivery.

          If expectant management is planned regular monitoring of pulse, BP, temperature and uterine tenderness is performed at least 3 to 4 times per day.

         Serial growth scans for fetal growth and well being should be performed every 2 to 3 weeks. FBC and CRP are required twice a week to assess risk of infection and HVS is required weekly for the assessment of genital tract infection.

        If gestation is progressed to 34 weeks, delivery should be planned with advice from HIV physician. If the viral load is less than 50 copies/ml, she can have augmentation for vaginal delivery and if viral load is more than 50 copies /ml, she should have delivery by C/s

           A) Management should be multidisciplinary including, obstetrician, HIV physician, specialist midwife, paediatrician, support groups, psychiatrist, drug dependency specialist if necessary and health advisor.

             I’ll counsel her about the risk of vertical transmission and need of interventions. I’ll document the plan of care.

            I’ll advice her screening for other sexually transmitted infections and genital tract infections, co infection with hepatitis C increase the risk of vertical transmission, and genital tract infection increase the viral load in genital tract as compared to plasma and increase the risk of ascending infection. Screening for genital tract infections is again offered at 28 weeks.

           She should be advised against cigarette smoking and illicit drug use as it increases MTCT. Use of illicit drugs is also associated with increased risk of preterm delivery.

           If invasive procedures are required she should be referred to fetal specialist unit where advice o HIV physician should be sought. Nutritional deficiency should also be taken care of as there is evidence that deficiency of vitamin A increases the risk of MTCT.

           High plasma viral load and low CD4 lymphocyte count is associated with increased MTCT therefore advice should be sought from HIV physician to start antiretroviral therapy. If she needs ART for her own health she should be commenced on highly active antiretroviral therapy (HAART) which includes zidovudine (ZDV). Criteria for commencing HAART are the same as for non pregnant individuals that is <200/mm3, or plasma RNA levels more than 55,000copies/ml. if she does not need treatment for herself the HAART should be started between 20 to 28 weeks and continue till delivery. If the viral load is less than 10,000, and she is prepared to be delivered by elective caesarean section zidovudine monotherapy is an alternative.  

            A decision about mode of delivery should be made by 36 weeks. An elective C/S is recommended at 38 weeks if she is on HAART and plasma viral load is greater than 50 copies, if she is on zidovudine  monotherapy or if she has HIV with hepatitis C coinfection. Delivery by c/s on maternal request or due to obstetric indication should be delayed till 39 weeks in women who have plasma viral load more than 50 copies /ml to reduce the risk of transient tachypnoea.

           Avoidance of breast feeding reduces the risk of MTCT  from 25 to 30% to less than 1%.

B)    I’ll inquire the details of other symptoms that is abdominal pain bleeding, the duration of rupture of membranes, colour of liquor, any offensive smell or fever.

               I’ll ask about urinary and bowel symptoms also, that is frequency and burning of micturation suprapubic or loin pain and diarrhea or colicky abdominal pain.

               I’ll ask details of obstetric history including her LMP regularity of cycles, number of children and their mode of deliveries and any history of preterm labour.

                Medical history should also be elicited like diabetes, hypertension UTI or autoimmune disease.                       

                Social history is also very important in her case as smoking and illicit drug abuse can lead to preterm labour. Stress and social deprivation and malnutrition are other factors which can contribute.

              I’ll assess her weight and height, note pallor, fever, tachycardia and hypotension . Abdominal examination should be performed for fundal height, lie, presentation, amount of liquor and tenderness.

              Speculum examination is required to note the colour of liquor, and tale low and high vaginal swabs, for BV and GBS, endocervical swab should be taken for Chlamydia.

            Investigations required are FBC, to check Hb level to detect anemia, WBCs and platelet counts. CRP for risk of infection.  CD4 count and viral load for the severity of HIV. MSU for microscopy and culture sensitivity. USG is advised for gestational age, fetal well being, and amount of liqour.

          Management is multidisciplinary including senior obstetrician, HIV physician, specialist nurse, paediatrician, health advisor and psychologist if indicated.

