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ESSAY 177 - HIV

Posted by heba Y.
Dear Dr/PAUL :
Would you please correct mmy answer.
Thanks a lot


HIV is a retro virus that can be transmitted through sexual relations ,blood transfusion,and vertical transmission from mother to her fetus.
To decrease the risk of the fetus/neonate and the mother ,good assessment of the case should be done .
Full history should betaken about previous blood transfusion,other sexually transmitted infections,sexual life,drug misuseand any current medications.
Examination should assess general well being,chest examination,UTI and genital infections.
Investigations should include FBC, viral load, cD4 count.
Investigations for STIs asHBV,syphilis,cultures for chlamydia and gonorrhea.

For thee benifit of the fetus,the mother should advised about anti-retroviral therapy as a mean to reduce fetal affection.
Invasive methods should be avoided as these increase the risk of transmission.
Anomaly scan at 20 wks and serial growth scans should be offered.
Planned cs is found to reduce the risk of transmission significantly in patients receiving treatment . The delivery should be conducted in a centre with facilities and expertise in management HIV. Neonatologist should attend the delivery for fetal rescusltation,and assessment . The cord should be clambed immediately after delivery and the baby should be bathed as soon as possible as these measures help to reduce transmission .
If the mother refused antenatal anti viral treatment,IV ziidovudine should be started 4 h before delivery either vaginally or by cs(as the benifit of cs is controversial ln this case ) and continue till the end of delivery .The cord should be clambed immediately after delivery and the baby should be bathed as soon as possible .Fetal zidovudine to be prescribed by the neonatologist.
Breast feeding is contraindicated and it should be discouraged and feeding formula to be prescribed by the neonatologist.
HIV antiboy test is not reliable untill the baby is 18 month and the HIV status can be knowwn by PCR .Appointement for neonatal follow up after delivery should be given.

For the mother:sensitive,sympathetic management in a non judgeemental manner to gain her trust is essenntial and reassurance about confedentiality.Multidispilinary care witth HIV pphysician,urologist,specialist nurse and psychatrist is of great importance in her care.
Counselling about her status , the effect of HIV on pregnancy,the management plan and the opptions sshe has .
The patient may opt forr TOP and this should be respected .
If the patient choice is to continue pregnancy,she should be advice about HAART and the regimen and doses by the HIV physician.
Managemment of any infection durinng pregnancy should be meticulous ..
psychological support all over antenatal period,deliveryand postpartum with suppport groups and may be psychatrist.
Information leaflets should be given .
postpartum adice about contraception with effective method and condoms to prevent transmission to the partner who must know about her HIV status and how to practice safe sex.

For the ftaff,the HIV status should be disclosed to all staff included in her care.
staff education aabout preventive measures and training about dealing with HIV patients should be esttablished.
Careful handling of blood ,other body fluids and the baby and staff should be double gloved and special eye gogglles to be used during management of delivery.
All equipmeents used should be carefully llabelled and sent to sterilization section for proper sterilization.
If a needle brick during management ,immediate wash of the site of brick under running water ,zidovudine prophylaxis and screening after 3 to 6 months.

Posted by Kingsley  .
HIV is now a very common infection in pregnancy and the incidence is increasing especially in developing countries.It is associated with a significantsocial & psychological consequences to the woman, and risk of transmission the both the neonate and the health workers.

This woman just test positive to the screening test which have to be confirm by first repeating the test and then confirmatory test with western blot.

The major aim of HIV test in pregnancy is to minimise feto-maternal transmission, this can be done by the following interventions. Initiating antenatal Zidovudine, avoiding invasive procedures such as ECV, amioncetencesis,CVS and other iteruterine procedures.

Anomally scan as well as serial growth scan should be done since this neonates are at increase risk of IUGR.

Ceasarean section is the best mode of delivery as it reduces the risk of vertical transmission for about 50% to less the 30%, when combined with antiretroviral the rate of transmission is reduce to about 3%.

