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MRCOG PART 2 SBAs and EMQs

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Essay 234 - HIV in pregnancy

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		Posted by Ahmed A. Mon Jul 2, 2007 01:08 am
(a) I would explain to her that screening for HIV early in pregnancy provides the opportunity for appropriate antenatal interventions including antiretroviral therapy, delivery by caesarean section and avoidance of breastfeeding that can reduce the risk of maternal-to-child HIV transmission from 25?30% to less than 2%. (b) Positive results should be given to the woman in person by an appropriately trained health professional. I would involve multi-disciplinary team including HIV physician, midwife, pediatrician, support groups and psychiatrics, social workers and drug dependency specialists if necessary. I would reassure her regarding confidentiality. I would document and explain the plan of care to the woman. I would perform plasma viral load and CD4 count that should be reviewed by an HIV physician on a regular basis to determine the timing and choice of anti-retroviral therapy and the need for prophylaxis against Pneumocystis carinii pneumonia. This prophylaxis usually administrated when the CD4 count is below 200 million /l. I would consider that the First-line treatment is co-trimoxazole (a folate antagonist) + folic acid. I would perform screening for other STDs including HepB & C, syphilis which would repeat at 28 weeks. I would Offer pre-natal diagnosis as per routine care and if CVS or amniocentesis are required, I would discuss with HIV / fetal medicine specialist and I would consider prophylaxis with HAART, as the effect of such invasive procedures on risk of vertical transmission is unknown. If the woman does not require anti-retroviral therapy for her own health, the treatment is required to prevent vertical transmission. Anti-retroviral therapy usually commenced at 28-32 weeks through delivery and the post-natal period. I would discuss timing of cessation of treatment with HIV physician. I would start treatment earlier if woman at risk of pre-term delivery. The treatment options are Zidovudine orally (antenatal) + iv (intra-partum) with delivery by C/S and treatment discontinued after delivery or HAART during pregnancy and discontinued shortly after delivery provided maternal viral load is undetectable (short-term anti-retroviral therapy, START). I would take maternal blood sample at delivery for viral load. Women taking anti-retroviral drugs should be monitored for drug toxicities (full blood count, urea and electrolytes, liver function tests, lactate and blood glucose). Symptoms / signs of pre-eclampsia, cholestasis or other signs of liver dysfunction may indicate drug toxicity and review by HIV physician should be requested. (c) I would advice her to avoid breast-feeding, because the breastfeeding increases the risk of vertical transmission by 14%. The neonate should receive anti-retroviral therapy from birth and continued for 4-6 weeks. The neonate should be screened for HIV infection by PCR at birth, 3, 6 weeks and 6 months and with an HIV antibody test at 18 months. I would discuss contraception and follow-up by HIV physician.
		Posted by Ahmed A. Mon Jul 2, 2007 01:13 am
(a) I would explain to her that screening for HIV early in pregnancy provides the opportunity for appropriate antenatal interventions including antiretroviral therapy, delivery by caesarean section and avoidance of breastfeeding that can reduce the risk of maternal-to-child HIV transmission from 25?30% to less than 2%. (b) Positive results should be given to the woman in person by an appropriately trained health professional. I would involve multi-disciplinary team including HIV physician, midwife, pediatrician, support groups and psychiatrics, social workers and drug dependency specialists if necessary. I would reassure her regarding confidentiality. I would document and explain the plan of care to the woman. I would perform plasma viral load and CD4 count that should be reviewed by an HIV physician on a regular basis to determine the timing and choice of anti-retroviral therapy and the need for prophylaxis against Pneumocystis carinii pneumonia. This prophylaxis usually administrated when the CD4 count is below 200 million /l. I would consider that the First-line treatment is co-trimoxazole (a folate antagonist) + folic acid. I would perform screening for other STDs including HepB & C, syphilis which would repeat at 28 weeks. I would Offer pre-natal diagnosis as per routine care and if CVS or amniocentesis are required, I would discuss with HIV / fetal medicine specialist and I would consider prophylaxis with HAART, as the effect of such invasive procedures on risk of vertical transmission is unknown. If the woman does not require anti-retroviral therapy for her own health, the treatment is required to prevent vertical transmission. Anti-retroviral therapy usually commenced at 28-32 weeks through delivery and the post-natal period. I would discuss timing of cessation of treatment with HIV physician. I would start treatment earlier if woman at risk of pre-term delivery. The treatment options are Zidovudine orally (antenatal) + iv (intra-partum) with delivery by C/S and treatment discontinued after delivery or HAART during pregnancy and discontinued shortly after delivery provided maternal viral load is undetectable (short-term anti-retroviral therapy, START). I would take maternal blood sample at delivery for viral load. Women taking anti-retroviral drugs should be monitored for drug toxicities (full blood count, urea and electrolytes, liver function tests, lactate and blood glucose). Symptoms / signs of pre-eclampsia, cholestasis or other signs of liver dysfunction may indicate drug toxicity and review by HIV physician should be requested. (c) I would advice her to avoid breast-feeding, because the breastfeeding increases the risk of vertical transmission by 14%. The neonate should receive anti-retroviral therapy from birth and continued for 4-6 weeks. The neonate should be screened for HIV infection by PCR at birth, 3, 6 weeks and 6 months and with an HIV antibody test at 18 months. I would discuss contraception and follow-up by HIV physician.
