Professional Documents
Culture Documents
Iris C. Coln, MD
Associate Chief
Maternal-Fetal Medicine
Dept. of Obstetrics and Gynecology
Santa Clara Valley Medical Center
Case Presentation
25y/o
Objectives
Outline
Historical
Perspective
Epidemiology
HIV Testing
Standards for Treatment in Pregnancy
Outline
Prevention
of Perinatal Transmission
Pharmaceutical Interventions
Surgical Interventions
Modification
of Obstetric Practices
Historical Perspective
June
5, 1981 MMWR
Reports on 5 homosexual men diagnosed
with P. carinii pneumonia.
Subsequently, etiologic agent discovered,
diagnostic tests developed, public health
interventions instituted and pharmaceutical
agents developed.
Epidemiology
1.2
40,000
Epidemiology
200,000
Majority
African-American
Epidemiology
7,000
HIV Testing
Serostatus
HIV Testing
Why
universal screening?
Attempts to identify those at risk fail to
identify some infected patients.
Avoids stereotyping and stigmatizing.
HIV Testing:
ACOG Committee Opinion 2004
HAART
HAART
Original
Regimens
include 2 nucleoside/nucleotide
RT inhibitors plus a third agent from either
protease inhibitor, non-nucleoside RT
inhibitor, or fusion inhibitor.
HAART
Nucleoside RT Inhibitors
Zidovudine (ZDV,AZT)*
Lamiduvine (Epivir, 3TC)*
Zalcitabine (ddC, HIVID)
Didanosine (ddi, Videx)
Staduvine (Zerit, d4T)
Abacabir (Ziagen, ABC)
Nucleotide RT Inhibitors
Tenofovir DF (Viread)
Fusion Inhibitor
Enfuvirtide (Fuzeon)
Non-nucleoside RT Inhibitors
Nevirapine (Viramune)
Delavirdine (Rescriptor)
Efavirenz (Sustiva)
Protease Inhibitors
Indinavir (Crixivan)
Ritonavir (Norvir)
Saquinavir (Fortovase)
Nelfinavir (Viracept)
Amprenavir (Agenerase)
Lopinavir/Ritonavir (Kaletra)*
HAART
Adherence
Maternal Evaluation
Maternal Evaluation
Case follow-up
March:
Viral load 25,823 copies/ml, CD4 count 100
Started on HAART Lamivudine/Zidovudine (Epivir/AZT) and
Lopinavir/Ritonavir (Kaletra)
Sulfamethoxazole/trimethoprim prophylaxis
April:
Viral load 103 copies/ml, CD4 count 150
LSIL Colposcopy multiple condylomatous cervical lesions
Perinatal Transmission
Possible mechanisms:
Microtransfusions during contractions
Ascension through the cervix and vagina during
parturition
Exposure to secretions and blood at delivery
Absorption through infants GI tract
Perinatal Transmission
Supporting
evidence:
Increased infection with increased duration of
ruptured membranes
Reduced rates of transmission with elective
cesarean delivery
Strongest predictor of perinatal transmission:
maternal viral load
Perinatal Transmission
Pharmacological
Interventions
HAART
ZDV
ZDV Regimen
100mg ZDV PO, 5 times/day,
start 14 wks
Neonatal
Intrapartum ZDV
Intravenous
Perinatal Transmission
Surgical
Interventions
Data from two prospective studies ( French
and Swiss), an international randomized trial
and a meta-analysis using 15 prospective
cohort studies indicate that there is a
significant relationship between mode of
delivery and vertical transmission.
Perinatal Transmission
Case follow-up
August
Vaginal delivery at term
is contraindicated in US.
Postpartum care contraception, pap smear.
Summary
Questions?
References
References
References
References
References