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Approach to the Case of HIV in Pregnancy

May 27 | 3:30 PM

During pregnancy, HIV can pass through the placenta and infect the fetus. During labor and delivery, the baby may be exposed to the virus from a woman's blood and other fluids. When a woman goes into labor, the amniotic sac breaks. Once this occurs, the risk of transmitting HIV to the baby increases. What all prophylactic measures do we need to take in all three trimesters? What's the correct approach? Let's understand the right approach to the case of HIV in pregnancy from Dr. Swati Gawai.

[Music] good evening everyone uh i dr rucha welcome you all on behalf of team netflix uh welcome to another interesting session uh so we have dr swati gawai with us today uh mam is assistant professor uh at ltmc and sign hospital mumbai in the department of obstetrics critics and gynecology uh welcome ma'am uh to another interesting session and we are looking forward to it thank you last time also you had discussed amazing in interesting important issues like uh mtp act so right now uh we're sure that we will get some amazing insights so with this i had to go to mom thank you thank you so today's topic is hiv in pregnancy and how is it different from normal other non-pregnant women we don't just have to evaluate and treat the hiv infection but apart from that we have to prevent the transmission of the infection from a mother to the child so in this session for next 30-40 minutes we are going to see the diagnosis and treatment we are going to discuss the counseling of hiv infected women of reproductive range we are going to see the obstetric particular obstetric medical anesthetic and post-partum management of hiv-infected pregnant women so the mode of transmission most commonly is heterosexual and in the last 10 years in india almost 17 lakhs of people have got the disease due to unpredicted sexual intercourse so currently in india there are more than 23 lakhs of people with hiv and out of which almost 83 000 are children many of them are under 15 years of age so in eos there is some racial uh increase in the incidence of hiv mostly in african american age group of 25 to 34. the incidence is also more may be because of lack of the perception of risk and because of the relationships dynamics and inability to negotiate the use of condom and fear of violence this might be the reason of increased incidence in u.s so how do we screen is it compulsory so in pregnancy it is not compulsory it is recommended we can say it is mandatory the woman can opt out that is the woman can deny to get the hiv test done during pregnancy but we should explain the risks and consequences so it is a mandatory test it should be done early in pregnancy at the first visit and it should be repeated in third trimester if the early testing was not done or was initially negative in an at-risk woman so the risk factors includes the specific prevalence geographic areas or the health care facilities and the personal factors like drug abusers injection users or commercial sex workers or the sex partners of hiv infected women of life infected persons or drug users or a new or more than one sex partner during this pregnancy so rapid hiv testing is uh is to be done at the time of labor if it is not done or if it is not documented in the index pregnancy so what are the diagnostic tests we detect it by rna pcr and the standard is elisa that is enzyme immunolink amino acid and there are various different rapid tests also available over quick where we can perform an overall fluid sample and a positive test it should be confirmed with the second most specific test which is western blood test immunofluorescence seo or hiv rna bcr it detects the antibodies to specific hiv antigens and the positivity requires the presence of antibodies to two of either p24 gp41 and gp 120 or 160. so testing which is indeterminate indeterminate if the elisa is positive and the western dot shows antibody to only a single hiv antigen and negative conformity testing should be repeated in third trimester again for the address chroma and even if it is in the indeterminate then also we have to repeat it and the results of this indeterminate test may be because of partial serum conversion or advanced acquired immunodeficiency syndromes with decreased antibody titers or blood transfusions organ transplantation autoimmune diseases and experimental hiv vaccines so risk factors must be assessed when evaluating an individual test so a hiv infection is unlikely in low risk patients with repeat interpretation test in three months if it is negative in three months then it is unlikely less likely that they are positive so the patients who are in the process of zero conversion will usually have a positive western plot within a period of one month so a gestational age should also be considered in making decision about the treatment in case of indeterminate testing so waiting of one to three months to repeat testing is reasonable in early pregnancy the patient is coming advanced pregnancy then better to start if a viral testing can be used and if negative the treatment can be deferred pending follow up antibody testing and if it is close to delivering then we have to start the treatment just like a positive testing at the time of labor or delivery so pathogenesis uh first the primary infection occurs then there is an increase in the viremia it it manifests it manifests in the form of fevers adrenal fatigue malaise malaysia myalgia pharyngetist rash and septic meningitis in some cases so cells with cd4 receptors become infected and the viral replication begins within them the infected cells release varions by surface of budding analysis and it cause causes the infection so the sequence becomes incorporated into the dna during replication and it remains their life until the death of the cell so the reservoir begins and the t cells is established early on and in the end process for many years