		Posted by AMNA K. Mon Jul 2, 2007 04:46 am
a)Purpose of screening this woman is to know her HIV status as incidence of heterosexually acquired HIV infection in UK is rising steadily and one third of them are un aware of their status. By screening test it is possible to know her HIV status and if in case she is found to be positive then risk to her fetus/neonates(which is approximately 25 -30%) can be reduced to2% by adopting appropriate strategies and interventions. These interventions are giving of highly active anti-retroviral therapy(HAART)to the mother(antenatally and intrapartum) and neonate for first 4to 6 weeks postnatally,( Antiretroviral therapy is the combination of three or more potent antiretroviral drugs highly active against HIV)and delivery by caesarian section. .Both these interventions can reduce risk of transmission from mother to fetus to8% from 30% and this can be further reduced to 2% if breast feeding is avoided By knowing her HIV status she can be counselled regarding possible risk of transmission to her partner if he is screen negative for HIV And appropriate advice about use of condom as per exposure risk of HIV infection from unprotected sexual intercourse is 1:500. Knowledge of her HIV status will also help to reduce risk to the staff that be minimized by appropriate precautions (double gloves , protective goggles, water proof gowns, avoiding needle stick injuries and appropriate labeling and disposal of infected material)if she is screen positive. b)Regarding her antenatal management it is important that her positive result should be given in person by an appropriate trained professional who can be HIV physician, specialist nurse or an obstetrician and she should have an appropriate post test counseling .She must be reassured that her confidentiality will be respected and information to other clinicians will be on a need to know basis, her test result will not be entered in her case notes and with her consent a ghost file can be created and can be stored in hospital. She will be managed by multidisciplinary approach involving obstetrician, HIV physician, mid wife,and pediatrician. Support groups, psychiatrist, and social worker and drug dependency specialist if needed. Her Plan of care will be decided , documented and will be explained to her. Her partner will be screened and she will be encouraged to inform her sxual partner if he is not aware of her HIV status. HIV status of woman may be disclosed to her partner in order to protect him from acquiring infection if he is screen negative and woman must be told of such disclosure. She will be screened for other STDs like Chlamydia trachomatis and neisseria gonorrhea as they increase the risk of HIV transmission from mother to fetus . She should also be screened for bacterial vaginosis which by causing chorioamnionitis, PPROM and preterm delivery can indirectly increases the risk of vertical transmission of HIV, and if she is found negative then screening should be repeated at 28 weeks. Screening for syphilis , hepatitis C and B should also be done if not done before. Maternal and fetal prognosis will be discussed with her and she will be told that pregnancy had no known effect on progression of HIV and there is no conclusive evidence that HIV effects pregnancy outcome in developed countries. Interventions to reduce vertical transmissions will be discussed (HAART antenatally , intrapartum to the mother and neonate in the first 6 weeks, delivery by c/s and avoidance of breast feeding.) High viral load ,low cd4 count, advanced disease prolong rupture of membrane (<4hours),invasive procedures,vaginal delivery and, smoking increases the risk of vertical transmission. Termination of pregnancy should be discussed if her disease is in advanced stage because of risk of vertical transmission and reduced life expectancy of woman. Prophylaxis against pneumocystis carinii(opportunistic infection) with co trimoxazole+5mg folic acid will be given if CD4 count is less then 200/ml. Antenatally regular assessment of viral load, cd4 count, liver function test (as HAART is associated with liver dysfunction) lactate level and glucose tolerance test to screen for GDM to rule out HAART toxicity.Sign and symptoms of pre-eclampsia and obstetric cholestasis indicate HAART toxicity and review by HIV physician is requested. Ultrasound for fetal well being and growth will be advised and if there is an element of IUGR then umbilical artery doppler will be requested. She will be reported to the national study of HIV in pregnancy and childhood at Royal college of obstetrician and gynaecologist. Written information will be given to her and name of support group and contact number will be provided. c) Early clamping of cord and immediate bathing of neonate may . reduce the risk of transmission.Mother will be advised not to breastfeed as breast feeding increases the risk of transmission from 14 to 30%. Neonate will receive antiretroviral therapy from birth and continued 4to6 weeks and will be screened for HIV infection by PCR at3 ,6,,weeks and 6 months and with HIV antibody test at 18 months future contraception will be discussed with her and follow up with HIV physician.
