Perintal Care of Hiv+ Ve Mother- New

7/30/2019 Perintal Care of Hiv+ Ve Mother- New

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DR.JAVED ALI, MD(O&G)

ASSIATANT PROFESSOR

GMCH,GUWAHATI


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1-2 Per thousand pregnant women in US.

Less than 0.5% in most asian countries.

In India the rate varies from 0-2.4%.

54 seropositive women detected in departmentof O&G GMCH.

14 cases underwent caesarian section and 33

cases had vaginal delivery in our department. The rate of transmission from mother to child is

in between 15-48%.


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Over 5,90,000 children are infected with HIVeach year by vertical transmission.(USAIDreport 1997).

Estimated risk of infection to the health careproviders after parenteral or mucousmembrane exposure is 0.36%.


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A. MATERNAL viral load Biological prototype of virus Unprotected sex during pregnancy Smoking & illicit use of drugs in mother Maternal level of CD4 & lymphocyte count. Low maternal vit A level. Presence of RT9/ST9 in mother. Time of rupture of membranes & choriomeningitis Episiotomy & operative vaginal delivery Presence & amount of virus in genital tract.


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B.FETAL

Fetus can ingest the virus

Fetal scalp electrode, scalp blood sampling &

umblical blood sampling.

Duration of exposure to maternal secretions( first twin).

Via breast milk depending upon the immuneresponse of the fetus, duration of breastfeedingand infectivity of mother.


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Does not enhance disease progression.

Serious infections do occur if CD4 count is


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Fertility not impaired in initial stages.

Late HIV disease may cause IUGR, pretermdelivery, IUD, neonatal death, higher incidence

of birth canal sepsis, and opportunisticinfections.


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KNOWN HIV+VE CASE Booked/Unbooked

DETECTED ONLY IN LABOUR

PRESENTING WITH AIDS


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THE KEY

1. Optimal care of the pregnancy- Nutritious diet

- Prevent anaemia, hypoprotenemia- Choice of MTP/continuation of

pregnancy

- Discontinue smoking, illicit drugs

- Regular check up

- Detect & treat opportunistic infections

- Proper intranatal care in hospital

2. Care of the HIV infection


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PERVENT VERTICAL TRANSMISSION

PREVENT SPREAD OF INFECTION

Take universal precaution

Proper disposal wastes Disinfection and sterilisation of linens and equipments.

THE APPROACH-

KEEP UTMOST SECRECY

BE NON INSISTENT BUT GENTLE.


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SHAVING

ENEMA

CATHETERISATION

PV EXAMINATION

IV CANULATION

INJECTION

DRAWING BLOOD OR COLLECTIING URINESAMPLES


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SHOULD WE DO ELECTIVE CESAREANSECTION?

OR

ALLOW VAGINAL DELIVERY?


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Each time after examining the patient, washhand in automatic water tap with soap.

Always keep delivery tray ready with linen

and cord clamp. Take universal precautions while conducting

delivery

Never deliver a women without gloved

hands(taxi/toilet delivery) Never keep sharp instruments around

perineum on delivery table to avoid cut tomother/ baby or to the health worker.


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Avoid repeated per vaginal examination to avoidinfection

Avoid catheterisation unless indicated. Drape perineal area with sterile linen while

delivering a woman or suturing episiotomy andperineal tears. A maternal sample for plasma viral load should be

taken at the time of delivery. Amniotomy, application of scalp electrodes, scalp

blood sampling should better be avoided. Mechanical suctioning(


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Never guide the needle with fingers

Non touch technique is the best.

Any spillage of blood or fluid over skin areashould be washed immediately.

Put wash proof band aid over any cut or abrasionbefore putting on gloves.

In case of accidental needle prick or spillage overskin or mucus membrane with breach, takeimmediate prophylaxis, triple therapy for 4 wks.

Cord should be clamped early.

Baby should be bathed immediately.


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Double gloves Special puncture resistant glove if available. Using eye glasses, shield, special gowns and boots. Spinal anaethesia preferable Liberal incision There should not be active bleeding from incision

wound while extracting the baby. Disinfection of anesthesia equipments.

Other precautions already mentioned inprecautions in vaginal delivery.

Universal precautions by anaethetist andpaediatrician.


