[CG] HIV in pregnancy and prevention of vertical transmission individualised management

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Between 10 and 25 women living with HIV deliver within GG&C every year. With universal antenatal screening, treatment with antiretrovirals, planned mode of delivery and support for appropriate infant feeding the vertical transmission rate can be kept extremely low with national rates now less than 0.3%. As well as preventing vertical transmission we aim to provide comprehensive obstetric and sexual health care to the women accessing our services.

This guideline was written with reference to the BHIVA guidelines for the management of HIV in pregnancy and postpartum 2018 (2020 interim update).

Please note this guideline does not cover care of women with Hepatitis co-infection or care of the neonate.

Antenatal Screening

All women should be offered screening for HIV (along with syphilis and Hepatitis B) at booking. If testing is declined it should be clearly documented in Badgernet and re-offered at 20wks. If needle phobia is the reason for declining then dry blood spot testing (can also include Hep B and Hep C testing) should be made available if more acceptable to the patient. For those declining screening the baby should be tested at delivery using cord bloods and the mother should be informed of this. 

Certain women are at risk of continued exposure during the antenatal period and should be offered repeat screening at 28wks and 36wks. These include those with a partner living with HIV, victims of sexual exploitation including trafficked women, and women involved with illicit drugs. Any woman who has a risk of recent exposure but not ongoing should be offered repeat screening after 4 weeks and again after an 8 week window period. 

Newly Diagnosed Antenatal Patients

If a patient is found to be HIV positive on antenatal screening a copy of the result is sent to the Special Needs in Pregnancy (SNIPs) Lead and the Sandyford Shared Care team. This team will inform the Blood-borne Virus (BBV) Clinical Nurse specialists at the Brownlee Centre. Ideally, a multidisciplinary team consisting of obstetric and BBV staff will arrange to meet the patient together to discuss the diagnosis and plan care. 

Disclosure of the woman’s HIV status to any sexual partners should be handled sensitively.  Contact tracing and management of sexual partners will be managed by the Sandyford Shared Care team – based at Sandyford and Brownlee sites. Advice should be given on barrier methods to reduce the risk of onward transmission. Women should be offered access to specialist counselling which is provided by the HIV team at the Brownlee Centre. 

Antenatal Care

Antenatal care is managed by the SNIPs team at PRMH unless the patient prefers to remain under her own obstetric consultant. Antenatal care is shared with the HIV team who will review her regularly.

All women are discussed at a monthly MDT. Paediatricians should be informed at the time of diagnosis or booking. Care plan should be documented and updated on Badgernet in the antenatal management plan. 

Antiretroviral therapy (ART)

  • Treatment with ART will be managed by the HIV service.
  • All women should be commenced on 5mg folic acid from the first trimester. Women who have conceived on Dolutegravir should be advised there is a slight increase in risk of neural tube defects to 0.2% compared to background risk of 0.1% however they should not stop or change their medication without advice from the HIV team.
  • Be aware that many commonly used medications prescribed in pregnancy such as antiemetics, antibiotics and antacids may interact with ART. These can be checked here https://www.hivorg/or discussed with the specialist HIV pharmacy team.

Sexual health screening

  • Offer lower genital tract screening (charcoal low vaginal swab and vulvovaginal swab for chlamydia and gonorrhoea PCR) at booking and again at 32wks.
  • Offer repeat syphilis screen at 28wks.
  • Offer cervical smear if routine annual repeat due during pregnancy.

Fetal Monitoring and Screening

  • Offer women screening for chromosomal abnormalities with first trimester combined biochemical and ultrasound screening. If this is not possible then second trimester quadruple test will be offered but advise women that use of ART can increase the false positive rate.
  • Women who screen positive for chromosomal abnormality will be offered non-invasive prenatal testing.
  • If amniocentesis is indicated then this is considered safe for women on ART with a supressed viral load although limited data exists. If not yet on ART and invasive testing cannot be delayed then liaise with HIV team to commence ART to include Raltegravir or Dolutegravir and give a single dose Nevirapine 200mg 2-4hrs prior to the procedure.
  • Offer routine 20wk anomaly scan.
  • Offer third trimester growth scans at least monthly from 28wks.

Laboratory Monitoring

  • Viral load and LFTs will be checked monthly until 36wks. Viral load should then be checked weekly from 36wks until delivery. Lab monitoring is performed by the HIV team until 32wks when it will be taken over by the SNIPs team to coincide with routine antenatal appointments.
  • Therapeutic drug monitoring and CD4 count will be performed by the HIV team where appropriate.

