Perinatal transmission of bloodborne infections: Difference between revisions

Latest revision as of 15:28, 18 September 2020

Main risk is for HIV and HBV

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
Viral Load	ART	Zidovudine	C-section	Management of Infant
<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

@@ Line 1: / Line 1: @@
-* Main risk is for [[HIV]] and [[HBV]]
+*Main risk is for [[HIV]] and [[HBV]]
-== 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==
-==== Antepartum management ====
-* See [[HIV in pregnancy]] for management of an HIV-positive mother
-* Note that integrase inhibitors are effective for achieving fast viral suppression
+*Risk of transmission from an untreated HIV-positive mother is approximately 25%, but less than 1% if treated
-==== Peripartum management ====
-* 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"
+! 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
-|-
-| 14 days  || CBC/diff, nevirapine level, and HIV PCR || Dose-adjust nevirapine if needed
-|-
-| 4 weeks  || CBC/diff and ALT; ?HIV PCR? || Stop nevirapine if prior HIV PCR is negative, and continue other ART
-|-
-| 6 weeks  || ?HIV PCR? || Stop zidovudine and lamivudine if HIV PCR has been negative
-|-
-| 2 months || || Review as needed
-|-
-| 6 months || CBC/diff and ALT ||
-|-
-| 18 months || HIV serology || Developmental assessment
-|-
-| 3.5 years || || Developmental assessment
-|-
-| 5.5 years || || Developmental assessment
-|}
+* See [[Neonatal HIV#Prevention|prevention of neonatal HIV]] for information about preventing disease in the newborn
-==== Breastfeeding ====
+* An HIV PCR should be obtained within 48 hours of delivery, then regularly following delivery
-* Generally recommend against breastfeeding for HIV-positive mothers in Canada, even if HIV is well-controlled
+** If any single HIV PCR test is positive, then they are diagnosed with HIV and need ongoing treatment
-** 10-20% risk if breastfeeding and uncontrolled; less than 1% if fully and reliably suppressed
+* 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
-* 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 B virus==
-=== Background ===
-* Pregnant women are screened with HBsAg for active infection
-* Transmission mostly occurs intrapartum, and is highest if they have acute infection in the third trimester
+*[[Hepatitis B in pregnancy#Management|Management of the mother]]
-=== Management ===
+*[[Neonatal HBV#Prevention|Management of the neonate]]
-==== Antepartum management ====
-* [[Tenofovir]] is safe in pregnancy; [[lamivudine]] and [[telbivudine]] are alternatives
+==Hepatitis C virus==
-==== Peripartum management ====
-* Prophylaxis should be considered it mother has active hepatitis B (i.e. HBsAg positive), or her status is unknown
-** If status is unknown, try to get HBsAg done STAT (but often not possible)
-* Prophylaxis is with [[hepatitis B immune globulin]] (HBIG) 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
-* Despite optimal treatment, there is still a 2% risk of vertical transmission
+*[[Hepatitis C virus#Management|Management of the mother]]
-==== Postpartum management ====
+*[[Neonatal HCV|Management of the neonate]]
-* Remember to screen other family members for [[hepatitis B]]
-* Recommend breastfeeding
+==Further Reading==
-== Hepatitis C virus ==
-* About 5% risk of vertical transmission, though higher if coinfected with [[HIV]]
-** About half are transmitted antepartum and half intrapartum
-* 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]]