Should the woman opts for Vaginal delivery the Zidovudine should be given fir at least 4 hours before delivery and continued until the cord is clamped.the neonate should be screened by 6months and then 9 month.
Postnatally Zidovudine is given orally for at least 6 weeks and breast feeding avoided
Once the neonate is delivered, all blood on the neonate should be clenaed immidiately and the cord clamped as soon as possible.

Minimising the risk to the women should have began with adequate conselling prior to the blood test with the implication of a positive test explained to the woman and consent obtained.

Further explanation of the result should be done in a sensitive and empathetic approach. The woman may need a professional counsellor to deal with the psychological impact of HIV positivity.

Further test will be needed to assese the CD4 count and viral load to determine the best tiome to introduce anti retroviral medication for the woman and this is best done by infectious disease consultant hence appropriate referral.

A screening for other infectious diseases, contact tracing notification of of appropraite authority is important since it is a notifiable diseaes.

Risk to the medical staff can be minimised by adequately identification of case notes, blood and other body fluids with bioharzard sign. double gloving,ane use of face mask and eye sheilds during operative procedures. Where posible blunt needles should also be used for suturing.

Infectious control department of the hospital should also be informed.

With above measures, the risks of transmission to the neonate, medical staff can be minimised while an optimal outcome to the woman\'s health can be achieved.




.