		Posted by Mohammad H. Mon Jul 2, 2007 06:37 pm
I will explain to the patient that HIV test is offered to high risk patientsand I will explain to her why she is at increased risk. I will explain to her that if she is HIV positive ,there will be twenty percent risk of transmitting the infection to her baby. The modification of antenatal care(as giving HAART,avoiding invasive diagnostic techniques) ,mode of delivery(as casearean section is associated with less risk of vertical tranmission) and postpartum care(avoidig breast feeding) will reduce the risk of transmission to two percent. If she is HIV positive ,she may opt for termination of pregnancy.The partener(s) will be screened and protected if negative. ANTENATAL CARE The result should be explained to the patient in a sympathetic manner and she should be reassured that her HIV status will not be disclosed to others but she should be encouraged to inform her partner(s)about her HIV status and in case that she is reluctant to do ,her HIV status may be disclosed to her partner. History of recreational drug abuse and screening for sexually transmitted infections (STIs) as hepatitis B , hepatitis C ,chlamydia and gonorrhea should be done . The patient should be referred to GUM clinic for STIs screning and contact tracing. Investigation should include viral load, CD4 count and basic investigations as full blood count,urea &electrolytes and blood sugar . Inclusion of a HIV physician in the care of the patient should be considered.HAART should be offered to the patient and mode of delivery should be discussed with the patient (casaerean section is the preffered mode of delivery in patients not taking HARRT) as this will reduce the risk of vertical transmission FORM TWENTY PERCENT TO TWO PERCENT . HAART toxicity should be monitored by FBC,UREA &ELECTROLYTS All health carers included in the patient\'s care should be aware about her HIV status to take the needed precautions during patient\'s management . Avoid invasive procedurs as amniocentesi,fetal blood sampling as these are associated with increased risk of fetal transmission. Health education about safe sex practice if the prtner is HIV negative and information leaflets should be offered. The diagnosis of HIV is has psychosexual impact on the patient so the referral to psychologist may be needed and support group contact( HIV support group) is beneficial. POSTPARTUM CARE The patient should be advised to avoid breast feeding as this is associated with fifty percent reduction in HIV transmission as compared to breast fed babies. Zidovudine should be offered to the neonate a for six months and pediatrician should be included in the care of the baby. Screen the baby for HIV infection at one ,three and six month after birth using PCR technique as antibody test may be negative in affected babies up to 18 month of age . AT 18 month antibody test should be done if previous PCR testing were negative. Contraception should be discussed with the patient and reliable contraceptive method should be offered. Condoms are protective to the patrner and IUCD should be avoided as it is associated with increased risk of PID. Follow up of the mother with HIV physician should be offeredfor her own health. Information leaflets and contact with support group is beneficial.
		Posted by Dr. Umme H. Mon Jul 2, 2007 07:03 pm
a) The patient should be informed that incidence of HIV in pregnancy is increasing nowadays and it is associated with risk of vertical transmission to the fetus. To reduce the risk of vertical transmission its screening at booking visit is advocated. The HIV positive patient will require modified antenatal intra-partum and post-partum care. Earlier detection, using HAART (Highly Active Anti Retro-viral Therapy), elective caesarian section and avoidance of breastfeeding will reduce vertical transmission to less than 2%. Health professional should be aware about the diagnosis and will be appropriately trained up in managing this patient properly and they should be protected if it is detected at booking visit. b) Multidisciplinary team will be involved in this HIV positive patient\'s care including an obstetrician, midwife, HIV physician, paediatrician, support group and psychiatrist. Drug abuse and social worker should be involved if needed. Her hepatitis B, hepatitis C and syphilis should be detected if it is not done before. The treatment plan should be documented and should be discussed with the patient. HIV physician should monitor her viral load and CD4 count at a regular interval to detect her disease status, to reduce the risk of vertical transmission and the timing and need for anti retro viral therapy. If the woman has a high viral load she should receive highly active anti retro viral therapy after the first trimester. If the CD4 count is below 200 million per litre of blood then the patient will receive antibiotic prophylaxis against pneumocystic carini infection. While taking HAART, patient should be monitored to detect drug toxicity by using full blood count, urea and electrolyte, liver function test, blood glucose and serum lactate level. If the patient does not require anti retro viral therapy for her own health she should receive anti retro viral therapy at 28 to 32 weeks, which should continue till labour delivery and in the peuperium. Timing and mode of delivery should be discussed with paediatrician and HIV physician. In case of the patient taking HAART with undetectable viral load, value of elective caesarian section to reduce vertical transmission remains uncertain. After the detection of HIV status, the woman should inform it to her sexual partner. Her sexual partner should be informed if she has not informed him and she cannot be persuaded to do so. She must also be assured that her confidentiality is respected. c) Breastfeeding should be avoided as it doubles the risk of vertical transmission. Neonate should be screened for HIV by using PCR at birth, at 1 week, at 3 weeks, at 6 weeks and 6 months. HIV antibody should be tested at 18 months of age. The neonate should also receive zidovidine therapy for 6 weeks.
