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.
- 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.