Posted by BAHAA-Uddin BOR B.
HIV has become the scourge of the modern world,with the number of HIV-positive heterosexuals in the UK is rising .
A detailed history and examination should be undertaken including possible modes of transimission.
A woman diagnosed as HIV-positive should managed by multidisciplinary team .
Risk of vertical transimission 15-20% in non-breastfeeding woman in Europe and 25-40% in breast-feeding African woman.
There are several measures can be taken to reduce the mother-to-child transmission
(MTCT) such as anti-retoviral ( HAART,Highly Active Ant-retroviral Therapy ).,delivery by caesarean section and avoidance of breast-feeding.
The woman should be informed that these interventions can reduce MTCT from 25-30% to less than 2%.
She should be screened for genital infections and to be repeated at around 28 weeks,as bacterial vaginosis may be associated with premature delivery and agreater chance of MTCT. Other genital infections may also lead to higher vaginal viral load.
Any infection detected should be treated according to UK national guidelines.
Screening for Down syndrome and fetal anomalies should be offered .
Where invasive prenatal diagnosis is contemplated as second trimester amniocentesis the advice of fetal medicine and HIV physician should be sought and prophylaxis with HAART considered.
Plasma viral load and CD4 count should be reviewed by an HIV physician on regular basis to determine the timing and choice of ant-retroviral therapy and prophylaxis against Pneumocystis carnii,with drop CD4 count below 200/mm3.
Monotherapy with zidovudine is appropriate for prevention of vertical transimission up to 68% in the third trimester.
The decision on combination therapy will depend upon viral load and clinical condition,with combination of protease inhibitors and nucleoside analogue reverse transcriptase inhibitors being favoured in case of high viral load. Optimal use should suppress viral load to undetectable levels < 50 copies /ml.
Elective caesarean section should be offered ,as with combination of prophylactic zidovudine reduce MTCT to < 2%.
If she opts vaginal delivery ,she should have her membrane left intact as long as possible ,use of Fetal Blood Sampling and Fetal Scalp Electrode
Should be avoided.She should continue HAART during labour and IV zidovudine if required at the onset of labour and continued until the umbilical cord is clamped.
The cord should be clamped as early as possible after delivery and the baby should be bathed immediately after the birth.
She should be advised not to breastfeed her baby ,as it doubles the MTCT.
The neonate should receive ant-retroviral therapy from birth and continued for 4-6 weeks and may receive spiramycin.
The neonate should be screened for HIV infection by PCR at birth ,3,6 weeks and 6 months and with HIV antibody test at 18 months.
The Mother should be managed by Multidisciplinary team-HIV physician ,Obstetrician,Midwife.,Support groups and Psychitrics,Social workers and Drug dependency specialists if needed.
Presentation with symptoms or signs of pre-eclampsia ,cholestasis,or signs of liver dysfunction during pregnancy may indicate drug toxicity and early liaison with HIV physician and she should be monitored closely during pregnancy.
The woman should be counselled regarding the fact that there is no certainty regarding the long-term safety of anti-retroviral agents and she should be reassured that confidentiality will be respected .
Emphasis should be placed on education and counseling of the woman .Appropriate advice should be given to optimize the chance of conception while minimizing the risk of sexual transmission.
Contact tracing and contraceptive advice forms an important part of this.
All professionals caring for the woman should be aware of the diagnosis.
All the women with HIV should be reported to the National Study of HIV in Pregnancy and Childhood at the Royal College Of Obstetricians & Gynaecologists
( NSHPC ).
It is advised that those looking after HIV-positive woman :
- Wear adequate eye protection ,protective clothing and double gloves ,particularly for operative delivery.
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Posted by BAHAA-Uddin BOR B.
It is advised that the professionals caring for the woman that :
- Wear adequate eye proptection,protective clothing and double gloves ,particularly for operative delivery.
-avoid needle stick injuries.
-sterilise instruments by autoclave.
-THE Pediatrician should be warnned of fortcoming delivery.
-Avoid mouth-operated suction devices.
Posted by BAHAA-Uddin BOR B.
Dear Dr. Paul:
THANKS FOR READING AND CORRECTING MY ANSWER , WHICH WAS DIVIDED IN TWO MESSAGES. .
SORRY FOR THIS .,AS THIS THE FIRST TIME TO SEND ANSWERING.
WOULD YOU MIND PLEASE., TO ACCEPT MY MISTAKE.
THANKS .
Posted by adnan S.
HIV infection is a blood born viral infection transmitted sexually ,through blood products or via shared needles.The disease transmitted vertically to the fetus during pregnancy ,labour ,and in the neonatal and infant period through breast feeding.
Positive results should be given to the women in person by an appropriately trained health professional this may be specialist nurse ,midwife HIVphysician or obstetrician.Post test counseling should be provided about the implication of an HIV-positive diagnosis during pregnancy ,which must be addressed over several visits.Reassure her regarding confidentiality,.
If utreated the risk of mother ?to-child transmission of HIV varies between 15%&20% ,2/3rd of transmission occur around the time of delivery.Breast feeding doubles the risk.Maternal factors like high viral load ,low CD4 counts,advanced disease ,.obstetric factors like vaginal delivery ,duration of membrane rupture ,chorioamnionitis &preterm labour are associated with increase risk of vertical transmission.The first step to minimize the risk of transmission to fetus is to reduce the viral load by offering HAART determined by an HIVphysician in antenatal ,intrpartum period &zidovudin to neonate, it reduce the risk of vertical transmission from 25% to8%shown in RCT S.Screaning and treating bacterial vaginosis has shown to reduce risk of vertical transmission.Procedures like amniocentesis ,external cephalic version should kept to minimal as risks of vertical transmission is un certain ,.Elective c section should be offerd ,which significantly reduces the risk of vertical transmission,however the benefit in women taking HAART with minimal viral load is un certain.Elective c section should be timed to take place after 38 wksof gestation.AZT should be started 4 hours before c section and should continue until the umbilical cord has been clamped .Bloodless technicque of doing c section may further reduces the risk of vertical transmission.If women opted for vaginal delivery avoid invasive monitoring ,keep membranes intact as long as possibleand use chlorhexidine to cleance vaginamay reduce risk of transmission.Early clamping of umbilical cord .washing off maternal blood may be helpful.Neonate should receive zidovudine from birth until 4to 6 wks.Breast feeding increase the risk by 14 % should be avoided.