		Posted by Natalie P C. Mon Jul 2, 2007 11:07 pm
A I will explain to her that it is a routine test that we offer to all women who are pregnant. We offer it because if she is positive her baby may also become positive. I will explain that if she is positive that there are measures that we can take during the pregnancy and labour and after delivery to reduce the risk of the baby becoming infected. The measure would include medication during the pregnancy and during delivery, careful choice of how she delivers and treatment for baby after delivery. It also allows her to have counselling about the disease and perhaps not infect her partner if he is not positive too. B I would book an appointment for her in the joint GUM/Obstetrics clinic as a multidisciplinary team is available. This will allow her to see the genitourinary physician, obstetrician and Paediatrician in one visit. I would offer her written information on HIV and advise contact tracing. In addition to routine antenatal care such as a 20 week anomaly scan, 28 week full blood count and antibody check and screening for problems such as proteinuria and hypertension, she would have monthly CD4 counts and viral load checks. She would be offered HAART therapy from 24 weeks until delivery because therapy during pregnancy can reduce vertical transmission from 30% to 3-5%. I will explain to her that general recommendation are that Caesarean section reduces risk of transmission to baby. She would have 4 hours of intravenous AZT before her Caesarean section. I would also let her know that new evidence may suggest that if her viral load was undetectable and she went into spontaneous labour and had a quick delivery that the risk may not be increased but her membranes must not be ruptured for more than 4 hours and she is not allowed invasive measures like a fetal scalp electrode or fetal blood sampling. The paediatrician can explain treatment of the baby once born and the GUM physician can explain if she needs to continue treatment after the delivery or not. C Postpartum management will include bottle feeding as breastfeeding increases vertical transmission. Her medications will usually cease unless her viral load was still high. She would be followed up in the GUM clinic. The baby would be assessed as low or high risk and would receive treatment. This is usually AZT for 6 weeks. The baby would be offered testing for viral load at the 6 week check as antibody testing is unreliable.
		Posted by Fahima A. Tue Jul 3, 2007 02:10 pm
a) I will tell her that HIV test is routinely offered to all pregnant women during their antenatal check up. The reason behind it is that HIV infection has very high mortality & morbidity. There are many women with HIV infection becomes pregnant each year and many of them are unaware about the status. If she is HIV negative she can be reassured. However if she is HIV positive her antenatal care can be modified by giving her ante retroviral drug, elective caesarean section & avoidance of breast feeding. With this intervention the rate of transmission to child can be decreased from 25% to less than 2%. The ante retroviral drugs also prevent the disease progression of mother & thereby delay the development of AIDS. The health workers can also protect themselves. The test is very simple & reliable. The confidentiality will be maintained all the time. However there may be a problem with insurance or mortgage. If she wishes she can refuse the test to be done.Information leaflet should be given to the mother. b) The mother should be explained about the diagnosis especially by a person who is appropriately trained in this area ( may be a midwife, HIV physician. or obstretician). As she will be very upset psychological support should be given. Her care should be in a multidisciplinary team including obstretician, HIV physician, social worker, psychiatrist, support group, drug dependency team( according to her need) . Confidentiality should be maintained but she should be asked to inform her partner due to risk of infection. Her file should not be flagged rather a hidden file should be kept secret with the consent of the patient. A STI screening should be done now & again at 28 weeks as she may have increased risk of STI. She should also screened for hepatitis B , C & syphilis if not done in booking. Mother may want TOP if disease is advanced & her decision should be respected. She should be informed that pregnancy has no effect on the disease & the infection has no role in pregnancy outcome. Ante retroviral is to be prescribed to the woman by HIV physician depending upon plasma viral load & CD4 T lymphocyte count. Most of the cases highly active ante retroviral agents ( HAART) given as they are very effective & does not cause resistance strain. If the patient does not require for ante retro viral therapy for herself she should be started short acting therapy ( START) from 34 weeks to prevent transmission to fetus. The side effects of the drugs are that they cause lactic acidosis which mimic pre eclamsia like symptoms. Drug toxicity should be monitored with regular monitoring of FBC, creatinine, liver function test & lactic acid level. To prevent pneumocystis carini infection Cotrimoxazole tablet is to be given to the mother with folic acid supplement as it is a folic acid antagonist. A detailed anomaly scan to see any fetal anomaly should be done due to the effects of the drug. If she required amniocentesis opinion from HIV physician should be sought. c) After delivery baby should be bathed immediately. Baby should be given prophylactic oral zidovudine for 6 weeks . Breast feeding is contraindicated to protect child from infection. Baby should be screened for HIV infection at birth , 3 weeks, 6 weeks, 3 months, 6 months by PCR but definitive test is dine ay 18 months. No contraceptive is contraindicated on basis of HIV infection only.
