HIV and Pregnancy: Prevention of

Mother-to-Child Transmission
Advances in Maternal and Neonatal Health

JEANNET E. CANDA, RN, MAED
NDDU, COLLEGE OF NURSING
2 HIV and Pregnancy
Session Objectives
To discuss best practice for antenatal, intrapartum and
postpartum care of the HIV-positive mother to reduce mother-
to-child transmission
To review the evidence supporting these practices
3 HIV and Pregnancy
HIV-Related Counseling Issues
During Pregnancy
Educate/counsel regarding HIV and pregnancy before
pregnancy:
Impact of HIV on pregnancy and pregnancy on HIV
Maternal health
Long-term health of mother and care for children
Perinatal transmission
Use of antiretrovirals and other drugs in pregnancy
4 HIV and Pregnancy
Adverse Pregnancy Outcomes and
Relationship to HIV Infection
Pregnancy Outcome Relationship to HIV Infection
Spontaneous abortion Limited data, but evidence of possible increased
risk
Stillbirth No association noted in developed countries;
evidence of increased risk in developing
countries
Perinatal mortality No association noted in developed countries, but
data limited; evidence of increased risk in
developing countries
Newborn mortality Limited data in developed countries; evidence of
increased risk in developing countries
Intra-uterine growth
retardation
Evidence of possible increased risk
Anderson 2001.
5 HIV and Pregnancy
Adverse Pregnancy Outcomes and
Relationship to HIV Infection (continued)
Pregnancy Outcome Relationship to HIV Infection
Low birth weight Evidence of possible increased risk
Preterm delivery Evidence of possible increased risk, especially w/
more advanced disease
Pre-eclampsia No data
Gestational diabetes No data
Amnionitis Limited data; more recent studies do not suggest
an increased risk; some earlier studies found
increased histologic placental inflammation,
particularly in those with preterm deliveries
Oligohydramnios Minimal data
Fetal malformation No evidence of increased risk
Anderson 2001.
6 HIV and Pregnancy
Mother-to-Child Transmission
2535% of HIV positive pregnant mothers will pass HIV to their
newborns
In the absence of breastfeeding:
30% of transmission in utero
70% of transmission during the delivery
Meta-analysis showed 14% transmission with
breastfeeding and 29% transmission with acute maternal
HIV infection or recent seroconversion
DeCock et al 2000; Dunn et al 1992; WHO/UNAIDS 1999.
7 HIV and Pregnancy
Risk Factors for Mother-to-Child
Transmission
Viral load (HIV-RNA level)
Genital tract viral load
CD4 cell count
Unprotected sex with multiple
partners
Smoking cigarettes
Substance abuse
Vitamin A deficiency
STDs and other coinfections
Antiretroviral agents
Preterm delivery
Placental disruption
Invasive fetal monitoring
Duration of membrane rupture
Vaginal delivery vs. cesarean
section
Breastfeeding
Anderson 2001.
8 HIV and Pregnancy
Interventions to Reduce Mother-to-Child
Transmission
HIV testing in pregnancy
Antenatal care
Antiretroviral agents
Obstetric interventions
Avoid amniotomy
Avoid procedures: Forceps/vacuum extractor, scalp
electrode, scalp blood sampling
Restrict episiotomy
Elective cesarean section
Remember infection prevention practices
Newborn feeding: Breastmilk vs. formula
9 HIV and Pregnancy
HIV Testing during Pregnancy
Advantages:
Possible treatment of mother
Reduce risk of mother-to-child transmission
Future family planning issues
Precautions against further spread
If negative, advise about HIV prevention

Counseling is important!
10 HIV and Pregnancy
Antenatal Care
Most HIV-infected women will be asymptomatic
Watch for signs/symptoms of AIDS and pregnancy-related
complications
Unless complication develops, no need to increase number of
visits
Treat STDs and other coinfections
Counsel against unprotected intercourse
Avoid invasive procedures and external cephalic version
Give antiretroviral agents, if available
Counsel about nutrition
11 HIV and Pregnancy
Antiretrovirals
Zidovudine (ZDV):
Long course
Short course
Nevirapine
ZDV/lamivudine (ZDV/3TC)

