Perinatal transmission of bloodborne infections: Difference between revisions

From IDWiki
(→)
No edit summary
 
(12 intermediate revisions by the same user not shown)
Line 1: Line 1:
* Main risk is for [[HIV]] and [[HBV]]
*Main risk is for [[HIV]] and [[HBV]]
* Also see [[HIV in pregnancy]] for management of an HIV-positive mother
** Note that integrase inhibitors are effective for achieving fast viral suppression


== Investigations ==
==Investigations==
===== Unknown maternal serostatus =====
=====Unknown maternal serostatus=====
* If possible, send STAT maternal HIV serology, HBV, HCV, and syphilis; can consider viral load
* For infant:
** At birth send HIV, HBV (sAg, sAb, cAb), HCV-Ab, and syphilis serologies, as well as an HIV PCR (''not'' viral load)
** Repeat HIV PCR at 1, 2, and 4-6 months


*If possible, send STAT maternal HIV serology, HBV, HCV, and syphilis; can consider viral load
== HIV ==
*For infant:
=== Diagnosis ===
**At birth send HIV, HBV (sAg, sAb, cAb), HCV-Ab, and syphilis serologies, as well as an HIV PCR (''not'' viral load)
* Up to 18 months of age, only use '''HIV PCR'''
** In general, all infants with perinatal exposure should be checked at 14 to 21 days, 1 to 2 months, and 4 to 6 months
**Repeat HIV PCR at 1, 2, and 4-6 months
** If high risk, can also check at birth and 2 to 4 weeks after stopping antiretrovirals
** Confirm a positive result with repeat testing
* '''Serology''' can be tested starting at 18 to 24 months


=== Management ===
==HIV==

==== Peripartum management ====
*Risk of transmission from an untreated HIV-positive mother is approximately 25%, but less than 1% if treated
* Immediate management depends on maternal viral load and treatment status
* In general, a mom with HIV should get IV [[zidovudine]] during labour
** If it is unavailable or resistant, could use any pregnancy-safe medication


{| class="wikitable"
{| class="wikitable"
! rowspan="2" |Viral Load
! VL !! Antenatal Rx !! C-section !! Neonatal Rx
! colspan="3" |Management of Mother
! rowspan="2" |Management of Infant
|-
|-
![[HIV treatment|ART]]
| >1000 || Any || Yes || ART
![[Zidovudine]]
![[Cesarean section|C-section]]
|-
|-
|<40
| 40-999 || None || Yes || ART
|yes
|yes
|no
|[[zidovudine]] for 4 to 6 weeks
|-
|-
|40-999
| 40-999 || ART || Maybe || ART
|yes
|yes
|consider
|combination ART, or [[zidovudine]] monotherapy for 4-6 weeks
|-
|-
|≥1000
| <40 || None || Maybe || ART
|yes
|yes
|yes
|combination ART
|-
|-
|unknown
| <40 || ART || No || [[Zidovudine]] x4 weeks
|-
|yes
|yes
| Unknown || None || Maybe || ART
|-
|yes
|combination ART, adjusted based on results of maternal viral load
| Unknown || ART || Maybe || Unclear
|}
|}


==== Selection of antiretrovirals ====
=== Management of Mother ===
* Can either do a prophylactic regimen, or treat empirically
* Prophylaxis:
** ZDV/NVP: [[Zidovudine#Neonatal HIV prophylaxis|zidovudine]] x6 weeks, plus [[nevirapine#Neonatal HIV prophylaxis|nevirapine]] x3 in the first week of life
* Empiric treatment:
** ZDV/3TC/NVP: [[Zidovudine#Neonatal HIV prophylaxis|zidovudine]] for 6 weeks, plus [[lamivudine#Neonatal HIV prophylaxis|lamivudine]] and [[nevirapine#Neonatal HIV prophylaxis|nevirapine]] for 2 to 6 weeks (preferred)
** ZDV/3TC/RAL: [[Zidovudine#Neonatal HIV prophylaxis|zidovudine]] for 6 weeks, plus [[lamivudine#Neonatal HIV prophylaxis|lamivudine]] and [[raltegravir#Neonatal HIV prophylaxis|raltegravir]] for 2 to 6 weeks
** Regarding duration, in the UK they typically treat for 2 weeks while in Canada it is typically 4 weeks


* See [[HIV in pregnancy]] for information about managing the mother ante-, intra-, and postpartum
==== Follow-up ====
* Mothers should be treated with antiretroviral therapy and monitored during pregnancy
{| class="wikitable"
* Intrapartum management is based on viral load, and includes continuing antiretrovirals, giving intravenous [[zidovudine]] during labour, and consideration of [[Cesarean section]]
! Age !! Investigations !! Management
* Following delivery, mothers should be counselled about the risks of breastfeeding
|-

| Birth || CBC/diff, ALT, lactate, and HIV PCR || Start ART as described below
=== Management of Neonate ===
|-