		Posted by Idris O. Wed Jul 4, 2007 11:35 am
Offer pre-test counselling that antenatal testing identifies patients who requires treatment to prevent progression of the disease. Antenatal treatment also shown to prevent transmission of infection to the fetus. This also offer safe practices to prevent transmission to others.Offer post-test counselling if positive result and information leaflet. Be aware that antiretroviral therapy, caesarean section and avoiding breast feeding has been shown to reduce vertical transmission of infection to the baby. Antenatal care would be a multisiciplinary care involving the social worker, HIV physician, Obstetrician, specialist midwife and GP. Offer screening for other STI\'s like hepB, Syhilis and chlamydia. Check viral load and CD4 count and commence HAART regime if CD4 count less than 400 and viral load above 10,000 copies/ml. Offer sulphadimidine to prevent pneumostic carina pneumonia if CD4 less than 200. Offer Downs screening with quadruple test and anomaly sreening at 20weeks. Serial growth scan at 28 and 34 weeks. Invasive testing can be offered for Downs sreening in the second trimester but associated with miscarriage of 1%. Avoid in the third trimester. There is an increased risk of vertical transmission with preterm delivery, prolonged rupture of membranes and chorioamninitis. Caesarean section at term shown to reduce vertical transmission with anti retroviral drug at least 4h before delivery. Be aware that vaginal delivery is possible if viral load undetectable but risk of transmission to the fetus unknown. Postpartum the baby is giving AZT for 6weeks and PCR done at 1 and 3months and antibody checked at 18months to determine if baby is infected. Mother is advised to avoid breast feeding as shown to reduce vertical transmission. Barrier contraception is offered to to the mother and seif insemination during the fertile period if desire pregnancy and the partner is negative. Offer Down screening with quadruple test and anomaly screen at 20weeks. Offer serial growth scan at 28 and 34 weeks. Invasive testing like amniocentesis can be offered for Downs screening in the second trimester but associated with 1% risk of miscarriage. Avoid invasive testing in the third trimester. There is an in Caesarean section has been sho
		Posted by Jancy V. Fri Jul 6, 2007 06:47 am
(a) I would advise her that screening of all pregnant for HIV is essential , because maternal to child transmission of HIV can be reduced from 30% to less than 3% if HIV positivity is detected early in pregnancy and appropriate antenatal care given. It is ideal to do the test in the booking visit or as early as possible in pregnancy because plan of care has to be decided and implemented early . Antiretroviral therapy to the mother and newborn, delivery by Cesarean and avoiding breast feeding can effectively reduce the transmission of HIV to the child. Eventhough HIV infection has a high incidence of mortality and morbidity ; effective treatment can prolong life and improve the quality of life of the mother. (b) Management of an HIV positive mother requires a multidisciplinary team involving HIV physician, obstetrician, neonatologist, midwife and if needed the psychiatry team and support groups. A carefully documented detailed plan of care and multidisciplinary meetings are essential. The woman?s HIV status and plan of care should be informed to all staff involved in her antenatal and intrapartum care and this should be informed to the woman. However she should be assured that her confidentiality will be respected. . The woman should be encouraged to attend antenatal clinic regularly. Social workers and community midwifes should be involved in women with social difficulties. She should be screened for genital tract infections like gonorrhea and Chlamydia and for bacterial vaginosis at booking and at 28 weeks, as there is high incidence of these infections in these women. Screening for Hepatitis B and C and syphilis should be done at booking. The woman should be offered Down?s syndrome screening. A detailed anomaly scan at 20 weeks should be offered , because of the use of antiretroviral drugs and folate antagonists in first trimester. It is better to avoid invasive prenatal testing as it may increase the maternal-child transmission. Antiretroviral therapy should be started in order to reduce HIV transmission to the fetus and to control the disease progression in the mother. The optimum treatment is decided in liaison with HIV physician on case to case basis. Zidovudine is the only drug indicated for use in pregnancy and the only drug available as IV doses. However, Highly active anti retroviral therapy (HAART) is used in indicated cases. Monitoring of CD4 count and viral load should be done at regular intervals by the HIV physician. If CD4 count falls less than 200, prohylaxis against pneumosystic carinii using cotrimoxasole should be given. Women on antiretroviral drugs should have regular lab tests- complete blood count , renal and liver function tests to monitor toxicity of these drugs. Women with symptoms of cholestasis, pre eclampsia and liver dysfunction should be refered to HIV physician as these may indicate drug toxicity. Elective Cesarean section should be planned at 38 weeks as it has clear benefit in reducing maternal-child transmission of HIV. (c) Women should be advised not to breastfeed their babies as this reduces the risk of transmission from 28% to 14%. Safe infant feeding alternatives should be advised. All infants born to women with HIV should be treated with antiretroviral therapy using zidovudine. Contraceptive advice should be given to the mother prior to discharge from hospital . She should be encouraged to attend follow up with the HIV physician and continue antiretroviral therapy.