it can harvard drug resistant virus when patients are exposed to sub-optimal treatment achievement the number of cd4 lymphocytes decline acutely then they rebound as the immunity is regained and rebound and then cd4 and t lymphocytes in particular works to control the viral replication so after few attempts of this an active equilibrium is reached in which the rate of production of new cd4 c cells equals the rate of destruction and the person may remain asymptomatic during these number of years so the replication continues and over the time the plasma viral load increases and the number of cd4 lymphocytes decline so monitoring is of the cd4 cells is very important to establish the stage of hiv disease so mild symptoms like weight loss lymphadenopathy and various skin problems like mucocutaneous ulcers rash or hairy leukoplakia thrash vaginal candidiasis this often occurs in symptomatic hiv disease most aids related opportunistic infection do not occur until the cd4 count falls below 200. so the risk of disease progression increases with time and is thought to ultimately be very high without treatment so although mild symptoms can occur early in the occur early in the course of hiv disease the patient can remain completely asymptomatic for a long period of time so the absence of symptoms should not preclude hiv testing so hiv virus mutates readily and several viral variants have emerged in an individual some of which are capable of immune control also so chronic immune system inactivation activation is thought to contribute to cd4 cell loss and reduce efficacy of b cell responses to the bacterial pathogens so more severe symptoms and development of uh aids defying illness occurs when the significant number of cd4 have been destroyed and production cannot be matched or the production is not equivalent to the destruction so this pcp that is pneumocystis carrying it is because of this generic bacteria which is the most common opportunistic infection although uh the pcb prophylaxis the incidence has decreased nowadays so other infections are also there like cryptococcal meningitis uh bacterial infections cerebral toxoplasmosis bacteremia pneumococcal pneumonia and copy simplex infection later on other disseminated cytomegalovirus mycobacterium avm complex this can also occur so the time course of hiv infection uh in the early weeks of infection it is acute infection for the early disease it usually takes months to years for mid-range disease it is years and for advance it is more than many many years so what happens to cd4 sales usually they are more than 500 and in early disease they range from 350 to 500 for mid-range disease 200 to 350 and advanced decision it is less than 200 and hiv hiv rna it is usually more than 25 000 but it can often be more than 5 lakh also and in various early made and advanced diseases it varies the irony depending upon the immunity or our immunity if it is immunities drop because of something else then it it will rise the clinical symptoms for acute infection are usually fever rash loose emotions pharyngeitis lymphadenopathy early disease since the body adapts usually there might be no symptoms also or sometimes only zoster infection herpes roster oral or night sweats are there and when the disease is establishing in mid-range disease there is weight loss lymphadenopathy oral brush nights with diarrhea and full blown aids all other opportunistic impressions are there so what is the role of arv it prolongs the life and extent the disease free survival in hiv infection so efficacy is charged by improvement in the cd4 count and suppression or decrease in the viral load so combination of highly active antiretroviral agents these are associated with greatest efficacy english development of resistance so various groups are there nrti and then rdi and protease images so inhibitors and other groups are also included nowadays so combination of usually two to three group of arv is beneficial so coming to uh preconception counseling with the use of this highly active antiretroviral therapy the hiv infected women they are living longer and they are living healthier also so the attitude of having like previously like 10 years back they were directly told that you do not conceive or you can adopt child and they nowadays the trend is changing now they can they are also thinking to have children with a good continuation of medicine and good control and monitoring of cd4 count so all women who are of reproductive age should receive preconception counseling and stating during hiv early during hiv kn and it the counseling includes information about mother to child transmission the importance of maximizing the health minimizing the viral load surrounding the pregnancy utilization of art and potential short-term and long-term implications of hiv treatment during pregnancy for women and the infant so it also offers the opportunities opportunity to advise on safe sex practices and discuss the methods to prevent unintended pregnancies so hiv testing of sex partners is to be encouraged uh for discordant couples like the couple where only one partner is positive and the other one is negative we can use various we can suggest them for intravaginal or insemination another assisted reproductive techniques to achieve pregnancy counseling and reference for cessation of smoking because usually they are uh having these other habits also drug abuse smoking so this they should also be counsel them preconception only and if not preconception many of the women are identified or are diagnosed with hiv during prenatal testing so these women need to receive the same same information like mother to child transmission art their own health long term follow-up short-term follow-up followed by the preconception counselling so without ait the transmission rates uh centers around 25 percent and which occurs mainly it can occur any time anti-part-time intra-bottom and post-partum also through breastfeeding so total two thirds