12 HIV and Pregnancy
ZDV Perinatal Transmission Prophylaxis
Regimen: ACTG 076 Trial
Antepartum Initiation at 1434 weeks gestation and continued
throughout pregnancy
PACTG 076 regimen: ZDV 5 times daily
Acceptable alternative regimen: ZDV 2 or 3 times
daily (depending on dose)
Intrapartum During labor, ZDV IV over 1 hour, followed by a
continuous infusion of IV until delivery
Postpartum Oral administration of ZDV to newborn for first 6
weeks of life, beginning at 812 hours after birth
Anderson 2000.
13 HIV and Pregnancy
Intrapartum vs. Postpartum Regimens
for HIV-Infected Women in Labor with
No Prior Antiretroviral Therapy
Drug
Regimen
Maternal
Intrapartum
Newborn
Postpartum
Data on
Transmission
Nevirapine One oral
dose at onset
of labor
One oral dose at
age 4872 hours (if
mother received
nevirapine < 1 hour
before delivery,
newborn given oral
nevirapine as soon
as possible after
birth and at 4872
hours)
Transmission at 6
weeks 12% with
nevirapine
compared to 21%
with ZDV, a 47%
(95% CI, 2064%)
reduction
Anderson 2001.
14 HIV and Pregnancy
Intrapartum vs. Postpartum Regimens
for HIV-Infected Women in Labor with
No Prior Antiretroviral Therapy (contd.)
Drug
Regimen
Maternal
Intrapartum
Newborn
Postpartum
Data on
Transmission
ZDV/3TC ZDV orally at
onset of labor
followed by
dose orally
every 3 hours
until delivery
AND
3TC orally at
onset of labor,
followed by
dose orally
every 12 hours
ZDV orally every
12 hours
AND
3TC orally every
12 hours for 7
days
Transmission at
6 weeks 10%
with ZDV/3TC
compared to
17% with
placebo, a 38%
reduction
Anderson 2001.
15 HIV and Pregnancy
Intrapartum vs. Postpartum Regimens
for HIV-Infected Women in Labor with
No Prior Antiretroviral Therapy (contd.)
Drug
Regimen
Maternal
Intrapartum
Newborn
Postpartum
Data on
Transmission
ZDV IV bolus, followed
by continuous
infusion of every
hour until delivery
Orally every 6
hours for 6
weeks
Transmission
10% with ZDV
compared to
27% with no ZDV
treatment, a 62%
(95% CI, 19-82%)
reduction
Anderson 2001.
16 HIV and Pregnancy
Intrapartum vs. Postpartum Regimens
for HIV-Infected Women in Labor with
No Prior Antiretroviral Therapy (contd.)
Drug
Regimen
Maternal
Intrapartum
Newborn
Postpartum
Data on
Transmission
ZDV and
Nevirapine
IV bolus, then
continuous
infusion until
delivery
AND
Nevirapine single
oral dose at
onset of labor
Orally every 6
hours for 6
weeks
AND
Nevirapine single
oral dose at age
4872 hours
No data
Anderson 2001.
17 HIV and Pregnancy
Obstetric Procedures
Because of increased fetal exposure to infected maternal blood
and secretions, increased transmission may come from:
Amniotomy
Fetal scalp electrode/sampling
Forceps/vacuum extractor
Episiotomy
Vaginal tears

18 HIV and Pregnancy
Delivery: Cesarean vs. Vaginal Birth
Risk of mother-to-child transmission increased 2% each hour
after membranes have been ruptured
Cesarean section before labor and/or rupture of membranes
reduces risk of mother-to-child transmission by 5080%
compared with other modes of delivery in women on no
antiretroviral therapy or on ZDV alone
No evidence of benefit with cesarean section after onset of
labor or membranes have been ruptured
Cesarean section, however, increases morbidity and possible
mortality to mother
Give antibiotic prophylaxis for cesarean section in HIV-infected
women
International Perinatal HIV Group 1999;
Semprini 1995.
19 HIV and Pregnancy
Recommended Infection
Prevention Practices
Needles:
Take care! Minimal use
Suturing: Use appropriate needle and holder
Care with recapping and disposal
Wear gloves, wash hands with soap immediately after contact
with blood and body fluids
Cover incisions with watertight dressings for first 24 hours

20 HIV and Pregnancy
Recommended Infection
Prevention Practices (continued)
Use:
Plastic aprons for delivery
Goggles and gloves for delivery and surgery
Long gloves for placenta removal
Dispose of blood, placenta and waste safely
PROTECT YOURSELF!
21 HIV and Pregnancy
Newborn
Wash newborn after birth, especially face
Avoid hypothermia
Give antiretroviral agents, if available
22 HIV and Pregnancy
Breasfeeding Issues
Warmth for newborn
Nutrition for newborn
Protection against other infections
Safety unclean water, diarrheal diseases
Risk of HIV transmission
Contraception for mother
Cost
23 HIV and Pregnancy
Breastfeeding Recommendations
If the woman is:
HIV-negative or does not know her HIV status, promote
exclusive breastfeeding for 6 months
HIV-positive and chooses to use replacements feedings,
counsel on the safe and appropriate use of formula
HIV-positive and chooses to breastfeed, promote exclusive
breastfeeding for 6 months