          She should be admitted and should be counseled about the increased risk of preterm delivery with HAART.

          Oral erythromycin should be started. If there is risk of chorioamnionitis broad spectrum intravenous should be started.

         Steroids should be given for fetal lung maturity.

          If there is indication of fetal compromise or chorioamnionitis advice from HIV physician should be sought to expedite delivery.

          If expectant management is planned regular monitoring of pulse, BP, temperature and uterine tenderness is performed at least 3 to 4 times per day.

         Serial growth scans for fetal growth and well being should be performed every 2 to 3 weeks. FBC and CRP are required twice a week to assess risk of infection and HVS is required weekly for the assessment of genital tract infection.

        If gestation is progressed to 34 weeks, delivery should be planned with advice from HIV physician. If the viral load is less than 50 copies/ml, she can have augmentation for vaginal delivery and if viral load is more than 50 copies /ml, she should have delivery by C/s

           A) Management should be multidisciplinary including, obstetrician, HIV physician, specialist midwife, paediatrician, support groups, psychiatrist, drug dependency specialist if necessary and health advisor.

             I’ll counsel her about the risk of vertical transmission and need of interventions. I’ll document the plan of care.

            I’ll advice her screening for other sexually transmitted infections and genital tract infections, co infection with hepatitis C increase the risk of vertical transmission, and genital tract infection increase the viral load in genital tract as compared to plasma and increase the risk of ascending infection. Screening for genital tract infections is again offered at 28 weeks.

           She should be advised against cigarette smoking and illicit drug use as it increases MTCT. Use of illicit drugs is also associated with increased risk of preterm delivery.

           If invasive procedures are required she should be referred to fetal specialist unit where advice o HIV physician should be sought. Nutritional deficiency should also be taken care of as there is evidence that deficiency of vitamin A increases the risk of MTCT.

           High plasma viral load and low CD4 lymphocyte count is associated with increased MTCT therefore advice should be sought from HIV physician to start antiretroviral therapy. If she needs ART for her own health she should be commenced on highly active antiretroviral therapy (HAART) which includes zidovudine (ZDV). Criteria for commencing HAART are the same as for non pregnant individuals that is <200/mm3, or plasma RNA levels more than 55,000copies/ml. if she does not need treatment for herself the HAART should be started between 20 to 28 weeks and continue till delivery. If the viral load is less than 10,000, and she is prepared to be delivered by elective caesarean section zidovudine monotherapy is an alternative.  

            A decision about mode of delivery should be made by 36 weeks. An elective C/S is recommended at 38 weeks if she is on HAART and plasma viral load is greater than 50 copies, if she is on zidovudine  monotherapy or if she has HIV with hepatitis C coinfection. Delivery by c/s on maternal request or due to obstetric indication should be delayed till 39 weeks in women who have plasma viral load more than 50 copies /ml to reduce the risk of transient tachypnoea.

           Avoidance of breast feeding reduces the risk of MTCT  from 25 to 30% to less than 1%.

B)    I’ll inquire the details of other symptoms that is abdominal pain bleeding, the duration of rupture of membranes, colour of liquor, any offensive smell or fever.

               I’ll ask about urinary and bowel symptoms also, that is frequency and burning of micturation suprapubic or loin pain and diarrhea or colicky abdominal pain.

               I’ll ask details of obstetric history including her LMP regularity of cycles, number of children and their mode of deliveries and any history of preterm labour.

                Medical history should also be elicited like diabetes, hypertension UTI or autoimmune disease.                       

                Social history is also very important in her case as smoking and illicit drug abuse can lead to preterm labour. Stress and social deprivation and malnutrition are other factors which can contribute.

              I’ll assess her weight and height, note pallor, fever, tachycardia and hypotension . Abdominal examination should be performed for fundal height, lie, presentation, amount of liquor and tenderness.

              Speculum examination is required to note the colour of liquor, and tale low and high vaginal swabs, for BV and GBS, endocervical swab should be taken for Chlamydia.