to three quarters occurs during or close to the intra pattern like in third trimester during labor so in resource limited settings breastfeeding accounts for approximately forty percent of the peripheral post atoms so our country is a resource limited country like uk and u.s they are resource enhanced they have other resources so maternal factors which uh with uh with a mother to child transmission includes advanced like the mothers who are in advanced hiv disease with high viral load lower cd4 count poor maternal nutrition maternal illicit drug use smoking and stds so they these this group are having increased chance of transmitting the infection to their babies obstetric factors like prolonged rupture of membranes chorionitis and root of delivery like vaginal will be more fetal factors like low birth weight prematurity and genetic susceptibility viral phenotype and genotype may also affect the transmission rate the two most important factors affecting mother to child transmission are maternal viral low and art used during pregnancy so viral load near term correlates with the risk of mother-to-child transmission among both untreated women and women treated with attitudinal pregnancy so with rna levels thousand copies have a very low rate of mother-to-child transmission however with a viral transmission have been documented even with if sometimes the low the rna copies are less but then also it is uh transmitted so this there is a discordant uh data regarding this transmission so combination of three arv agents is usually uh enough to decrease the transmission compared to those who are not on any drugs so current guidelines recommend anti-partum intrapartum and postnatal infant arv for fetal and neonatal protection regardless of viral road breastfeeding it is not recommended in research resource-rich countries but in india being very we are not we are developing countries so we don't have resources so we usually uh ask them to breastfeed but it it increases the risk of transmission so we have to tell the woman about the side effects of arv and inform of the safety concern they have to they should be aware of the needs of short-term and long-term monitoring for the woman herself as well as for the baby for the infant for potential effects of exposure to the baby of arv during pregnancy so it is seen that a pregnancy does not accelerate the immunological decline or affect the disease progression and survival amongst hiv infected women so there are reports of postpartum increase in hiv rna regardless of continuation of art after delivery so it might be because of decreased adherence or change in the art postpartum so antipartum how do we manage we have to take the basic care of hiv infected pregnant women it includes first evaluation and therapy for maternal hiv disease then ait for fetal protection and as appropriate for maternal health monitoring for ait toxicities peripater management including selection of fruit of delivery then a neonatal art arrangement for long-term health care for both mother and the infant comprehensive care and the uh entails a team approach with coordinated efforts by multiple service providers we have to take help from everybody psychiatrist also neonatologists so the obstetric care it should be supplemented by maternal fetal medicine or infectious diseases uh it may be transferred to referral centers with expertise in hiv or aids and the management includes the hiv education and the counseling hiv testing of sexual partners and other family members also psychological assessment and ongoing counseling drug abuse management if it is their supportive services and adherence strategies they should be asked to come to be compliant so we have to see that they will take the uh medicine and the visits to ait centers so if the woman is receiving hiv care prior to pregnancy the results of recent lab live in lab investigation and currently prescribed iit should be confirmed if a woman has not been receiving medical care or was recently diagnosed then the obstetric provider must initiate evaluation for hiv dc staging and frequently other co-existing infections like stds drug use alcohol use and smoking these all these factors should be evaluated in studies so antiretroviral the choice of agent and initialization of therapy uh all the women should receive combination therapy of at least three drugs uh during pregnancy for fetal protection regardless of the necessity of ait for maternal health at least for preventing transmission they should be given the arv the exact regimen should be individualized based on the stage of maternal hiv disease then the primary prior history of ait also and genotypic resistance to arv the regimen recommended for women who have not previously received ait are those recommended as initial therapy for other hiv adults so if the woman is on a stable ait that has achieved good virological control and immunological effect this should not be stopped during pregnancy this continuation of ait can lead to viral rebound with the possibility of in neutral infection and emergence of resistant virus and no major teratogenic effect of commonly used arv agents have been demonstrated except for e5 variancy five arranges associated with neural tube disorders where it it has a in including dandy walker syndrome is also found within fibers so if the other agent should be substituted for efforts during preconception counseling or as early as possible once the pregnancy has been documented the timing of initiation of art during pregnancy is determined by the indication for its use if maternal viral load is low and immunological suppression is minimal and the indication is fetal protection then arv can be started after the first trimester also if the indication is for maternal here and a rt has to be then the art has to be started irrespective of whatever uh gestational each immediately we have to start effectiveness and safety of ait are influenced by adherence to the drug regimen