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UNIVERSAL PRECAUTIONS


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nn

NEONATOLOGIST(WITH UNIVERSAL PRECAUTIONS)


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MEMBERS OF THE OPERATING TEAM


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ISSUES-

- Gestational age

- Severity ( viral load/ CD4 count)

- Tolerance of regimen during pregnancy

- Potential adverse effects


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ACTG O76 TRIAL-

Zidovudin-100mg 5times a day from 14wksuntil labour.

During labour-2mg/kg over 1st 2hrs

maintainence dose of 1mg/kg/hr until

deliveryzidovudin syrup- 2mg/kg 4times a day for the6 weeks to the neonate


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SHORT COURSE ZDV-

300mg zidovudin twice daily from 36wks until onsetof labour then every 3hrs till delivery

neonate is given 2mg/kg ZDV syrup QID for 1 week

HIV NET 02-

Nevirapin 200mg 2 tabs to mother at the time ofdelivery

neonate- Nevirapin syrup 2mg/kg in single dosewithin 72 hrs

In case of LSCS- Nevirapin is given 4 hrs beforeprocedure


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IF ON ART OPTIONS ARE-

Suspend therapy temporarily during 1sttrimester.

Continue the same therapy Change to a different regimen

If not on ART- prophylaxis (PPTCT)


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ART may be delayed if in the 1st trimester

Weigh the severity of the disease and thepotential benefits/risks of delaying ART until

after 1st trimester. For the women who are severely ill, the benefit

of early initiation of ART may outweigh therisk to fetus.


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Postpartum care


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Actual HIV status of the baby can only beascertained by PCR and P24 Antigen.

After 15 months of breastfeeding HIV-1transmissions to the infant is around 32%

The mother should be counseled regarding therisks and benefits. She should be helped to makean informed choice.

In India because of the potential risks of diarrhoeaand other diseases involved in alternative feeding,

breastfeeding has not been routinely disregarded. If breast feeding is chosen as an option, encourage

exclusive breastfefeeding and advise earlycessation.


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Awareness about infection-

Burning micturation

Fever

Foul smelling lochia

Cough sputum,shortness of breath

Redness,pain,pus,discharge from

incision/episiotomy Lower abdominal pain

She should be told about disposal of sanitary

pads etc. and care of perineum and breast.


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COTRACEPTIVE ADVICE-

- condoms

- sterilization


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Regular gynecological care including papsmears.

Regular HIV/AIDS care- medical follow up/

visit to ART centre. Nutrition and dietary care

Family planning services.


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1.RED CONTAINER/BAGS-syringes, canula , catheter, needles , blood bag, drip set ,gloves& any infectious item.

2. YELLOW CONTAINER/ BAGS-Blood soaked articles like cotton bandages, dressings, plasters,pathological and anatomical wastes and other laboratorywastes.

3. BLUE CONTAINER/ BAGS-Broken glass , blades, scalpels.

4. BLACK CONTAINER/BAGS-

Office wastes, kitchen& canteen wastes. other non infectiouswastes


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Put soiled linen, gloves and instruments in 10%hypochloride solution/ bleach solution for 10minutes before washing. A toothbrush may beused for cleaning the instruments.

Pour bleach solution on labour table for half anhour. It can also be disinfected using 10% lysol or2% gluteraldehyde.

Put the placenta in a bag with bleaching powder-either incinerate or burry with bleaching powder

all around. Floor soiled with blood or amniotic fluid should be

cleaned with antiseptic/ bleach solutionimmediately.


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Disposable syringes and needles should bedisinfected using bleach solution/gluteraldehyde/mutilation/ shredding.

Universal precautions should also be adoptedby workers in the labour room.

Heavy duty gloves or utility gloves best beused.


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Every obstetrician or maternity service provider hasalready delivered or will deliver HIV+VE motherknowingly or unknowingly.

We must keep abreast with the recent developments in

HIV/AIDS. Need not be panicked. Keep secrecy, be non insistent,

but gentle this will help her not to disappear.

Proper care can help prevent vertical transmission and

as well as prevent spread of the disease. There is a little risk to service provider if universal

precaution is adopted.


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THANK YOU!

Perintal Care of Hiv+ Ve Mother- New

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