Lectures on HIV AIDS and pregnancy

2021-03-21 12:00 AM

According to data from the World Health Organization, worldwide there are about 5 million people with HIV, half are women.

Outline

Human Immunodeficiency Virus (HIV) causes Acquired Immuno Deficiency Syndrome (AIDS) is a contagious disease. Although it has only been reported since 1981, the disease probably appeared long ago and spread from Africa to America (North America), Europe, then to Asia and Latin America. Since then, the epidemic has not stopped growing, has spread all over the world. 

The disease is transmitted through different ways such as blood, semen, vaginal secretions and through breast milk when breastfeeding.

The cause of the disease is now known to be caused by viruses of the Retrovirus family, which contain a reverse transcriptase that allows them to enter the host cell chromosomes, which reside in the genomes of infected cells. and multiplied there. When entering the bloodstream, the HIV virus destroys the T4 Lymphocytes and Central Nerve Cells, causing cellular immunodeficiency, resulting in a variety of tumors and opportunistic infections and causing the risk of death.

HIV transmission routes to women:

Unprotected intercourse (through semen).

Using syringes infected with HIV, blood transfusion and blood products containing HIV.

A mother who is infected with HIV during pregnancy can pass it to her baby (through vegetable cakes during pregnancy, blood and vaginal fluids during labor, through milk while breastfeeding).

Epidemiology

According to the World Health Organization, worldwide there are about 5 million people with HIV (+) (1997), half are women. In 2000 the number of women infected with the disease was about 14 million and about 4 million of which would die of AIDS.

In the United States, about 89% of women with immunodeficiency syndrome are of childbearing age. About 6% of pregnant women are infected with HIV, yet 50% of them still decide to keep the pregnancy.

By the end of 2003, at least in the world, 42 million people living with HIV were still alive and about 30 million people had died. Every day, 14,000 new people become infected with HIV.

In Vietnam, as of December 31, 2004, the cumulative number of people detected to be infected with HIV nationwide was 90,380 people, of which 14,428 cases of AIDS and 8,348 cases of AIDS died. It is forecasted that by 2010, Vietnam will have about 350,000 people infected with HIV / AIDS.

According to the National AIDS Committee, the number of children infected with HIV is increasing. In 1997, 7 cases were found and by 2002, 20 cases under 5 years old were found to be infected with HIV from their mothers. Meanwhile, after 2 years, the proportion of pregnant women infected with HIV has doubled (from 0.2% in 2000 to 0.4% in May 2002).

Risk factors and infection in HIV during pregnancy

Risk factors for mother-to-child transmission of HIV  

Virus concentration is higher than 1,000 animals / ml plasma.

Poor immune status.

Do not take antiviral medication during pregnancy.

There is a sexually transmitted disease.

Prolonged rupture of membranes (some studies show this to be over 4 hours, others show an increased risk with each hour of rupture).

Amniocentesis.

Transmission of HIV during pregnancy

Pregnancy: HIV has the ability to transmit to the fetus through vegetable cakes. This transmission can occur during pregnancy, but the transmission rate is high when the gestational age is more than 18 weeks.

During labor: HIV transmission usually occurs late in labor; This is due to the uterine contraction that pushes the mother's blood carrying HIV into the vegetable cake circulation or the child comes into direct contact with HIV-containing vaginal fluids, especially in cases of difficult delivery, premature rupture of the amniotic fluid, prolonged labor, many mother's organizations were crushed, ...

Breastfeeding stage: HIV transmission through breast milk is the most common mode of transmission. This risk is related to a long or short lactation period.

Clinical

Stage of HIV infection: HIV-infected people do not show any clinical signs, diagnosis is mainly based on tests.

Stage of AIDS: is divided into 4 phases depending on HIV-related diseases such as status:

Weight loss, persistent fever, sore throat. . .

Opportunistic infections.

Malignant diseases.

The level of physical activity in the body.

Subclinical

Based on ELISA test (Enzyme Linked Immunosorbent Assay): allows detection of anti-HIV antibodies with a sensitivity of # 99% .- Positive ELISA results are confirmed by Western blot test.

Immunofluorescence technique: for infected cells to come into contact with the patient's serum, the (+) reaction is calculated if antibodies are permanently present on infected cells visible by fluorescence.

The RIPA (Radio-Immuno Precipitation Assay) technique is the most specific technique using radioactive active substances. This test is indicated when previous results are suspected or confirmed.

PCR (Polymerase Chain Reaction) is a sensitive specialized method used to determine the type of DNA. Today it is used as a test to determine the DNA of the HIV virus.

The clinical progression of the disease was assessed by the total number of CD4 T-lymphocytes:

If the total CD4 count is greater than 500 cells / cell / mm3, it is considered that there is no immunodeficiency, and there is no need for treatment.

A total CD4 count of 200-500 cells / mm3 requires intervention.           

The total CD4 count is less than 200 cells / mm3 or higher, but with a fungal infection or a latent fever above 37.8oC, the patient is at increased risk of complications.