            Investigations required are FBC, to check Hb level to detect anemia, WBCs and platelet counts. CRP for risk of infection.  CD4 count and viral load for the severity of HIV. MSU for microscopy and culture sensitivity. USG is advised for gestational age, fetal well being, and amount of liqour.

          Management is multidisciplinary including senior obstetrician, HIV physician, specialist nurse, paediatrician, health advisor and psychologist if indicated.

          She should be admitted and should be counseled about the increased risk of preterm delivery with HAART.

          Oral erythromycin should be started. If there is risk of chorioamnionitis broad spectrum intravenous should be started.

         Steroids should be given for fetal lung maturity.

          If there is indication of fetal compromise or chorioamnionitis advice from HIV physician should be sought to expedite delivery.

          If expectant management is planned regular monitoring of pulse, BP, temperature and uterine tenderness is performed at least 3 to 4 times per day.

         Serial growth scans for fetal growth and well being should be performed every 2 to 3 weeks. FBC and CRP are required twice a week to assess risk of infection and HVS is required weekly for the assessment of genital tract infection.

        If gestation is progressed to 34 weeks, delivery should be planned with advice from HIV physician. If the viral load is less than 50 copies/ml, she can have augmentation for vaginal delivery and if viral load is more than 50 copies /ml, she should have delivery by C/s

           A) Management should be multidisciplinary including, obstetrician, HIV physician, specialist midwife, paediatrician, support groups, psychiatrist, drug dependency specialist if necessary and health advisor.

             I’ll counsel her about the risk of vertical transmission and need of interventions. I’ll document the plan of care.

            I’ll advice her screening for other sexually transmitted infections and genital tract infections, co infection with hepatitis C increase the risk of vertical transmission, and genital tract infection increase the viral load in genital tract as compared to plasma and increase the risk of ascending infection. Screening for genital tract infections is again offered at 28 weeks.

           She should be advised against cigarette smoking and illicit drug use as it increases MTCT. Use of illicit drugs is also associated with increased risk of preterm delivery.

           If invasive procedures are required she should be referred to fetal specialist unit where advice o HIV physician should be sought. Nutritional deficiency should also be taken care of as there is evidence that deficiency of vitamin A increases the risk of MTCT.

           High plasma viral load and low CD4 lymphocyte count is associated with increased MTCT therefore advice should be sought from HIV physician to start antiretroviral therapy. If she needs ART for her own health she should be commenced on highly active antiretroviral therapy (HAART) which includes zidovudine (ZDV). Criteria for commencing HAART are the same as for non pregnant individuals that is <200/mm3, or plasma RNA levels more than 55,000copies/ml. if she does not need treatment for herself the HAART should be started between 20 to 28 weeks and continue till delivery. If the viral load is less than 10,000, and she is prepared to be delivered by elective caesarean section zidovudine monotherapy is an alternative.  

            A decision about mode of delivery should be made by 36 weeks. An elective C/S is recommended at 38 weeks if she is on HAART and plasma viral load is greater than 50 copies, if she is on zidovudine  monotherapy or if she has HIV with hepatitis C coinfection. Delivery by c/s on maternal request or due to obstetric indication should be delayed till 39 weeks in women who have plasma viral load more than 50 copies /ml to reduce the risk of transient tachypnoea.

           Avoidance of breast feeding reduces the risk of MTCT  from 25 to 30% to less than 1%.

B)    I’ll inquire the details of other symptoms that is abdominal pain bleeding, the duration of rupture of membranes, colour of liquor, any offensive smell or fever.

               I’ll ask about urinary and bowel symptoms also, that is frequency and burning of micturation suprapubic or loin pain and diarrhea or colicky abdominal pain.

               I’ll ask details of obstetric history including her LMP regularity of cycles, number of children and their mode of deliveries and any history of preterm labour.

                Medical history should also be elicited like diabetes, hypertension UTI or autoimmune disease.                       

