© Springer India 2016
Alpesh Gandhi, Narendra Malhotra, Jaideep Malhotra, Nidhi Gupta and Neharika Malhotra Bora (eds.)Principles of Critical Care in Obstetrics10.1007/978-81-322-2686-4_1717. HIV in Critical Pregnancy
(1)
Department of OB-GYN, GCS Medical College, Ahmedabad, Gujarat, India
(2)
Munshi Hospital Ahmedabad, Ahmedabad, Gujarat, India
(3)
Munshi Hospital and Pulse Hospital, Ahmedabad, Gujarat, India
(4)
Department of OB-GYN, Visiting Endoscopist, P.S. Medical College, Karamsad, Gujarat, India
Introduction
In India, approximately 49,000 women living with HIV become pregnant and deliver each year which is about 6–10 % of the total world figure [1].
Most of the pregnant women are unaware of their HIV status at the time of diagnosis of pregnancy and some of them even are not aware of their status until labour. Maternal HIV-1 infection has been associated with an increased risk of PTB, but mechanisms underlying this association are undefined [2].
HIV-infected women were more likely than HIV-uninfected women to have pregnancy-induced hypertension, anaemia, breech presentations, stillborn babies and foetal deaths [Indian Study] [3].
Furthermore, pregnancy does not seem to affect survival of women infected with HIV [6].
Testing pregnant women for HIV at the time of labour and delivery is the last opportunity for prevention of mother-to-child HIV transmission (PMTCT) measures, particularly in settings where women do not receive adequate antenatal care. However, HIV testing and counselling of pregnant women in labour is a challenge, especially in resource-constrained settings. In India, many rural women present for delivery without any prior antenatal care. Those who do get antenatal care are not always tested for HIV, because of deficiencies in the provision of HIV testing and counselling services [7].
HIV impacts on direct (obstetrical) causes of maternal mortality by an associated increase in pregnancy complications such as anaemia, postpartum haemorrhage and puerperal sepsis.
HIV is also a major indirect cause of maternal mortality by an increased susceptibility to opportunistic infections like tuberculosis and malaria [8].
Impact on Mother and Foetus
Antiretroviral therapy (ART) during pregnancy should focus on the reduction of perinatal transmission and the treatment of maternal human immunodeficiency virus (HIV) disease.
ART can reduce perinatal transmission by several mechanisms, including lowering maternal antepartum viral load and preexposure and post-exposure prophylaxis of the infant. Therefore, for prevention of perinatal transmission of HIV, combined antepartum, intrapartum and infant antiretroviral prophylaxis is recommended.
Combination drug regimens are considered the standard of care for treatment of HIV infection and for prevention of perinatal HIV transmission [9].
Assuming that due diligence has been observed in the diagnosis and treatment of anaemia and the patient has been on ART, we are left with the modalities of treating the critical stage when an active mode is to be employed.
While prevention measures are preferred to emergency management, in a resource-poor setting, it is not always possible.
That is when critical care management assumes importance in the reduction of maternal morbidity and mortality.
We will focus on some of these conditions like postpartum haemorrhage, sepsis and malaria in the context of HIV-positive pregnant women in a resource-poor setting.
HIV/AIDS Precautions: CDC Recommendations
Isolation of Patient during Treatment and Incineration of Disposables Recommended
All used syringes or other sharp instruments should be routinely placed in “sharps” containers for proper disposal to prevent accidental injuries and risk of HIV transmission.
For most HIV exposures that warrant PEP, a basic 4-week, two-drug (there are several options) regimen is recommended, starting as soon as possible after exposure. For HIV exposures that pose an increased risk of transmission (based on the infection status of the source and the type of exposure), a three-drug regimen may be recommended. Special circumstances, such as a delayed exposure report, unknown source person, pregnancy in the exposed person, resistance of the source virus to antiretroviral agents and toxicity of PEP regimens, are also discussed in the guidelines. Occupational exposures should be considered urgent medical concerns, and PEP should be started within 72 h—the sooner the better; every hour counts.
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