		Posted by Reena M. Fri Jul 6, 2007 06:03 pm
HIV is a relatively new fatal, sexually transmitted disease, associated with significant maternal and fetal morbidity and mortality. It has no curative treatment but can be prevented from being transmitted to the unborn fetus , with appropriate antenatal antiretroviral therapy, elective lscs at term and avoiding breast feeding to <2%. If not, incidence can be as high as 25-30%.HIV screening is now recommended universally at the booking clinic in early pregnancy (RCOG REC A).The patient is reassured , of confidentiality if test result is positive.However people involved in her antenatal, intrapartum care , obstetrician, midwife and the paediatrician will be made aware.,toprotect them. Her sexual partner is informed about the same by herself or by treating personnel so as to protect him from acquiring the disease and also screen him for HIV and other STDS.,Once tests are positive, she is counselled in a nonjudgemental supportive manner.The test result is conveyed to her by a senior specialist involved in her care. Introduce her to similar group of patients, drug dependency social support groups , if a drug addict. Her management is by a multidisciplinary team consisting of HIV PHYSICIAN, OBSTETRICIAN, MIDWIFE ,PAEDIATRICIAN , psychiatrist.She is explained about the need to undergo blood tests to detect her viral load, CD4-Tlymphocyte count, CBC, urea and electrolytes, LFT, blood glucose, screen for STDS, chlamydia, gonorrhoea, bacterial vaginosis, syphilis , HEP B , C, CMV ,TOXOPLASMA. If screening for bacterial vaginosis negative to be repeated at 28 wks of gestation. Starting of HAART drugs, will be decided by HIV physician , duration of use and when to stop, usually if her CD4 COUNT is less than 200x106/l and high viral load of >10,000-20000 copies , she is started with these drugs. Made aware of toxic side effects like nausea, fatigue, fever rash,She is advised to undergo monthly evaluation of these tests . To report in the event of infection, may need Pneumocystis Carini prophylaxis . Drug of choice is clotimaxazole. She has to come for more frequent antenatal follow ups.She is educated about signs and symptoms of s/s of eclampsia and obstetric cholestasis and report soon.She is assured ,of less chances of teratogenicity to her fetus as the first trimester is over. She is offered Downs syndrome screening and amniocentisis, risk of MTCT,transmission is not available, Need to be referred to fetal medicine specialist for anomaly scan. Offered termination of pregnancy if she is inadvanced stage disease.If she is in remission, zidovudine monotherapy is started from 28-32 wks antenatally bid , a date for elective lscs at 38 wks is given. Zidovudine(only drug for parenteral use) intravenous infusion is started with loading dose of 2mg/kg/1hr and maintenance dose of 1mg/kg/hr 4 hrs prior to surgery and stopped once the cord is clamped. Post op prophylactic antibiotics is given, continuation of retroviral drugs is according to HIV physicians opinion. Breast feeding is avoided, contraception in form of MIRENA and condoms is advised as certain antiretroviral drugs if she is on ,has enzyme inducing action. Advised to undergo a pap smear after 6 wks ,as chances of developing cervical cancer is more. If negative , needs to be followed up annually. Neonate , cord is immediately clamped, washed of maternal scretions, maternal blood and neonatal blood collected for maternal plasma viral load and to detect infection in neonate. Neonate is on montherapy of zidovudine orally for 4-6 wks, if test negative, test repeated at 3 wks, 6 wks and 6 months. HIV antibody test done at 18 months, if negative confirms the baby is not infected.All the above measures, if appropriately taken can reduce maternal to child transmission rates to less than 2%, and improve better quality of life to the patient and her partner.
		Posted by Sabahat S. Sat Jul 7, 2007 11:27 pm
A) Testing for HIV is offered as a routine to all pregnant patients. It is a simple, highly effective test. Effective interventions are available at all stages of pregnancy ? Can effectively bring down the rate of vertical trnsmission from 40% to less than 2% The baby will be protected from aquiring the vertical infection, she herself will be benefit by treatment for her own benefit, also the partner can be protected after the HIV states is known. She will be reassured that the confidentiality will be maintained at all stages. Written information is provided to support the verbal councelling & she should be informed that she has the option to refuse the test if she wishes. B) The result of the positive HIV test should be given to the woman in person , by an appropriately trained person- preferably an obstetrician, a midwife,an HIV physician. She will be psychologically disturbed, Adequate time should be set aside for the councelling of this patient. She should be reassured that very effective interventions in the form of antiretroviral therapy ? monodrug (only zidovudine) or multidrug ( highly active antiretroviral therapy ) can be started . she will require a multidisciplinary careincluding an obstetrician, neonatologist, HIV physician psychiatrists, social workers, midwife. Anomaly scan of the fetus is done at about 20 wks to rule out any congenital malformations routine screening for down syndrome is also offered. In case of positive anamoly scan , invasive testing (amniocentesis) can be offered after consultation with the HIV physician (as the risk of vertical transmission thro amniocentesis is unknown) if the patient so wishes she can be offered T O P C D 4 counts &viral load should be checked at fixed intervals. & the therapymodified accordingly in consultation with the HIV physician. She may receive HAART through out her pregnancy or only START ( short term antiretroviral therapy )from 28 ? 