Perinatal transmission of bloodborne infections
From IDWiki
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:
- ZDV/NVP: zidovudine x6 weeks, plus nevirapine x3 in the first week of life
- Empiric treatment:
- ZDV/3TC/NVP: zidovudine for 6 weeks, plus lamivudine and nevirapine for 2 to 6 weeks (preferred)
- ZDV/3TC/RAL: zidovudine for 6 weeks, plus lamivudine and 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
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
- Tenofovir is safe in pregnancy; lamivudine and telbivudine are alternatives
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 18 months for diagnosis
- If significant anxiety, can send HCV-PCR