Planning for delivery

Mode of delivery should be discussed at each visit. The patient should be aware of the options available to her depending upon her obstetric history and viral load. All women should be advised to deliver in a unit with immediate access to obstetric and neonatal support. 

HIV viral load should be reviewed at 36wks for a final decision to be made regarding mode of delivery. Delivery plan should be clearly documented using the intrapartum management plan on Badgernet.

  • For women with a viral load <50 HIV RNA copies/ml at 36wks and in the absence of obstetric contraindications, a planned vaginal delivery is recommended.
  • For women with a viral load ≥50 HIV RNA copies/ml at 36wks a planned Caesarean delivery should be recommended between 38 and 39wks with steroid cover for fetal lung maturation.

If Caesarean delivery is planned for obstetric reasons alone then this can be planned for 39wks unless earlier delivery otherwise indicated. In the case of breech presentation, external cephalic version can be offered to women with viral load <50 HIV RNA copies/ml from 36wks, in the absence of obstetric contraindications. No additional ART cover is required. HIV infection alone is not a contraindication to trial of vaginal birth after caesarean.

Planning for postnatal care

  • Infant feeding should be discussed regularly in the antenatal period. It should be explained that regardless of viral load and ART, breastfeeding is strongly discouraged due to the risk of vertical transmission. Women will be given information from the HIV team on accessing formula milk free of charge. Currently in NHS GGC this is facilitated by Waverley Care.
  • Postnatal contraception should be discussed at each visit (see more detail below) and the patient’s preference clearly documented in Badgernet, with a plan to administer post-partum.

Intrapartum Care

For untreated women presenting in labour please refer to Checklist for Management of the

Untreated HIV Positive Patient Presenting in Labour

Follow most recent intrapartum management plan documented on Badgernet. Inform paediatric team on admission. A sample should be sent on admission to check maternal HIV viral load. A trial of vaginal delivery is reasonable for women on ART who had an undetectable viral load (<50 HIV RNA copies/ml) on a sample taken within the past 14 days.

  • HIV infection is not a contraindication to pool delivery.
  • HIV infection alone is not an indication for continuous electronic fetal monitoring in labour.
  • Patient should continue to take her ART as normal throughout labour with timings documented on drug chart. If patient unable to take orally then consider need for IV Zidovudine (see below).
  • Timing of rupture of membranes should be clearly documented and progress recorded on the partogram. Delivery should aim to be achieved within 24hrs of rupture of membranes as the risk of vertical transmission can increase after this time.
  • Amniotomy is considered safe but attention should be paid to timing to reduce length of ruptured membranes. In the case of induction of labour where the cervix is unfavourable then additional vaginal prostaglandins may be preferable to an early ARM.
  • Women presenting with pre-labour spontaneous rupture of membranes should be offered immediate induction of labour.
  • Current evidence does not confirm the safety of fetal scalp electrodes or fetal blood sampling in labour and therefore these should be avoided due to the potential risk of vertical transmission.
  • Intrapartum pyrexia should be treated with immediate intravenous antibiotics and consideration should be given to expediting delivery.
  • Instrumental delivery is not contraindicated and instrument used (ventouse or forceps) can be as per practitioner preference.
  • Cord should be clamped as soon as possible after birth. Baby’s eyes should be cleaned at delivery and they should be bathed early. Paediatricians should be informed of the time of delivery as post exposure prophylaxis for the neonate should be commenced within 4hrs. There are no contraindications to Vitamin K.
  • Confirm plan for mother’s postnatal ART regime, this should be documented in Badgernet. 

Intrapartum Intravenous Zidovudine

IV Zidovudine is indicated for women presenting in labour or with SROM in the following circumstances:

  • Known HIV viral load ≥50 RNA copies/ml
  • Viral load not known
  • Mother poorly compliant with ART since last viral load estimation  No antenatal treatment for HIV*.

In these cases delivery by CS is usually indicated. Delivery should not be delayed to allow completion of IV Zidovudine regime. 

IV Zidovudine is indicated for women presenting for planned Caesarean section in the following circumstances:

  • Known HIV viral load ≥50 RNA copies/ml
  • Viral load not known
  • Mother poorly compliant with ART since last viral load estimation.