inconsistent use with the time periods of sub-therapeutic drug levels promotes the development of resistance and biological failure also in case of hyperemesis the arv should be stopped and not instituted unless the medication can be taken as prescribed if the nausea and vomiting is started after arv then anti-antimatrix can be utilized and hospitalization for directly absorbed therapy and treatment of side effects may increase the adherence to the treatment if required we can always hospitalize them counsel them for one two hour days 24 to 48 hours and once they are better we can send them home it will make ensure the adherence of the drug so nrti and nnrti agents they are not affected by pregnancy and usually the dose alteration is not required in pregnancy so there are substantial differences during pregnancy and pharmacokinetic profile of protease inhibitors so we need to adjust the dose so negligible level of protease inhibitor is also found in the cord blood they are metabolized by the in the liver by cytochrome p5450 and the changes are likely due to alteration in the hepatic metabolism during pregnancy as well as the placental protein synthesis and drug metabolism so some of this pi and nnrti fibrins can induce and inhibit the hepatic metabolism of other medications so thereby they alter the drug levels and may cause or enhance toxicities so particularly use of argutamine and [Music] has been associated with exaggerated visa constructive response so postpartum we should avoid using alcohol i mean if the patient is on protease if for uterine atony we should use some alternative drug the chine viral load and cd4 counts are checked within two to four weeks after initiating or changing ait and once an effective regimen has been established then cd4 cell counts are checked every three months and hiv viral loads are checked every two months and between 34 and 36 weeks of gestation in order to assist in determination of mode of delivery so these are the drugs like zyto vegan lamin they they don't change during pregnancies so there there is no requirement of changing the dosage during pregnancy for all these drugs zydovidina by kevin navy wrapping fiber ends indian avail all this stress these drugs individual during pregnancy so we need to modify the dose we need to adjust those for these drugs so how do we assess initially we have to stage the disease and we have to start the antiretroviral management we have to check for cd4 count viral load genotype then coexisting conditions also we have to see like hepatitis b surface antigen if it is positive then we have to do the dna pcr hepatitis c antibody if it is positive then do the rna pcr of hepatitis c then serological dispersive phyllis toxoplasmosis cytomegalovirus gonorrhoea chlamydia and pepsi so these tests are to be this this we have to assess and the goal behind this is to achieve a non-detectable viral load prior to delivery for common hematological renal hepatic and metabolic side effects of arv should occur periodically anti-partum and whenever suggestive signs and symptoms occur so many experts recommend thought trimester monitoring for fetal growth and wellbeing if women are receiving an arv that has not been commonly used during pregnancy it is better to do it so these are the drug interaction like navy wrapping it interact with methadone and it decreases the dose of methadone so we have to to get that desired action we have to increase the dose of methadone like protease inhibitors uh along with argo talk orgotamine it will cause increased vasospasm so we have to avoid we can use other alternative if protease inhibitor is given with midazolam then it will prolong the sedation so avoid possible or give an alternative like lure as a pumpkin similarly there are other methyl none before between close up in these drugs are there so the levels are increased so if possible we give other drugs alternatively so how do cd4 count so cd4 count and quantitative hiv viral load we have to do every trimester one month after continue initiation or changing the arv and as needed for evaluating or adjusting the therapy for genotype when the viral hiv genotype when the viral load is increased while on arv or when virus detected when previously suppressed while on a rv uh you have to purify protein derivative early in pregnancy or if suggestive uh chest x-ray if the symptoms are there some cbc usually in first trimester and sos whenever required if the symptoms are there liver function test electrolyte mileage all these tests where sos when they are required and 50 gram glucose challenge test early in pregnancy and then again third trimester usually at 28 weeks of the station ultrasound usually it is for prosthetic standard and every four to six weeks for assessment of the fetal growth and efi that is amnetic fluid volume nst or biophysical profile it is weakly indicated for assessment of fetal wellbeing so most arv they cause gastrointestinal side effects particularly during initial use till the patient gets adopted and the rates are not higher during pregnancy if initiation is in first trimester anemia is a known side effect of nrti in particularly zydovidin it occurs more frequently in hiv infected pregnant women receiving any arv than those in not on medication so long term use of pi is associated with hyperglycemia including neurons in diabetes mellitus so potential for glucose intolerance remains of concern among women with long-term pi use and so they should be evaluated and the test should be done early also 24 to 28 weeks of gestation sometimes deaths from hepatic failure have been deported in pregnant women on combination art containing never happened during pregnancy severe navy raping hepatic toxicity in adults have been observed through after the onset of use soon after the onset of use more commonly in woman and is often associated with rash and mostly in those who are having cd4 count of 20 to 50. its true rate of occurrence is unknown as it as is