Pregnancy has no no known effect on HIVdisease progression.No conclusive evidence that HIVaffects pregnancy out come in developed countries.If presents with advance disease anti-retroviral therapy prevents disease progression.Some studies have suggested that post operative complications particularly sepsis is increased related to the level of immunocompramise,antibiotics prophylaxis should be given.
To minimse the risk of transmission to medical staff HIVpositive results should be informed to the clinicians on a need to know basis,womans case note should be annotated with risk of infection in a place easily noticed by staff using the notes,but on the cover to maintain confidentiality egon the inside of cover.The case should be last on the elective list for the day of the operation ,so that theater can be sterlised afterwards .Staff attending delivery should be properly equipped,ie water proof disposable gowns and masks,eye protection ,double gloves to wear during surgery. Avoid needle pricks during surgery.All the body substances such as blood samples and waste should be treated as an infectious hezard and labelled appropriately .Infection control team should be informed and there help should be requested to minimize the risk of transmission to medical staff
Posted by Zaibunnisa khan K.
please check my essays.
Human immunodeficiency virus(HIV) infection is associated with high morbidity and mortality.The risk of vertical transmission of HIV varies from 15% to 20% in the west and up to 40% in the developing world.There are several measures that can be taken to minimize the risk to the woman and to the fetus and neonate .The woman diagnosed HIV positive should be managed by multidisciplinary team
It is now well established that advanced maternal disease ,low maternal CD4T- lymphocyte counts and high maternal viral load are associated with increase risk of mother to child transmissionHighly active antiretroviral drug therapy (HAART) should be recommended to reduce the viral load to undetectable level . Optimum treatment with antiretroviral drugs will full suppression of viremia to undetectable level .
The treatment should be continued to the of delivery, and sometime beyoud depending upon treatment regimen..Montherapy with Zidoviudine in case the woman is clinically well and viral load is low ,reduces the transmission by up to68%.This is because the risk of transmission is mainly during labor.
The woman should be advised against unprotected intercourse ,the use of illicite drug especially cocaine and cigarette somoking thoughout pregnancy.Unprotected intercourse or and multiple sexual partners during pregnancy are mre likely to transmit HIV to the fetus independent of the presence of sexual transmitted disease (STD).The use of illicite drugs is associated with an increase risk of preterm rabour , placental abruption and,premature rupture of membranes .All of which increase risk of vertical transmission (VT).Cigarette smoking is independent risk factor for VT.She should be screened for STD as this is risk factor for VT .Co infection with hepatitis c and HIV increased VT of both.Vitamin A deficiency increases the risk of VT and vitamin A also has direct stimulatory affect on immune system and helps to maintain the integrity of the mucosal surfaces therefore vitamin A supplement should be advised.
Termination of pregnancy is one to minimize the risk to the woman .
Elective caesarean section(c/s) ,when performed before the onset of the labour and before the rupture of the membranes reduces the risk of VT to 2%. The procedure of bloodless caesarean section is an attempt to achieve minimal exposure to maternal secretions.Zidovudine should be started 4 hours before C/S until umbilical is clamped also reduce the risk of transmission.
Invasive procedure such as amniocentesis, cordocentesis, artificial rupture of membranes use offetal scalpe electrodes and fetal blood sampling should be avoided.During vaginal delivery episiotomy should be avoided and forceps should be used to deliver the baby rather than vaccum extractor icase instrumental delivery is required . Chlohexidine disinfection reduces transmission in case of rupure of membranes before .Reduction of interval of delivery after sponteouse of membranes reduces VT risk.
Umblical cord should be clamped as early as possible.Baby should be bathed immediately .
Breast feeding increases the transmission to the neonate it should be discourged.Neonate should be given single agent oral zidovudine for 6 weeks.Haart should be considered for neonate in case mother started antiretroviral therapy late in pregnancy.
Treatment should be monitored by the pediatrician with special interest in HIV .Child should be tested at birth ,at 3 weeks ,6 weeks,at 6 month and 18 months to confirm uninfected state.
Medical staff should be aware of the risk of transmission of HIV. Staff dealing with HIV patient should wear impermeable gowns and goggles.Secretions should be disposd off .
The C/S should be performed by most experienced person available to reduce the risk injury to the staff. Double gloving reduces the risk of puncture of the inner glove.The use of blunt needles and tissue handling forceps further reduces the risk.Remove suture needles before tying suturesor use instrument rather than fingure for tying .Electrocautery ,blunt tipped needles and stapling devices may reduce the need for sharp instrument and needles.Use instruments rather than fingers for retracting and holding tissues during suturing .






