[Home] [Basic knowledge] [Diagnosis of AIDS and HIV Testing] [Diagnosis and Treatment] [Nursing and Nutrition]
Dr.
John Walsh
St Mary Hospital, London
United
Kingdom
1.
Antenatal HIV testing
2.
Termination of pregnancy,
3.
Anti-HIV therapy
4.
Modifying labour and delivery
5.
Modifying infant feeding
The
World Health Organisation (WHO) recommends that voluntary HIV testing and
counselling should be available in all antenatal clinics because:
If
the result is positive the woman can
seek early medical treatment and care of
opportunistic infections for herself and her children
make informed choices about preventing
transmission of HIV to their unborn child
encourage their partners to be counselled
and tested.
make more informed choices relating future
pregnancies
Widespread
access to testing can help normalise attitudes to HIV in the community.
Knowledge
of a negative result can reinforce safer sex practices.
Prevention
of mother to child transmission depends upon identifying HIV-positive women
during pregnancy
2. Termination of pregnancy
HIV
infection alone is not a reason for termination of pregnancy; however it is an
option that individual women might wish to consider
A
decision should not be made until the woman is made aware of other options to
prevent transmission below
Many
women are diagnosed HIV+ too late for a termination
3. Anti-HIV therapy
AZT: 076 study compared:
AZT:
to the mother from 24 weeks
i.v. during labour and delivery
to the infant at birth and for 6 weeks
no breast feeding
with no treatment
AZT ¯
transmission by 67%: this gave a transmission rate of 6-8% in Europe/USA
Several
studies have tried variations on this:
If AZT given from 36 weeks, but not to the infant (no
breast feeding):
¯
transmission by 50%
If AZT given from 36 weeks, but not to the infant (with
breast feeding):
¯
transmission by 30%
If
combine AZT with pre-labour Caesarean section transmission can fall to <2%
Nevirapine
Advantages:
after 1 dose:
rapidly absorbed
high levels in blood
last long time
high levels cross the placenta
might be much cheaper (US $4) and easier to use than AZT
HIVNET
012 study compared
1 dose of nevirapine given to mother during labour,
then
another to the infant at 2-3 days old
with
AZT given by mouth to mother during ;labour and to the infant for 1 week
All infants breast fed
At 1 year 16% of infants who received nevirapine were HIV+ compared with
24% on AZT
But nevirapine resistance emerged in 20% of mothers and 50% of HIV+ infants
Neither of these treatments prolong the
life of the mother: the priority in making decisions about starting anti-HIV
treatment in pregnancy should be the mother’s health; if combination therapy (HAART)
is required by the mother and is available it should be given
4. Modifying labour and delivery
Most
HIV transmission from mother to child is thought to occur around the time of
labour and delivery.
Factors
associated with an increased risk of transmission at the time of labour and
delivery include:
·
Vaginal delivery
Pre-labour Caesarean section at 38 weeks ¯
risk of transmission by 50%
but
may
risk of post-operative death of woman from infection
·
Prolonged rupture of membranes
>4 hours
Risk
of transmission
by 2% for every hour membranes ruptured
Membranes
should not be ruptured artificially.
·
Episiotomy
If
foetal distress occurs the consider emergency caesarean section as
this
has lower risk of transmission than use of forceps etc.
·
Invasive foetal monitoring e.g.
scalp electrodes
N.B.
use of Universal Precautions (including gloves and frequent hand washing) should
be adopted whether or not the HIV status of a mother is known
Risk
of transmission from breast feeding 10-30%
Where
safe alternatives such as replacement feeding exist, HIV positive mothers should
avoid breast feeding
For
HIV-negative mothers, breast feeding still remains the best option.
Problems
where resources are limited:
Women may need education about safe use of feeds
No safe water supply
Difficulties sterilising feeding equipment including lack of fuel
No refrigeration
Replacement feeds expensive
Supply may be inconsistent
Stigmatising: if everyone normally breast feeds; not breast feeding can
lead people
to
suspect the woman has AIDS
If
the HIV+ mother decides to breast feed the risk of transmission can be reduced
by:
Teaching the mother to inspect her child's mouth for thrush and sores
Stopping breast feeding or seeking early treatment for mastitis, breast
abscesses,
and
bleeding or cracked nipples.
Stopping breast feeding after 6 months when the baby can be safely weaned
Avoiding ‘mixed’ feeding as much as possible: seems to
transmission
Using expressed milk that is boiled and then cooled. (Boiling kills the
virus.)
[Home] [Basic knowledge] [Diagnosis of AIDS and HIV Testing] [Diagnosis and Treatment] [Nursing and Nutrition]