whether or not it is more common during pregnancy but it is common in women but we don't know whether they are pregnant there is no such study that it is seen in pregnant women but it is definitely more common in women so it should not be initiated if a cedar for countless 250 if therapy would never happen is initiated during pregnancy then lft should be monitored frequently at least for the first 18 weeks every month it should be monitored if it is deranged then more frequent every 15 days so most cases of hepatic toxicity resolve on discontinuing the medication never have been containing regimen that have been used since before pregnancy do not need to be discontinued maternal deaths in third trimester from lactic acidosis and hepatic steatosis in association with use of diadenosine and stavidin throughout pregnancy have been deported so symptoms are non-specific nausea vomiting malaise and lab findings can mimic those pregnancy related disorders such as help syndrome and fatty liver of pregnancy discontinuation of arv and supportive therapy often results in the full recovery so combination of steroidine and iodine ocean should not be used in pregnancy and possibility of metabolic syndrome with hepatic dysfunction should be investigated in women receiving nrti agents who present with suggestive symptoms in general arv use is not associated with that adverse abstractive objective outcome reports have shown improvement in obstetric outcome in women receiving arv compared to untreated woman so there is conflicting data to whether to use combination of art containing pi is associated with some say that it is associated with preterm delivery and some studies are there which don't say like that which are not supporting so there is a theoretical concern that short-term exposure to art for one or more pregnancies could result in emergence of antiretroviral resistance limiting the option for maternal health in the future but long-term outcome data is lacking so there is no long long term outcome data the advantage of arv during pregnancy for fetal protection outweighs any neonatal and infant toxicities immediate toxicities are limited to transient anemia and therefore it should be given so this is a study in road and they have seen this uh squamous tumor of skin lung and liver genital tract have been noted with cytobutane and the symptoms range in severity from severe disease including death in clinically apparent disease neurological involvement including seizure hypotonia encephalopathy and developmental delays typical and myopathic myopathy pancreatitis and cardiac toxicity can also occur with this hydrovd increase rate of femoral seizure in an rdi exposed infant is observed and analysis of data from cohorts have failed to document an associated association between in neutral nit exposure and mitochondrial disease the potential for delayed effects of inuit in neutral area exposure requires close communication between obstetric and so it is a it is always a multi-disciplinary approach documentation of such exposure if at all it is there so it should be documented and it should be followed for a long time so like long term study should be done so all are involved we have to uh involve the maternal and fetal medicine specialist hiv specialist and care coordinator or case manager psychiatrist social service drug treatment programmer and pediatrician so what are the other concerns during pregnancy the hiv management it also includes providing the therapy for hiv related coexistent conditions like with the woman with advanced immunosuppression to receive prophylaxis for prevention of opportunistic infections so mostly these opportunity infections like pcp or mycobacterium complex or encephalitis it is caused by another cause by toxoplasma as well as secondary prophylaxis or chronic therapy these are included in prophylaxis so new clinical symptoms and science should be investigated and appropriate diagnostic procedures should be performed to come to the diagnosis so most populistic infections uh is the same as for non-pregnant uh uh hiv infected person and for pcp usually we give septron that is uh trimethoprim sulfamethaxosol and pregnancy related respiratory changes may affect the absorption and distribution of aerosol as pentametine for mycobacterium infection azithromycin is the preferred drug and in during pregnancy also clarithromycin should be avoided as it is teratogenic and about efficient in animal models for fungal infections like candidiasis histoplasmosis descriptococy coccidosis aspergillosis and all these azoles fluconazoles intake reconnaissals are the uh safe are safe uh in continuous therapy and are safe but but the in continuous therapy it is not known for single dose it is safe but if it is required for a long time then it is unknown the studies are not there for cmp [Music] the treatment yeah it is embryo toxic or teratogenic ganciclovir is preferred and if the treatment of pre-existing cm infection uh for fetal protection is not if it is pre-existing then it's not indicated for toxoplasmosis in neutral transmission of the fetus has occurred in hiv infected hormone uh who are positive pre-pregnancy prophylaxis is generally with same trimethoprim in antibody positive woman and with avoidance of exposure in anti if antibodies is negative then better to avoid the exposure like toxoplasma is from cats and dogs for tuberculosis usual drugs these are sony as a reference in viral cinematic are there thermodynamic studies are there of these drugs so these drugs are used and but i inhibit it can cause hepatotoxicity for respiratory infection uh we have to administer influenza vaccine every year and pneumococcal vaccinating three every five years as indicated and do not uh use this clarithromycin or quinolones if the alternatives like acid through is available so don't use laryng the management of other conditions seen with increased prevalence in association with hiv infection is the same as for non hiv