34 wks. In case the CD4 counts fall below 200/ cumm anti pneumocystis carni prophylaxis should be started. Screening for other sexually transmitted infections should be carried out ? preferably in a GUM clinic & appropriate contact tracing carried out. Signs & symptoms of drug toxicity should be watched out for , which can manifest as preclampsia and / or lacticacidosis. CBP, LFT, blood urea, serum electrolytes, serum lactate should be done Written understandable information which she can take home & read, should be given to her & she should be put in contact with support groups. The patients confidentiality should be maintainedstrictly (however she should be encouraged to inform her HIV status to her partner ) Her file should not be flagged, but a secret code identification should be kept. C) Breast feeding should be advised against ( it reduces the rate of vertical transmission from 28 ? 14 % ) the baby should be bathed immediately after delivery of all maternal fluids &started on HIV therapy. Testing by PCR is done at birth, 3 wks, 6 wks, 3 mths, 6 mths & definitive testing at 18 mths. The baby will receive ART for 4 ? 6 wks or longer depending on his HIV status. She should be advised to use barrier contraception, along with any other contraceptive method that she chooses. IUCD should preferably be avoided. Before discharge she should be put in contact with support groups
		Posted by Malar R. Sun Jul 8, 2007 08:37 pm
This lady needs to be informed that this is a screening test and that she is not being offered the test due to prejudice. Every pregnant woman is offered the test especially as HIV prevalence is increasing and that treatment is available for woman and to prevent vertical transmission.However it is important to explore her reasons for being concerned as she may in fact think that she has been exposed to HIV and therefore be at risk of infection.Sometimes, in the case of asylum seekers, they can think that it will affect their asylum approval status.She should be encouraged to positively opt in for screening and the test not be done if she does not consent. Antenatal care will start with informing the patient about the diagnosis and providing support in the form of a specialist midwife experienced in HIV and support groups.HIV physicians and GUM physicians should be involved in her care to start investigations such as CD4 counts and monitor viral loads. Also GUM physcians can offer screening for other sexually transmitted disease such as gonorrhoea and chlamydia which can be treated and can be more prevalent in the presence of HIV.Also, the partner can be offered screening in GUM.Antiretrovirals might be started from diagnosis if the viral loads are high under the guidance of the HIV physician or empirically after 26 weeks to prevent vertical tranmission.USS for growth should be done monthly during the use of anti retrovirals due to association with IUGR. The patient should be reviewed regularly in ANC jointly with the specialist midwife, the obstetrician and the HIV physician for fetal surveillance and ensuring the woman is well supported and educated about her condition.Her viral load and CD4 counts should be monitored monthly and prohylaxis against pneumocystitis carinii started if CD4 counts are less than 200.She needs to know that antiretrovirals are safe in pregnancy and are not teratogenic.The paediatric team, preferably a consultant with an interest in HIV,should be involved and plan should be made about postnatal baby care and the woman informed af the need for baby to have antiretrovirals from birth. The woman should be advised against vaginal delivery due to the increased risk of HIV transmission to the baby especially in the presence of a high viral load.Also, she should be advised of increased in vertical transmission in the presence of prolonged ruptured membranes of more than 4 hours. She should be delivered by caesarean section if she agrees. If viral loads are very low and the woman declines a caesarean section , then vaginal delivery should be carefully carried out avoiding fetal blood sampling, difficult instrumental deliveries or artificial rupture of membranes to minimise transmission to baby. Postnatally, the paediatric team should be involved from delivery and the baby washed straight after birth to reduce risk of HIV infection from maternal blood and secretions.Zidovudine should be given to baby and blood test for HIV should be done at birth and at regular intervals until the HIV antibody test excludes infection.Breastfeeding should be avoided to reduce risk to HIV transmission. Antiretrovirals in mother can be stopped if they were only started to reduce risk of tranmission to baby, but should be continued if it was for maternal advanced disease. The HIV physician should closely liase with obstetric team for aftercare concerning antiretrovirals.