Posted by Vaani M.
HIV is transmitted from mother to fetus by placental transfer, at delivery and through the breast milk. It is associated with risk of immune deficiency and various infections to the woman.

HIV is known to have a risk of transmission from mother to fetus of 25-30 % which is reduced to 2% by anti-retroviral therapy, planned caeserean and avoiding breast feeding.

A detailed history has to be taken about known past HIV status and if she is receiving any treatment for the same. A test for serum viral load and CD4 count needs to be done. If she has a high viral load >10,000 and low CD4 count <200, she may need treatment with 3 or more drugs as per the HAART regime. If lower viral load with high CD4 count the risk to the fetus may be less and she may need treatment with multi drugs or single drug zidovudine after 28 weeks of pregnancy. All treatment for HIV, changes and management of complications must be done with the advise of the HIV physician only.

Screening for other sexually transmitted infections need to done and treated to reduce risk of transmission to the fetus.

She should be offered planned caeserean section after 38 weeks. Evidence of reduced transmission by CS with a low viral load and on HAART is lacking but all women should be offered CS. The woman will need intravenous zidovudine therapy in labour. Avoidance of fetal blood sampling, fetal scalp blood monitoring, or instrumental delivery should be done if she chooses to have a vaginal delivery. Early cord clamping, and immediate bath to the baby after delivery will reduce infection to the neonate.

Breast feeding doubles the risk of transmission of HIV to the neonate and should be avoided. The neonate should be tested for HIV status with PCR. Oral zidovudine may be required for 4-6 weeks for the neonate.

The woman should be encouraged to inform her sexual partners of her HIV status. If not willing the physician should inform her sexual partners of her status with her knowledge. Other relatives need not be informed. She should be reassured of confidentiality. She should be encouraged to use condoms always even if her partner is HIV positive to avoid risk of transmission of resistant strains of HIV virus.

The medical staff involved in the care of the woman should be informed to improve care for the woman and reduce risk of infection for the staff. They should use protective devices as eyewear, double gloves, disposable instruments and gowns. Proper handwashing techniques should be followed. If possible she should be posted last on the days operation list and the OT sterilised after any procedure.

With proper counselling of the woman and partner and multidisciplinary care involving obstetrician, neonatologist, anaesthetist, HIV physician, support groups and all staff caring for the woman the risk of infecting the fetus, staff and complications for the woman can be minimised.


