Perinatal transmission of bloodborne infections: Difference between revisions

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** About half are transmitted antepartum and half intrapartum
** About half are transmitted antepartum and half intrapartum
* Not urgent, as it is a chronic illness that may not manifest for decades
* Not urgent, as it is a chronic illness that may not manifest for decades
* Serology to be done at 18 months for diagnosis
* Serology to be done at 12-18 months for diagnosis
* If significant anxiety, can send HCV-PCR
* If significant anxiety, can send HCV-PCR at 3 to 6 months
** 25-30% will spontaneous clear it
** Still need serology at 12-18 months, and repeat PCR around 18 months


== Further Reading ==
== Further Reading ==

Revision as of 20:17, 4 December 2019

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

Diagnosis

  • 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
    • 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

Antepartum management

  • See HIV in pregnancy for management of an HIV-positive mother
  • Note that integrase inhibitors are effective for achieving fast viral suppression

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
VL Antenatal Rx C-section Neonatal Rx
>1000 Any Yes ART
40-999 None Yes ART
40-999 ART Maybe ART
<40 None Maybe ART
<40 ART No Zidovudine x4 weeks
Unknown None Maybe ART
Unknown ART Maybe Unclear

Selection of antiretrovirals

  • Can either do a prophylactic regimen, or treat empirically
  • Prophylaxis:
  • Empiric treatment:

Follow-up

Age Investigations Management
Birth CBC/diff, ALT, lactate, and HIV PCR Start ART as described below
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

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

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

Management

Antepartum management

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

Postpartum management

  • Remember to screen other family members for hepatitis B
  • Recommend breastfeeding

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 12-18 months for diagnosis
  • If significant anxiety, can send HCV-PCR at 3 to 6 months
    • 25-30% will spontaneous clear it
    • Still need serology at 12-18 months, and repeat PCR around 18 months

Further Reading