Management of pregnancy in women with HIV at Liverpool Women’s Hospital: A multidisciplinary approach AJ Roberts, KA Jilani, HL Longworth
Vertical transmission of HIV is now rare in the UK thanks to the introduction of routine antenatal HIV screening and early commencement of combination antiretroviral therapy (cART). Effective suppression of viral load has meant more women with HIV are now planning for, and safely achieving a vaginal birth. In 2018, The British HIV association (BHIVA) released their updated guidelines for the management of HIV in pregnancy and postpartum. Noteworthy alterations include: • The importance of multidisciplinary antenatal care. • Expansion of the psychosocial care section • Updated infant feeding advice including: the emotional impact that non breastfeeding may have, and discussion about cabergoline use in non breast feeding women. • New risk stratification to determine length of neonatal post exposure prophylaxis. • A new section on postpartum management of women with HIV.
We conducted a 24-month retrospective review of antenatal patients at Liverpool Women’s hospital between 1st April 2016 and 31st March 2018. We audited our antenatal HIV screening rates, and reviewed the subsequent management in seropositive women.
Results Over the 24-month period we screened 18,331, out of 18,705 eligible patients, for HIV (98.0%) (acceptable threshold 95.0%). HIV results were confirmed within 8 days of receipt in the laboratory in 99.5% of cases. There were 29 pregnancies in HIV positive mothers over the 24-month period and 6 of these were new diagnoses from the antenatal screening test. All of the newly diagnosed cases were seen for specialist assessment within 10 working days and all of these patients were screened for other sexually transmitted infections. There were 2 cases of HIV diagnosed late in pregnancy. Both of these patients were late bookers, one was an asylum seeker and the other was trafficked to the UK. Both women had a caesarean section. Sero-positive women had their booking viral loads and CD4 counts checked and these were then repeated at 28 weeks and 36 weeks. Multidisciplinary management care plans were distributed to the intrapartum, neonatal and acute admission areas and were updated on receipt of each viral load result.
Newly diagnosed HIV cases in pregnancy All of the 6 newly diagnosed cases of HIV in pregnancy were seen for specialist assessment by members of the multidisciplinary team within 10 days. At this first appointment after diagnosis: • The HIV test results were disclosed by practitioners trained in this field. • Further blood test are taken including CD4 count, viral load and antibody testing to define the subtype. A Liver profile including Hepatitis C screening and LFT is also taken • Contact phone numbers are given • Treatment (usually a multi drug regime) is provided there and then • Follow up appointments are arranged • Partner notification appointments are offered
OBSTETRIC MANAGEMENT (adapted from regional guideline) • Foetal ultrasound imaging should be performed as per national guidelines. • 1st trimester screening for trisomies 21, 18 & 13 is recommended, we offer NIPT (reflex DNA) with the high chance combined screens. This has the best sensitivity and specificity and will minimize the number of women who may need invasive testing. • Early referral to Paediatric Team with Management Plan for delivery e.g. Paediatric Alert Forms. Mode of delivery • For women with a viral load of <50 copies/mL at 36 weeks, and in the absence of obstetric contraindications, planned vaginal delivery should be supported.(see guidelines) • Ensure pharmacy has sufficient stock to cover the delivery (including an unexpected early delivery). • Drug chart written in advance. Await spontaneous labour unless obstetric indication to intervene. At labour • If indicated, zidovudine infusion should start 4 hours before section, or upon onset of labour, and continue until cord clamped. ENSURE other antiretroviral therapy is continued. Maternal postnatal care • Follow up with HIV Physician arranged • Contraceptive options discussed, including potential interactions with antiretroviral therapy
Conclusions Patient engagement and adherence to treatment was achieved in all sero-positive women and there were no cases of vertical transmission. We believe this demonstrates that effective multidisciplinary antenatal care can help achieve optimal pregnancy outcomes in HIV positive women.