Posted by Sarwat F.
Risk to fetus/neonate is due to vertical transmission and infection aquired at the time of delivery. Risk of vertical transmission is around 15% but it can be reduced to 2% by appropriate interventions. Risk is high with high viral load in maternal blood, p24 antigenemia, low CD4 count, prolonged rupture of membranes and preterm deliveries of less than 34 weeks. Risk is mainly of acquiring infection from mother. There are no more adverse fetal effects than in a HIV negative pregnancy. There are no methods of prenatal diagnosis which can predict which infants will acquire infection. Invasive prenatal diagnosis is contraindicated in HIV positive pregnant woman. Vertical transmission is reduced with high antiretroviral antibodies and low viral load. Various interventions which can reduce transmission of infection include elective caesarean section, avoiding breast feeding and use of HAART highly active antiretroviral therapy for mother as well as for neonate after delivery. If mother is already on HAART regime, viral load may be negligible and theoretically the risk of transmission to fetus is negligible. However the data regarding shedding of virus in vaginal secretions is scanty and vaginal delivery cannot be safely recommended. Patient will be explained about all available evidence and decision is made in collaboration with patients wishes. Regarding prenatal diagnosis detailed ultrasound scanning will be used to detect any abnormalities however the risk is low. The difficulty associated with diagnosing neonatal HIV infection is overcome by using DNA amplification techniques by PCR. Maternal antibodies may persist for upto 18 months igM antibodies are unhelpful in fetal diagnosis. Paediatrician will be informed about maternal risk factors.
Risk to woman will be due to the stress of pregnancy and decision regarding HAART therapy. Early involvement of HIV physician is essential. If woman is taking HAART therapy before pregnancy it will be continued. In other case HAART needs to be started. At present only zidovudine is licensed for use during pregnancy in U.K. It has a small risk of neonatal mitochondrial dysfunction and longterm safety data in infants and children exposed in utero is not available. Markers of disease progression are not adversely affected by pregnancy but despite this woman may opt for termination of pregnancy because of concerns for her unborn child and her own perceived reduced life expectancy. Psychiatric support will also be required to cope with screen positive result. Any signs and symptoms of liver dysfunction or pre eclampsia should alert about drug toxicity and advice of HIV physician sought in these cases.
Risk to medical staff is reduced by appropriate aseptic techniques while doing blood tests and during caesarean section. Disposable instruments should be used as much as possible and nondisposable are labeled as used for HIV infected patient before sending for sterilization. Surgeon and scrub nurses should use proper gown, gloves, face mask and goggles to prevent infection. Proper documentation regarding all interventions and decisions taken is also important.
Posted by Srivas  P.
Being told to be HIV positive can be totally shattering and devastating to the woman. She has to be handled with sensitivity and finesse while maintaining total confidentiality. Her positive HIV antibody test result should be given to her in person by an appropriately trained health professional like a specialist nurse, midwife, HIV physician or her obstetrician. Her management should be multidisciplinary with HIV physician, obstetrician, midwife, Pediatrician, psychiatric team and support groups.

The main aim of management is to control her illness, minimize mother-to-child transmission of HIV, protecting her partner if uninfected and protect the medical staffs who give her care from getting infected with HIV.

The risk of mother-to-child transmission of HIV varies between 15% and 20% in non-breastfeeding women and between 25% and 30% in breast feeding woman. About 80% of HIV transmissions from mother to child occur late in the third trimester, labor and delivery and just about 2% occur in 1st and 2nd trimesters. The main risk factors which increase vertical transmission are advanced maternal HIV disease, low antenatal CD4 count and high plasma viral load.Pre term birth, chorio- amnionitis, duration of membrane rupture and breast feeding too increase the risks with breast feeding alone increasing the risk 2 fold.

Three interventions which include anti-retroviral therapy, given antenatally and intrapartum to the mother and to the neonate for the first 4?6 weeks of life, delivery by elective caesarean section and avoidance of breastfeeding are associated with a vertical transmission rate of less than 2%. Aim for a maternal viral load less than 1000 copies /ml with antiretroviral therapy in collaboration with HIV physician using HAART, START or single Zidovudine as considered appropriate depending on Viral load and CD4 count. When invasive prenatal diagnosis is contemplated for prenatal diagnosis, prophylaxis with HAART should be considered. Invasive tests like Scalp PH and Instrumental delivery should be avoided. Cord should be cut early and baby bathed immediately after birth.

Genital tract infections with Chlamydia Trachomatis, Neisseria gonorrhoea and bacterial vaginosis and syphilis also increase vertical transmission and hence the woman should be screened and treated for these genital infections. This woman with her high risk sexual activity may also be Hepatitis B, Hepatitis C positive and may also have a drug habit All this exposes the fetus to risks. Mother should be screened for Syphilis, detected and treated during pregnancy preventing fetal infection while neonate should have HBV prophylaxis if the woman is Hepatitis B positive.

Other fetus risks include risk of Congenital Syphilis if mother is syphilitic. Fetus may also have increased risk of NTD if mother given antifolates like cotrimoxazole for prophylaxis of Pneumocystis carinii pneumonia (PCP), given if maternal CD4 T-lymphocyte count is below 200 million / liter and mother has not received increased folic acid prophylaxis needed in this case. Hence risk of NTD in fetus may be more than basal risk.