                Social history is also very important in her case as smoking and illicit drug abuse can lead to preterm labour. Stress and social deprivation and malnutrition are other factors which can contribute.

              I’ll assess her weight and height, note pallor, fever, tachycardia and hypotension . Abdominal examination should be performed for fundal height, lie, presentation, amount of liquor and tenderness.

              Speculum examination is required to note the colour of liquor, and tale low and high vaginal swabs, for BV and GBS, endocervical swab should be taken for Chlamydia.

            Investigations required are FBC, to check Hb level to detect anemia, WBCs and platelet counts. CRP for risk of infection.  CD4 count and viral load for the severity of HIV. MSU for microscopy and culture sensitivity. USG is advised for gestational age, fetal well being, and amount of liqour.

          Management is multidisciplinary including senior obstetrician, HIV physician, specialist nurse, paediatrician, health advisor and psychologist if indicated.

          She should be admitted and should be counseled about the increased risk of preterm delivery with HAART.

          Oral erythromycin should be started. If there is risk of chorioamnionitis broad spectrum intravenous should be started.

         Steroids should be given for fetal lung maturity.

          If there is indication of fetal compromise or chorioamnionitis advice from HIV physician should be sought to expedite delivery.

          If expectant management is planned regular monitoring of pulse, BP, temperature and uterine tenderness is performed at least 3 to 4 times per day.

         Serial growth scans for fetal growth and well being should be performed every 2 to 3 weeks. FBC and CRP are required twice a week to assess risk of infection and HVS is required weekly for the assessment of genital tract infection.

        If gestation is progressed to 34 weeks, delivery should be planned with advice from HIV physician. If the viral load is less than 50 copies/ml, she can have augmentation for vaginal delivery and if viral load is more than 50 copies /ml, she should have delivery by C/s

           A) Management should be multidisciplinary including, obstetrician, HIV physician, specialist midwife, paediatrician, support groups, psychiatrist, drug dependency specialist if necessary and health advisor.

             I’ll counsel her about the risk of vertical transmission and need of interventions. I’ll document the plan of care.

            I’ll advice her screening for other sexually transmitted infections and genital tract infections, co infection with hepatitis C increase the risk of vertical transmission, and genital tract infection increase the viral load in genital tract as compared to plasma and increase the risk of ascending infection. Screening for genital tract infections is again offered at 28 weeks.

           She should be advised against cigarette smoking and illicit drug use as it increases MTCT. Use of illicit drugs is also associated with increased risk of preterm delivery.

           If invasive procedures are required she should be referred to fetal specialist unit where advice o HIV physician should be sought. Nutritional deficiency should also be taken care of as there is evidence that deficiency of vitamin A increases the risk of MTCT.

           High plasma viral load and low CD4 lymphocyte count is associated with increased MTCT therefore advice should be sought from HIV physician to start antiretroviral therapy. If she needs ART for her own health she should be commenced on highly active antiretroviral therapy (HAART) which includes zidovudine (ZDV). Criteria for commencing HAART are the same as for non pregnant individuals that is <200/mm3, or plasma RNA levels more than 55,000copies/ml. if she does not need treatment for herself the HAART should be started between 20 to 28 weeks and continue till delivery. If the viral load is less than 10,000, and she is prepared to be delivered by elective caesarean section zidovudine monotherapy is an alternative.  

            A decision about mode of delivery should be made by 36 weeks. An elective C/S is recommended at 38 weeks if she is on HAART and plasma viral load is greater than 50 copies, if she is on zidovudine  monotherapy or if she has HIV with hepatitis C coinfection. Delivery by c/s on maternal request or due to obstetric indication should be delayed till 39 weeks in women who have plasma viral load more than 50 copies /ml to reduce the risk of transient tachypnoea.

           Avoidance of breast feeding reduces the risk of MTCT  from 25 to 30% to less than 1%.

B)    I’ll inquire the details of other symptoms that is abdominal pain bleeding, the duration of rupture of membranes, colour of liquor, any offensive smell or fever.