		Posted by Parveen Q. Tue Jul 10, 2007 09:54 am
The reason behind offering the HIV test is in the event of positivity, the outcome to the foetus is improved and the progression of disease reduced in mother. It is the test offered to all pregnant woman in U.K. patient can be reassured if the test is negative. HIV has a high rate of vertical transmission 15-25% which can be reduced to less than 2%if certain measures like highly active anti- retroviral therapy(HAART), elective caesarean section and avidance of breast feeding. Appropriate precautions for health care professionals taken in case of postive test . Tests for other sexually transmitted disese like chlamydia, gonorrhoea, and other tests like HBSAG, HCV, syphilis and tuberculosis can be done and treatment offered. all information should be backed by leaflets and documented in her notes. Her antenatal care involves disclosure of test results by senior obstetrician and supportive care given if needed. Confidentiality will be ensured at all times, and partner notification by patient is encouraged.Multidisciplinary team of obstetrician, HIV phsician, supportive nurse, counsellors, midwife, neonatalogist involved in her care. HAART therapy started in conjunction with HIV physician. The side effects are hyperglycemia, lactic acidosis , which mimcks pre eclampsia. Frequent monitoring of wbc, hb, blood sugar level done. HIV disease monitored by CD4 lymphocyte count, and viral load.If CD4 is less than 200, propylactic antibiotics aganist pneumocystisis carnii pneumonia by giving co trimaxazole,and folic acid given as it is folic acid antagonist. Viral load monitoring done as transmission can occur upto 1000copies. Foetal growth monitoring by growth scans to monitor for IUGR from 28weeks once in 2weeks. Any co existent STD treated, and immunisation planned for foetus, and a carepathway devised and documentd in notes. Elective C.S prevents vertical transmission rate ,but in the event of HAART therapy and insignificant viral load, the role of caesarean section is controversial. Cord should be cut immediately and baby bathed soon after delivery. Postpartum care involves, avoiding breast feeding reduces transmission to less than 2%. continue the antiretroviral therapy for mother, and baby should have the antiretroviral therapy for 4-6weeks,.HIV antibody test done at 3weeks, 6weeks, and at 6months. Negative test at 18months is reassuring. Contraceptive advise given, as there is no contraindication for any methods for HIV. Followup appointment given.
		Posted by Dr. Ruvana T. Sat Jul 21, 2007 03:59 am
(a) I will tell her that this screening test for HIV in pregnency will help to take decession for antiretro viral treatment, delivery by c/s, avoidence of breast feeding. This will reduce risk of mother to child transmission 25-30% to less than 2%. (b)I should give HIV positive result to patient by an appropriate trained professional and should involve Multi-deciplinary care- HIV physician, Obstetrician,midwife, paeditrician,support group, psychiatrics,social worker and drug dependency specialist. I shall also maintain confidentiality of the disease and encourage her to inform her sexual partner. Then I shall perform plasma viral load and CD4 count reviewed by an HIV physician on a regular basis and prophylaxis against pneumocytis carini (when CD4 count less than 200 million/l).In this regard 1st line antibiotic is co-trimoxazole. At the same time I shall screen for other STD including Hep. B & C and syphilis. After 1st trimester exposur to HAART or anti-folate agent, I shall offer pre-natal diagnosis and detailed scan.I shall also discuss with HIV physician or fetal medicine specialist regarding HAART prophylaxis.I shall be well alart about all side effects of HAART treatment like preeclamsia, cholestasis or other liver dysfunction, lactic acidosis. Women who donot require anti-retroviral therapy for their own health,I should council that treatment is only to prevent vertical transmission- usually from 28-32 weeks through delivery and postnatal period. (c)I shall advice to avoid breast feeding, as it will increase risk of vertical transmission 14% for women infected before delivery and 30% infected after delivery.Neonate should receive anti- retroviral treatment from birth and continue for 4-6 weeks.I should screen neonate by PCR at birth,3,6weeks and 6 months and HIV antibody test at 18 months.
		Posted by Dr. Ruvana T. Sat Jul 21, 2007 04:06 am
(a) I will tell her that this screening test for HIV in pregnency will help to take decession for antiretro viral treatment, delivery by c/s, avoidence of breast feeding. This will reduce risk of mother to child transmission 25-30% to less than 2%. (b)I should give HIV positive result to patient by an appropriate trained professional and should involve Multi-deciplinary care- HIV physician, Obstetrician,midwife, paeditrician,support group, psychiatrics,social worker and drug dependency specialist. I shall also maintain confidentiality of the disease and encourage her to inform her sexual partner. Then I shall perform plasma viral load and CD4 count reviewed by an HIV physician on a regular basis and prophylaxis against pneumocytis carini (when CD4 count less than 200 million/l).In this regard 1st line antibiotic is co-trimoxazole. At the same time I shall screen for other STD including Hep. B & C and syphilis. After 1st trimester exposur to HAART or anti-folate agent, I shall offer pre-natal diagnosis and detailed scan.I shall also discuss with HIV physician or fetal medicine specialist regarding HAART prophylaxis.I shall be well alart about all side effects of HAART treatment like preeclamsia, cholestasis or other liver dysfunction, lactic acidosis. Women who donot require anti-retroviral therapy for their own health,I should council that treatment is only to prevent vertical transmission- usually from 28-32 weeks through delivery and postnatal period. (c)I shall advice to avoid breast feeding, as it will increase risk of vertical transmission 14% for women infected before delivery and 30% infected after delivery.Neonate should receive anti- retroviral treatment from birth and continue for 4-6 weeks.I should screen neonate by PCR at birth,3,6weeks and 6 months and HIV antibody test at 18 months.
		Posted by Amen H. H. Wed Jan 2, 2008 09:47 pm
Can we answer old essays also ?