uh non uh hiv infected adults the syphilis of undetermined or advanced stages evaluate and consider the treatment for neuroscience we have to prevent neurosyphilis because this hiv hiv women they are immuno suppressed so they are more prone for getting a severe infection for hepatitis c we have to prevent the perinatal transmission there is if there is no evidence for decrease rate of perinatal hepatitis transmission with elective caesarean so they can undergo normal labor and treatment of hepatitis c in pregnancy is just not routinely recommended unless it is symptomatic so for a beta tech b hepatitis b uh hypertoxicity of arv may be enhanced and particularly with this slimy good idea so we have to avoid using these drugs hepatitis b flare-up also [Music] upon discontinuation of arv postpartum so we have to manage with the physician together so women who are hiv infected should be offered appropriate antenatal genetic testing including amniocentesis if it is required then it should not be referred just because they are hiv positive we have to do it if it is required though there is a theoretic concern that there is transmission of hiv during the procedure but practically it is not documented till now it is advisable when possible to control the hiv viral load prior to performing this procedure get the viral load and try to control it and then we can do it if we have time during labor uh all women should receive intravenous adividine during level unless it is uh allergic to her it is given intravenously as a loading dose of 2 gram per kilogram or an r followed by 1 gram per kilogram throughout labor other arv are also continuing whatever she is already on that has to be continued and discontinue a rt uh solely for fetal protection if the hat is given only for fatal protection then it can be discontinued after delivery the infant should receive six weeks of uh zydovidin duration uh of rupture of membrane increases the risk of mother to child transmission the effect in women on ait with viral suppression is not known so if the duration is more then better to do caesarean and we have to augment also we to shorten the length of labor the augmentation either can be oxytocin at the same test and we the artificial rupture of membrane should be avoided and any invasive procedure should be avoided unless it is obstetrically indicated like if there is fetal distress fetal drops are there then we are suspecting meconium then we have to do it so baseline test this test or the cbc is done for platelet count lft by bun creatine in electrolyte mileage and g6pd test stuff so electric cesarean delivery before labor onset of ruptured membranes decreases the transmission by 55 to 80 percent so electively test this to be done before the rupture of membrane then only it will avoid this transmission compared to other modes of delivery in women receiving either no art or zydovidi monotherapy so in women receiving art with undetectable viral load it is unlikely that elective scissor infection confers substantial fetal protection so if if the one is receiving and there is no detectable viral load then we if the woman wishes then we can give her a general trial similarly after labor on stop onset or ruptured membrane scissoring delivery for petal protection is not implicated once the membranes are ruptured or if the participation is gone in labor that is the service is dilated then the uh doing a cesarean section is of not much help the patient has to be not in labor for uh preventing the transmission so what are the recommendations uh elective scissor infection prior to labor onset and rupture membrane hiv viral rna copies of 1000 per ml or unknown hiv rna level and it has to be performed at 38 weeks of gestation administer zydovidin at least three hours prior to the procedure and use perioperative antibiotics as a prophylaxis so for hiv infected women who have not received ait prior to labor alternative recommendation for arv for fetal protection to maximize the efficacy are as follows first intravitamin travel is hydrovividine followed by six weeks of xiaomi to the baby and some people say that navy wrapping is also to be is is to be given in addition to intra button six weeks so it is up to it is depends upon the institute we we give at sign we give it so never happen resistance is also seen around 69 to 30 33 to 87 percent in women and infants after exposure to single dose in because this is because of the long half-life of navy raping and it is given alone or in combination with intravertigradovidin the additional administration of xyadovidine plus diabetes to the mother of for seven days postpartum is recommended to prevent the development of resistance anesthetic concerns uh most hiv infected parturians are otherwise healthy uh with a low iron load and silly four count of around 200 some women will undergo elective some will opt for elective cesarean delivery to reduce the transmission and those undergoing labor may reduce request for epidural energy and may need emergency and sometimes they may need emergency caesarean delivery most women will require input from an obstetric anesthesiologist so the anaesthetist has to decide they can be given labor analgesia either with a standard epidural or combined spinal epidural technique using loads of local anesthetic like point one percent of the pivocaine with two gram per amylopentane caesarean delivery there is no evidence that ga that is general anesthesia or regional anesthesia alters immunity or has other adversity so it depends upon the condition and the indication also for an elective or emergency caesarean delivery regional analyst single shot spinal or combined spinal epidural or epidural technique can be used an epidural catheter inserted for labor energy it can be topped up for emergency cesarean delivery or to provide anesthesia for operative vaginal delivery hiv virus it is a neurotropic virus so we have to prevent the transmission and the cns is infected early in