Maternal risks include progression of her HIV disease and she may need HAART instituted in first trimester or early second for her own illness or may have START or single agent Zidovudine as decided by HIV physician till her blood viral levels are decreased to below 1000 copies/ml and optimally below 50 copies/ml. Anti-retroviral drug toxicities include Pre ecclampsia , hepatotoxicity, rashes, glucose intolerance and lactic acidosis presenting with gastrointestinal disturbance, fatigue, fever and breathlessness and she should be monitored for drug toxicity (FBC, U&E, LFT, Lactate, blood glucose). She may be given PCP prophylaxis as discussed if CD4 levels low below 200-350 million /l. She should be screened for genital infections and treated as appropriate. She should have antibiotic prophylaxis before caesarean section as she may be more prone to puerperal infection.

The staffs dealing with this patient must be told about her HIV status so that universal precautions like double latex gloves eye goggles and shoe mask and non porous gowns can be used. The operation should be scheduled last in the operation theatre. Bloodless surgery if possible with use of staple gun minimizes risk to baby and attending staff. Avoid use of sharp needles wherever possible. Staff should be given HAART in case of inadvertent needle pricks.

Posted by Srivas  P.
Mr Paul

I will be grateful if you can mark my answer also.

Thanks
Posted by M H.
With current available treatment, people with human immunodeficiency (HIV) can enjoy a lifespan of at least twenty years. Vertical transmission rates in pregnancy can be reduced to 2% with effective measures taken.

A history and examination to exclude AIDS defining illness such as cryptcoccoccal pneumonia, Kaposi sarcoma will help to stage this lady?s disease. A CD4 count and a viral load should also be taken as this will help in counselling this lady about the stage of her disease and also the implications to the transmission rates.

She should then be referred onto a Infectious Diseases team and her management in her pregnancy should be a joint one. As she is already in her second trimester, antivirals can be commenced to reduce her viral load and thus the transmission rate to the foetus. Screening for other sexually transmitted diseases such as Hepatitis B should also be sought to further aid her management.

Her mode of delivery should be by the elective caesarean section as birth trauma during vaginal delivery contributes to most of the vertical transmission; especially if her viral load if high. It is recommended that intravenous AZT be commenced at least 4 hours prior to surgery and be continued till the umbilical cord is clamped. After delivery, the cord should be clamped as soon as possible and the baby bathed as soon as possible. A neonatologist should be on standby for the delivery if possible. This protective effect from Caeserian section is negate if in present of ruptures membranes for more than 4 hours. The role of elective c-section in a lady with an undetectable viral load remains controversial.

After delivery, the lady should be adviced not to breastfeed as this would increase the likelihood of vertical transmission. Prior to discharge, she should also be adviced about a suitable mode of contraception and that if she should be planning to embark on a future pregnancy to present herself and her partner to a preconception clinic so that help can be given to optimise her pregnancy. She should also be encourage to disclose her HIV status to her partner (s) and contact tracing should be undertaken. Relevant written information and referral to support groups should be made available to her and her partner.

All medical staff attending to this lady should be told about her HIV status and adhere strictly to universal precaution guidelines and the protocol of the hospital while attending to her.
Posted by hala M.
Mr. Paul, please correct my essay on the miscarriage.

This is a very upsetting and distressing situation and the breaking of the bad news needs an uninterrupted, dedicated and suitable time. A great care needs to be exercised during the consultation of this sensitive matter and it is necessary to use a suitable terminology when referring to the failed pregnancy. A silent miscarriage is a preferred term.
The presence of a partner or family member is helpful.

I would tell her that she still has a good chance of having a live birth and that this chance is even higher if she had a previous successful pregnancy.

I need to counsel her about the options available for the management of this pregnancy, explaining the methods, pros and cons of each of them. She does not need to be admitted urgently and she can go home and think about what she would like to do.

The options I need to tell her about are medical, surgical and expectant option. The medical option is to give her anal tablets and vaginal pessaries which would be followed by bleeding and some pain. This is good in avoiding general anaesthesia and has good success, but she might still need to have surgical evaluation in case of heavy bleeding. There is no risk of infection.
The surgical option is quick and successful and good in that the whole products can be sent in an ideal situation to the lab for cytology studies. Screening and/or treatment for infection is necessary.