IV Zidovudine should run for at least four hours prior to planned caesarean delivery. A loading dose of 2mg/kg is given over 1hr. This should be followed immediately with a maintenance dose of 1mg/kg/hr until the cord is clamped. If there is a gap of greater than 15mins between the loading and maintenance dose then the loading dose should be repeated. 

*For women presenting not on ART they should receive a STAT dose of Nevirapine 200mg and a regular oral regime of Combivir 1 tablet (Zidovudine 300mg and Lamivudine 150mg) BD and Raltegravir 400mg BD to preload the baby, in addition to IV Zidovudine as above. 

For women poorly compliant with ART they should receive their prescribed regimen as soon as possible in addition to IV Zidovudine as above. 

Women Presenting in Preterm Labour <37+0wks gestation

Optimum management will depend upon whether or not membranes are intact, as outlined below. In women not on ART or not thought to be fully suppressed commence treatment as above with the addition of a STAT dose of tenofovir 490mg to preload the baby as they may be unable to tolerate oral medication. Optimum timing is 2hrs prior to delivery. 

Threatened preterm labour with intact membranes

  • Manage according to obstetric indications.
  • Give antenatal steroids.
  • Take maternal sample for urgent HIV viral load estimation if not performed within last 14 days.
  • Inform paediatrician.

Preterm ruptured membranes <34+0wks gestation

  • Take maternal blood for urgent HIV viral load if not performed within last 14 days.
  • Take high vaginal swab.
  • Commence oral erythromycin if delivery is to be delayed.
  • Administer antenatal steroids, do not wait to administer second steroid if delivery is indicated.
  • Decision regarding timing of delivery will be made following MDT discussion taking into account gestation, viral load, presence of comorbidities and other factors.

Preterm ruptured membranes 34wks-36+6wks gestation

  • Take maternal blood for urgent HIV viral load if not performed within last 14 days.
  • Take high vaginal swab.
  • Give a single dose of antenatal steroids.
  • In these women the risk of vertical transmission outweighs risk of prematurity and therefore they should be offered immediate delivery.
  • If viral load <50 copies/ml and vaginal delivery anticipated then commence induction of labour with the addition of IV intrapartum antibiotics for Group B Strep prophylaxis.
  • If viral load <50 copies/ml and Caesarean delivery planned for obstetric indications then proceed to CS delivery.
  • If viral load ≥50 copies/ml then proceed to immediate Caesarean delivery with ART cover as outlined above.

Postnatal Care

Antiretroviral Treatment

  • If on IV Zidovudine this can be stopped after cord clamping.
  • A sample should be sent for maternal viral load following delivery.
  • Usual ART regimen should be continued postnatally as per plan documented in Badgernet.

Infant feeding

  • Breastfeeding is discouraged for all women living with HIV in the UK due to the risk of vertical transmission.
  • Women can be offered lactation suppression with Cabergoline 1mg STAT oral dose.
  • Women choosing to breastfeed should be advised to exclusively breastfeed for as short a duration as possible (and not greater than 6 months) and to abstain from feeding if they develop mastitis or their baby has gastrointestinal symptoms.
  • Those choosing to breastfeed should be advised of the increased risk of vertical transmission, even if viral load suppressed, and the need for increased monitoring including regular blood tests for her baby. The postnatal drug regimen for the baby is unchanged by her decision to breastfeed.
  • The financial, psychological and cultural implications of not breastfeeding can be significant for some women and they will require additional support. Access to free formula milk can be arranged via the HIV team as above.
  • Further information is provided in the infant feeding guideline on Staffnet and the BHIVA parent information leaflet on infant feeding.

Contraception

  • All women should be offered a reliable form of contraception prior to discharge home from the postnatal ward. This will also be re-visited when they are seen 6wks postnatally by the HIV service.
  • Be aware that certain ARTs can interact with hormonal contraceptives.
  • The efficacy of depo-provera, copper intra-uterine device and levonorgestrel intra-uterine system are not affected by concomitant ART use.
  • Intra-uterine devices are contraindicated (UKMEC 3) for women with a CD4 count <200 cell/mm3 due to the increased risk of infection.
  • For further details refer to the joint BHIVA/BASHH/FSRH guidelines 

Last reviewed: 01 March 2021

Next review: 31 March 2024

Author(s): Roseanna Metcalfe, Elizabeth Ellis, Rebecca Metcalfe

Version: 3

Approved By: GGC Obstetric Guideline Group