               I’ll ask about urinary and bowel symptoms also, that is frequency and burning of micturation suprapubic or loin pain and diarrhea or colicky abdominal pain.

               I’ll ask details of obstetric history including her LMP regularity of cycles, number of children and their mode of deliveries and any history of preterm labour.

                Medical history should also be elicited like diabetes, hypertension UTI or autoimmune disease.                       

                Social history is also very important in her case as smoking and illicit drug abuse can lead to preterm labour. Stress and social deprivation and malnutrition are other factors which can contribute.

              I’ll assess her weight and height, note pallor, fever, tachycardia and hypotension . Abdominal examination should be performed for fundal height, lie, presentation, amount of liquor and tenderness.

              Speculum examination is required to note the colour of liquor, and tale low and high vaginal swabs, for BV and GBS, endocervical swab should be taken for Chlamydia.

            Investigations required are FBC, to check Hb level to detect anemia, WBCs and platelet counts. CRP for risk of infection.  CD4 count and viral load for the severity of HIV. MSU for microscopy and culture sensitivity. USG is advised for gestational age, fetal well being, and amount of liqour.

          Management is multidisciplinary including senior obstetrician, HIV physician, specialist nurse, paediatrician, health advisor and psychologist if indicated.

          She should be admitted and should be counseled about the increased risk of preterm delivery with HAART.

          Oral erythromycin should be started. If there is risk of chorioamnionitis broad spectrum intravenous should be started.

         Steroids should be given for fetal lung maturity.

          If there is indication of fetal compromise or chorioamnionitis advice from HIV physician should be sought to expedite delivery.

          If expectant management is planned regular monitoring of pulse, BP, temperature and uterine tenderness is performed at least 3 to 4 times per day.

         Serial growth scans for fetal growth and well being should be performed every 2 to 3 weeks. FBC and CRP are required twice a week to assess risk of infection and HVS is required weekly for the assessment of genital tract infection.

        If gestation is progressed to 34 weeks, delivery should be planned with advice from HIV physician. If the viral load is less than 50 copies/ml, she can have augmentation for vaginal delivery and if viral load is more than 50 copies /ml, she should have delivery by C/s

           A) Management should be multidisciplinary including, obstetrician, HIV physician, specialist midwife, paediatrician, support groups, psychiatrist, drug dependency specialist if necessary and health advisor.

             I’ll counsel her about the risk of vertical transmission and need of interventions. I’ll

Dear Dr Paul,

          I have pasted my answer twice by mistake. Iam sorry for this.

Mother to child transmission can be reduced from 20-30% to less than 1% with the help of some interventions.She should be advised to avoid invasive testing like amniocentesis and if necessary take advice of HIV physician.She should be advised to start antiretroviral therapy after 20 wks and before 28 wks.She can continue taking Highly active retroviral therapy (HAART) during labour until delivery and if her plama viral load is less than 10,000 copies/ml and she agrees for elective caesarean section than she can take monotherapy of zidouvidine(ZDV) orally and intravenously at delivery.

At 36 wks she should be advised to deliver by elective C-Section at 38 wks to avoid labour and rupture of membrane.C-Section should be strongly advised if she is on HAART and plasma viral load is more than 50 copies/ml.or if she is on ZDV  or if should is found to have hepatitis C also.During C.Section maintain hemostasis and avoid rupture of membrane until delivery of head.

If she is found to have viral load less than 50 copies/ml she can be ofered planned  vaginal delivery provided no fetal scalp electrode or fetal blood sampling.Avoid amniotomy until delivery is imminent.Low cavity forceps instead of ventouse if instrumental delivery is indicated.She should be advisede against breast feeding.

b,

Involve mutidesciplinary team like HIV physician and paediatrician.She should be counselled about increase risk of preterm delivery esp with HAART and neonatology consultation should be made for information and plan of care should be made and documented in case notes and discussed with the women in detail.