The patient might prefer to do nothing (expectant) and to wait for the spontaneous events to happen and this is totally acceptable. This will give her the chance to feel that she is more in control of the situation, but we need to stress the importance of attending as soon as possible in case of heavy bleeding.

As this is considered now as recurrent miscarriage (RM), I need to tell her about the causes of RM and the possible investigations needed and the possible management.
I would discuss this with her briefly and in more detail in her subsequent follow up appointment when histology results are back in a few weeks time.

Balanced translocation with one couple can be identified on peripheral blood sample karyotyping and a referral to a geneticist is made in case of abnormalities.
After pregnancy a blood test for antiphospholipid antibody syndrome APS (Acquired and Congenital) can be done, and the use of low dose aspirin LDA and low molecular weight heparin (LMWH) is the treatment of choice for the next pregnancy in case of confirmed APS.
Polycystic Ovary (PCO) might cause RM, so after the miscarriage a blood test and ultrasound scan (USS) need to be arranged. Unfortunately there is no effective treatment for RM in PLO.

Continuous counselling and support is very important in this case and putting the patient on line with support groups and associations will help.

Posted by hala M.
Apologies for posting the incorrect content.

The foetal/ neonatal risks associated with HIV infection in pregnancy are mainly due to vertical transmission. In case of no intervention the risk of this is 25-30 %. It was found that this can be reduced to as low as 2% by giving antiretroviral therapy (ART) to the mother (from 28-32 weeks) antenataly, intrapartum and post natally to the baby until the age of 4-6 weeks. In addition to performing caesarean section (although the evidence in case of low viral load is lacking) and avoidance of breast feeding providing a safe formula is available.

As the presence of genital infections increases the risk of this transmission, then it is important to screen and treat for Chlamydia, Gonorrhoea and bacterial vaginosis. This should be done and repeated at 28 weeks gestation.

At caesarean section the risks to foetus/ neonate can be reduced by the use of bloodless technique, clamping the umbilical chord as soon as possible and bathing the baby immediately.
In case the woman had vaginal delivery the risk can be minimized by the avoidance of invasive procedures such as foetal scalp electrode (FSE), foetal blood sampling (FBS) and operative vaginal delivery. Delaying the artificial rupture of the membrane (ARM) as long as possible if practicable reduces the chance of transmission.
In case there is a need for invasive pre natal diagnosis (CVS and amniocentesis) an advice from the GU physician regarding the administration of ART should be sought.

The maternal risks can be minimised by the adaptation of a multi disciplinary approach in the management of the pregnancy by a team consisting of an Obstetrician, GU Physician, Midwife, GP, Social Worker, Drug Dependency Unit and psychological counselling. The involvement of a Paediatrician helps in reducing the foetal/ neonatal risks.

The post test counselling is very crucial as the diagnosis might have psychological consequences. This needs to be done by trained personnel through a confidential and non-judgemental approach.

Regular joint clinic with regular check of CD4, viral Load and full blood count is necessary to ensure the ART can be started when CD4 is les than 350 and viral load is above 10 000 to
20 000. The PCP Pneumocystic Carini Prophylaxis when CD4 is less than 200 needs to start because of the risk of opportunistic infections.
Monitoring of drug toxicity is necessary if she started the ART and this is done by a full blood count, urea and electrolyte, liver function test, blood sugar and lactate.
Prophylactic antibiotics before CS are necessary to reduce the risk of wound infection.

The risk to medical staff is reduced by the awareness of the staff looking after the patient about her condition so they take the necessary precautions such as wearing special gowns, double gloves and eye goggles. The use of disposable instruments is helpful in addition to careful handling of body fluids and the products of the pregnancy are paramount.
Awareness of the staff about the management of needle stick injury according to the local protocol and the availability of medication for prophylaxis (PEP) is very important in reducing the risk.