| 7 days || CBC/diff, nevirapine level || Dose-adjust nevirapine if needed
* See [[Neonatal HIV#Prevention|prevention of neonatal HIV]] for information about preventing disease in the newborn
|-
* An HIV PCR should be obtained within 48 hours of delivery, then regularly following delivery
| 14 days || CBC/diff, nevirapine level, and HIV PCR || Dose-adjust nevirapine if needed
** If any single HIV PCR test is positive, then they are diagnosed with HIV and need ongoing treatment
|-
* A decision to treat the infant with either [[zidovudine]] monotherapy for 4 to 6 weeks, or presumptive antiretroviral therapy for at least 6 weeks, depends on the risk of infection
| 4 weeks || CBC/diff and ALT; ?HIV PCR? || Stop nevirapine if prior HIV PCR is negative, and continue other ART

|-
==Hepatitis B virus==
| 6 weeks || ?HIV PCR? || Stop zidovudine and lamivudine if HIV PCR has been negative

|-
*[[Hepatitis B in pregnancy#Management|Management of the mother]]
| 2 months || || Review as needed
*[[Neonatal HBV#Prevention|Management of the neonate]]
|-
| 6 months || CBC/diff and ALT ||
|-
| 18 months || HIV serology || Developmental assessment
|-
| 3.5 years || || Developmental assessment
|-
| 5.5 years || || Developmental assessment
|}


==Hepatitis C virus==
==== Breastfeeding ====
* Generally recommend against breastfeeding for HIV-positive mothers in Canada, even if HIV is well-controlled
** 10-20% risk if breastfeeding and uncontrolled; less than 1% if fully and reliably suppressed
* As well as risk of HIV transmission, it could theoretically expose child's HIV to low-level antivirals which could induce resistance


== Hepatitis B virus ==
*[[Hepatitis C virus#Management|Management of the mother]]
*[[Neonatal HCV|Management of the neonate]]
* If mother has hepatitis B, or her status is unknown, then consider post-exposure prophylaxis with hepatitis B immune globulin and hepatitis B vaccine given within 12 hours of life
** Vaccine prevents about 90% of infections, with HBIG adding a bit more
** HBIG can be given up to 7 days of life but is most effective when given earlier


==Further Reading==
== Hepatitis C virus ==
* Not urgent, as it is a chronic illness that may not manifest for decades
* Serology to be done at 18 months for diagnosis
* If significant anxiety, can send HCV-PCR


*AIDSinfo. [https://aidsinfo.nih.gov/guidelines/html/3/perinatal/187/antiretroviral-management-of-newborns-with-perinatal-hiv-exposure-or-perinatal-hiv Recommendations for the Use of Antiretroviral Drugs in Pregnant Women with HIV Infection and Interventions to Reduce Perinatal HIV Transmission in the United States].
== Further Reading ==
*Ontario HIV Treatment Network. [http://www.ohtn.on.ca/mother-to-child/ Guidelines for the Prevention of Mother-to-Child HIV Transmission]. 2017.
* AIDSinfo. [https://aidsinfo.nih.gov/guidelines/html/3/perinatal/187/antiretroviral-management-of-newborns-with-perinatal-hiv-exposure-or-perinatal-hiv Recommendations for the Use of Antiretroviral Drugs in Pregnant Women with HIV Infection and Interventions to Reduce Perinatal HIV Transmission in the United States].
* Ontario HIV Treatment Network. [http://www.ohtn.on.ca/mother-to-child/ Guidelines for the Prevention of Mother-to-Child HIV Transmission]. 2017.


[[Category:HIV]]
[[Category:HIV]]

Latest revision as of 15:28, 18 September 2020

Investigations

Unknown maternal serostatus
  • If possible, send STAT maternal HIV serology, HBV, HCV, and syphilis; can consider viral load
  • For infant:
    • At birth send HIV, HBV (sAg, sAb, cAb), HCV-Ab, and syphilis serologies, as well as an HIV PCR (not viral load)
    • Repeat HIV PCR at 1, 2, and 4-6 months

HIV

  • Risk of transmission from an untreated HIV-positive mother is approximately 25%, but less than 1% if treated
Viral Load Management of Mother Management of Infant
ART Zidovudine C-section
<40 yes yes no zidovudine for 4 to 6 weeks
40-999 yes yes consider combination ART, or zidovudine monotherapy for 4-6 weeks
≥1000 yes yes yes combination ART
unknown yes yes yes combination ART, adjusted based on results of maternal viral load

Management of Mother

  • See HIV in pregnancy for information about managing the mother ante-, intra-, and postpartum
  • Mothers should be treated with antiretroviral therapy and monitored during pregnancy
  • Intrapartum management is based on viral load, and includes continuing antiretrovirals, giving intravenous zidovudine during labour, and consideration of Cesarean section
  • Following delivery, mothers should be counselled about the risks of breastfeeding

Management of Neonate

  • See prevention of neonatal HIV for information about preventing disease in the newborn
  • An HIV PCR should be obtained within 48 hours of delivery, then regularly following delivery
    • If any single HIV PCR test is positive, then they are diagnosed with HIV and need ongoing treatment
  • A decision to treat the infant with either zidovudine monotherapy for 4 to 6 weeks, or presumptive antiretroviral therapy for at least 6 weeks, depends on the risk of infection

Hepatitis B virus

Hepatitis C virus

Further Reading

Retrieved from "https://idwiki.org/index.php?title=Perinatal_transmission_of_bloodborne_infections&oldid=6900"
Powered by MediaWiki
Powered by Semantic MediaWiki