the course of the disease with isolation of varions and antibodies in the csf so it is seen that regional anesthesia does not cause cns hiv infection these are the studies various studies set up so it does not increase the neurological or infectious problems in hiv infected patients it is in when it is when indicated no routine contraindication exists it can be utilized hypotension is the most common which can which can occur in any other non-hiv patient also so it is usually even treated with use of phenylephrine it is associated with improved fetal umbilical cord blood gases when used to maintain the baseline systolic blood pressure during the spinal anesthesia so they can be used just like any other non hiv patient these this techniques can be used in hiv patients also so this postural puncture headache it is very common after spinal and accidental accidental dual puncture with an epidural needle it is most common complication of visual anesthesia and we can use this epidural blood patch or injection of the patient's own blood into the epidural space it is an effective method and there has been no serious complication related to epidural blood patch in the hiv infected patients conversely not treating a pdph we have to trade otherwise it may lead to a long-term neurological sequel in hiv patients so drug interaction so there is the potential for significant interaction between the uh anesthetic drug also like protease inhibitor it reduces the metabolism of multiple anesthetic like medicine fentanyl and cardiac drugs like amidaran and quinidine so we have to increase the dose may be wrapping any fibers they are inducers of cytochrome p450 and therefore the increased doses of anesthetic drugs may be needed with these drugs in practice with careful titration so we have to we should be aware of all these interactions so we have to titrate the drugs and these problems are uncommon or these problems can be sorted other anesthetic conditions for patients with advanced hiv disease it should be noted very various things should be noted like respiratory opportunity infections like pcp and tb they may cause respiratory distress and hypoxemia it can be aggravated by a decreased functional residual capacity during pregnancy so regional anesthesia may be preferable in such patients high motor block with intercostal muscle weakness may increase the respiratory problems cardiovascular long-standing aid can cause hyperglycemia hyperlipidemia dystrophy and accelerated coronary artery sclerosis pulmonary hypertension preoperative evaluation of cardiac function is to be done if it is an elective caesarean section like ecocardiography stress testing not stress testing patients who have been on long term ait if it is there then it has to be done if if some uh abnormality is there then we have to do it for cns hiv infection intracranial masses or apogee infection they may lead to cerebral edema and raise the intracellular pressure so in such cases regional anesthesia is contraindicated because it it it increasing brainstem coding hematological like bone marrow suppression and coagulation abnormalities including thrombocytopenia they may result in hiv infection so uh arv drugs or bone marrow infiltration by opportunistic infection or neoplastic disease so it is contraindicated to prevent this spinal hematomi because of this thrombocytopenia for infection the concurrent presence of hepatitis b or c infection it causes liver abnormalities and may alter the anesthetic may alter the excretion also occupational like universal precaution should also also should always be taken while handling body fluids tissues blood and blood products regardless of patients of hiv status postpartum the woman with hiv they may be at increased risk of postpartum infection and most studies have suggested that the complications are due to infections uh like including the fever endometritis one when wound infection it's caesar insection or episode infection uti urinary tract infection sepsis is an increase particularly among those who undergo cesarean section and or and instrumental operative delivery with and those who are with more advanced hiv infection in addition uh the reports have suggested an increase in blood loss requiring transfusion resulting in anemia this complication we can always anticipate and be prepared to handle or manage this complication in research resource rich countries where risk for infant mortality and mortality morbidity and mortality from infectious and diarrheal illnesses are small then the breastfeeding is recommended but in our avoid avoidance is recommended which means they should not breastfeed so women who are at particular risk of self-discontinuing art and dropping out of healthcare prosper woman usually postpartum depression and relapse in drugs both are very common and women may ignore their health care in defense to that of infant sometimes they'll just care for the baby and they'll ignore their own health so specific contact with hiv providers should be facilitated during the immediate postpartum period prior to hospital discharge all necessary medication or prescription should be given and visits for the health care including drug treatment should be scheduled they should be told that they have to come on this state at this particular time case management and social services should be arranged contraceptive services should be provided although the use of male and female condoms can prevent hiv study transmission but it is not uh highly effective in preventing pregnancies so combination hormonal contraceptives are highly effective in preventing pregnancies but interaction with arv agent can complicate their use among hiv-infected women so in addition uh oral hormonal contraception decreases the employee level and therefore the drug should not be administered together or they should not be co-administered alternative methods or backup contraception can be used simultaneously with oc bills transdermal or intraventional