HIV-infected people with a Lymphocyte count of less than 1200 cells / mm3 are considered to be severely immunocompromised.

Directions for treatment and prevention of mother-to-child transmission of HIV

Early diagnosis of pregnant HIV (+)

The question is how to detect HIV-infected pregnant women early, so it is necessary to do mass HIV tests for pregnant women with ELISA test, even when there are no clear risks. If testing ELISA (+), it is necessary to do more Western blot test to confirm diagnosis.   

According to current regulations, only a few centers with full equipment after re-checking a blood sample diagnosed as HIV (+) through tests are allowed to notify the pregnant woman.

Cases wanting to suspend pregnancy

For babies under 22 weeks, after being counseled, if the pregnant woman agrees to abortion, suction or abortion should be resolved depending on the gestational age. These cases will be performed in facilities with surgery, with an obstetrician. After abortion the disease is treated like other HIV patients.

If pregnant women want to keep the pregnancy, health facilities should send them to the District Hospital Department of Obstetrics and other higher-tech levels for management and preventive treatment for the child with anti-Retrovirus.

Management in case of HIV-infected pregnant women

Treatment is needed for pregnant women infected with HIV with the aim of reducing mother-to-child transmission, if the mother and her family, after being counseled, still want to keep the pregnancy.

At the commune level:

Counseling pregnant women on the possibility of mother-to-child transmission of HIV and referral to higher levels.

At the district level:

If the woman agrees to abortion:

Depending on your gestational age, to conduct safe abortion techniques.

Need advice about contraception and avoid spreading to others after abortion.

After abortion, transfer the patient to the Preventive Medicine Center for management and treatment.

If pregnant women want to keep pregnant:

Pregnancy management.

Counseling pregnant women about the risk of transmission to their children and the possibility of preventing infection only in three quarters of cases even though they have taken adequate medicines.    

Depending on the condition of the treatment facility, one of the following two regimens can be chosen:

Nevirapine regimen: At the onset of actual labor or before cesarean section, give a nevirapine 200mg tablet to pregnant women once.

Zidovudine regimen: Zidovudine 600mg / day, in two divided doses, starting from 36 weeks of pregnancy until labor. In the case of pregnant women coming to antenatal care late after 36 weeks of pregnancy, also give the same dose of Zidovudine 600mg / day until labor. During labor use a dose of 300mg every 3 hours until delivery.

Points to be taken during delivery:

For pregnant women:

Absolutely sterile during delivery.

Clean the vagina several times with a cotton pad soaked in 0.2% Chloride de Benzalkonium or Chlorhexidine.

Do not shave your genital area.

Avoid amniocentesis and episiotomy when not needed.

Indicated cesarean section when indicated obstetric.                        

Counsel the mother on the benefits of breastfeeding if possible to reduce the risk of transmission.

For babies:

Do not place electrodes on the head of the fetus (obstetric monitoring).

Do not take scalp blood for pH.

Bathe your baby right after birth.

Immediately after the baby was born, the obstetrician's medical staff had to notify the Pediatrics department so that the child could receive special care in both the hospital's Obstetrics and Pediatrics departments.

Postpartum treatment:

Treatment for newborns:

If the mother takes Nevirapine, give her child a single Nevirapine Syrup at a dose of 2mg / kg body weight within the first 72 hours after birth. Nevirapine should be given at birth if the interval between maternal nevirapine dose and delivery is less than 2 hours.

If the mother is taking Zidovudine, then after giving birth, 8-10 hours after giving birth, give your child Zidovudine at a dose of 2mg / kg of body weight, every 6 hours until 6 weeks of age. In the absence of Zidovudine, give Nevirapine as above.

Treatment for mothers:

If necessary and conditional, specific treatment will be applied to mothers with antiretrovirals and OI drugs.

Breastfeeding problems:

Should advise and advise mothers not to breast-feed to avoid transmission of disease through milk. Instructions for mothers how to use breastmilk substitutes. In the absence of conditions to use replacement milk, it is necessary to breastfeed the baby and pay attention to the wounds in the mouth of the newborn as well as do not let the mother suffer from nipple diseases such as cracked nipples, as it can increase risk of infection. In the case of preterm babies, breastmilk can be fed with a spoon or through the stomach, if formula is not available.

Preventive

Educational information is the most important step for all women, especially women of childbearing age to protect themselves and their children.

Safe in sex: to avoid sexually transmitted diseases (male and female condoms).

Advocate for a pregnant woman, husband or lover to have an HIV test to have a clear management attitude towards pregnancy. If possible, a woman should also know whether she is infected with HIV or not before deciding to become pregnant.

Even if a pregnant woman is HIV (-) calculated, it is necessary to counsel about how to prevent and avoid HIV infection and should retest HIV in the second trimester to rule out HIV infection during pregnancy.

In case of pregnancy that HIV (+) counts, abortion counseling and advocacy to reduce the rate of HIV transmission from mother to child. If the mother and her family, after counselling, still want to keep the pregnancy, they should advise and give anti-HIV drug treatment.