Genital infection screen should be performed and any infection found even asymptomatic should be treated.

she should continue her HAART theapy until delivery and if indicated after delivery. if on ZDV start intravenously in labour .and if C.Section 4 hrs before caesarean until cord clamp.steroids should be given for fetal lung maturation.and erythromycin should be started to delay labour and to prevent chorioamniotis.broad spectrum i/v antibiotics can be considered.

Check status of syphilis,hepatitis B,C and rubella together with varicella zoster,measeles and toxoplasmosis.Confirm dates by dating Scan and check result of anomaly Scan.Confirm dates by dating scan and check result of anomaly scan .Check for the signs of chorioamnitis and fetal distress and Fetal heart rate ,vital signs and respiratory rate should be monitoered 4 times a day .Full blod countat least once a Wk and Growth scan every 2 wks.

Any sign of choroiamnoitis or fetal distress deliver by C.Section if delivery is not imminent.Otherwise deliver at 34 wks according to fetal head presentation,bishops score and viral load .If cephalic,bishop is favorable and viral load less than 50 copies/ml can offer vaginal delivery by induction of labour otherwise c.section.Women should be involved in all decisions and social support provided. 

Without intervention there is a high risk of mother to fetal transmission. Interventions can help reduce the risk from approximately 25% to 1%. The diagnosis needs to be discussed with the mother as well as the implications for her, her unborn baby and her partner. She should be seen in a joint clinic with the HIV physicians. She should also be screened for other sexually transmitted infections and Hepatitis C as coinfection increases the risk of transmission. 

Depending on her health she may or may not need anti-retro viral therapy (ART). If she does not need ART for her own health then should should be offered the option of starting HAART from 28-32 weeks to limit the risk of transmission to the baby. She should be seen at 36 weeks to have her viral load (VL) checked and a plan of care clearly documented.

If her VL is <50 and she has been on HAART then she can have a vaginal delivery. She may need additional Zidovudine as per the HIV physician. If this is required it should be commenced from the onset of labour to delivery. Labour should be actively managed. The membranes should be left in tact for as long as possible. Invasive procedures such as fetal blood sampling and a fetal scalp electrode should not be used. If an instrument delivery is necessary forceps should be used as the reult in less fetal trauma.

For women who have been on single agent therapy and those who have a VL>50 should be offered a caesarean section (CS). 4 hours prior to the CS an infusion of zidovudine should be commenced. Delivery should be attempted with the membranes intact.

After delivery the cord should be clamped immediately and the baby washed. The mum should be advised not to breastfeed. The paediatricians should be informed and the baby should receive ART.

With premature prelabour spontaneous rupture of membranes (PPROM) at 28 weeks the risks of transmission have to be weighed against prematurity. The diagnosis should be confirmed with a speculum examination. She should have the standard treamtment for any woman presenting with PPROM. She should be admitted for 48hours as she is at risk of going into sponataneous labour. A set of observations should be perofrmmed and charted on an early warning score, and temperature should be recorded 4 hourly. An abdominal examination should be performed looking for any tenderness to suggest infection. A high vaginal swab and swabs for STIs should be performed. A CTG should be performed to assess fetal well being. Bloods should be sent for a full blood count looking for a leucocytosis and a CRP performed. If she has not recently had a VL checked this will also be necessary.

Steroids should be administered and the SCBU should be informed of her admission as well as the HIV physicians. If she is on ART this should be continued. If she does not go into spontaneous labour she can be managed as an outpatient as per the hospital protocol.

When the decision is made to deliver she could aim for a vaginal delivery if the VL <50 as the protective factor from a CS has been lost with the prolonged rupture of membranes. With PPROM delivery is usually performed after 34 weeks weighing up the risks of prematurity with delivery versus chroinitis with expectant management. Plus the risks of mother to fetus transmission of HIV. The care plan should ne mutli-disciplinary. The above management of reducing the risks should be performed and the baby should receive ART. Cord blood should be sent for VL and the baby should be checked at 1month 3months and a confirmatory test at 18months.

why do we need to Administer broad spectrum antibiotics in pre prom.? in view of hiv or other  infection?