hormonal contraceptive may be the other option but their pharmacokinetics and setting of ait have not yet been determined there are no studies actually metroxy progesterone levels appear to be unaffected by arv so it can be used in triotron devices they are safe and effective contraception uh for selected hiv infected women increased hiv genetic tract shedding has not been found like previously which was thought with iud use uh in fact this levon registered all in releasing with this marina it has an added advantage of decreased menstrual bleeding compared to the copper teeth copper iud spermicides have in vitro activity against hiv but this non-oxygenol 9 has been associated with increased vaginal inflammation irritation and decrease that so it alters the ph vaginal ph therefore theoretically it increases the hiv shedding in the genital tract in randomized placebo control trial among sex workers this non-oxygenol nine increased vaginal legends and possibly the increased acquisition of infection also so transitioning care postpartum human receiving art is low solely for the fetal protection may elect to discontinue arv postpartum post delivery regular monitoring of cd4 counts and viral load every four to six months should be maintained among women who stop treatment other chronic conditions like b and c infection nephropathies may influence the decision if if it is flared uh hepatitis b along with this then we have to continue we or any other condition which is suppressing the immunity like home orbit condition they should also be settled we should also be controlled then only we can think of stopping this arv all plans for continuing medical care with an hiv specialist should be developed prior to the delivery and instituted post-partum so the take-home message is these hiv infection should be viewed as any other chronic medical condition like diabetes in pregnancy hypertension in pregnancy like that only hiv in pregnancy should be considered and we should be up to date about the knowledge for maternal obstetric anaesthetic and fetal concerns and appropriate attention to current standards of adult management it will result in the optimum outcome for both the mother as well as the baby so these are the references national guidelines and rich guidelines yeah the ait drugs yes they cross the placenta but the effects are uh different for different different drugs some of them cause anemia to the baby but that is also transient so considering the risk benefit ratio we have to give this ait trust for tld regimen needs hyperglycemia we have to control the hyperglycemia and risk and benefit we have to we can always control we can stop for few days and we can restart the regimen because only one drug will be less so the two drugs usually it is three drug rich men so the two trucks will be there then usually usually once the drug is dropped then the recovery is there lipidaemia and hyperglycemia will also not be there you separate for no no not required separate routine we just have to fumigate the other formalin for 20 minutes we can use the same motif if the lady is not receiving erb and she gets pregnant should we start arv regardless of gestational age yes it is better to start arv to prevent the transmission to the baby but we have to evaluate other things also we have to see the cd4 count viral load everything ah man we'll just take a few more questions one question is there premarital uh premarital hiv testing so see it cannot be compulsory even for pregnant women it is uh not compulsory so premarital also we cannot say but if it is in individual choice if you want you can get it done we cannot make it compulsory thank you this is any specific psycho session education plan nutritional care educational education and nutritional care for this nutritional yes because they are immuno suppressed so they should increase protein content the weight loss is also there so the body fat should be adequate and psychologically yes because they think that they won't survive more or some arbitraries are also there even for small impressions they need to get admitted so yes they have to get the support counseling helps in such cases okay instruments like instruments we are going to reuse no we can sterile it autoclave it and use it rest of the things like gown and all we can we have to throw it usually in formalin we keep it deep and then we discard it in the yellow bag thank you ma'am any more question um i think you've covered all the questions laproscopic and sterilize with formalin only we can sterilize laproscope we usually keep our all our scopes and all informal in compartment hiv test usually it is done after six weeks for a newborn uh so we've covered most of the questions uh so with this i guess we can wrap up the session and thanks for your uh whole response everyone so i can see lot of amazing comments mom thank you very much it was excellent presentation thanks a lot ma'am there's one last question uh by dr prithviraj was the chance of getting infant hiv infection positive despite maternal mother reason so yes there are the chances depending upon the mode of delivery also if the chance is less if it is by elective cesarean section in c even though the woman is on ait and if she goes in labor and there is a prolonged labor or pprom prolonged rupture of membrane plus the baby's free term then there are increased chances of maybe getting hiv thank you so i hope uh dr pritish this answers your question uh mom with this i can't see any more questions so we can definitely yeah now thanks a lot for your time thank you good night everybody

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dr. Swati Gawai

Dr. Swati Gawai

Assistant Professor Obstetrician , Gynecologist and Endoscopist at LTMMC and Sion Hospital, Mumbai.

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dr. Swati Gawai

Dr. Swati Gawai

Assistant Professor Obstetrician , Gynecolog...

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