Objectives

1. Maternal and fetal outcomes of HIV positive pregnant women 2007 – 2011 at King’s College Hospital, London Dr Soha Sobhy1, Mr Haider Jan1, Dr Gavin Guy1; Miss Asha Jain1; Miss Devi Alexin1; Dr Jan Welch2, and Dr Mary Poulton21Department of Obstetrics and Gynaecology, Kings College Hospital, London; 2Caldecot Centre for GU Medicine and HIV, Kings College Hospital, London OPTIONALLOGO HERE OPTIONALLOGO HERE Background Results Results continued… Breastfeeding During this time no breastfeeding was supported, and all patients used formula feeding. Psychosocial factors Here at Kings, the antenatal services are provided as an MDT that Includes counselling service, lighthouse kings (housing, financial, legal, immigration), paediatricians, psych, HIV medical consultant) and specialist midwives who have extensive experience in high risk obstetrics (Known as the Ruskin Midwives). All our women are seen in this setting. Fetaloutcomes There was no increased neonatal morbidity over the last 5 years compared to the general KCH population from 2011. Over the 5 years there were 290 pregnant women with HIV and 70 women with PPROM or PROM. Bhiva guidelines: 1. Antenatal testing In England, the routine offer policy was implemented in 2000. By 2003 virtually all maternity units had implemented the antenatal screening policy, and over two-thirds had achieved >80% uptake, with about one-third reaching the 90% target 8,12. At kings the uptake rate for HIV testing had been consistently above 95%and routine screening for GU infections was offered and accepted by all. Nationally between 2000 and 2004 the majority of HIV-infected women diagnosed before delivery were identified through antenatal screening. However, since 2005 the situation has reversed and in 2010 about three-quarters of women diagnosed before delivery were already aware of their infection before they conceived, many of them diagnosed in a previous pregnancy 8,13 2. Antiretroviral treatment and viral loads. Most women received HAART- and achieved an undetectable viral load. HIV is a complex chronic medical condition which, if untreated, is associated with a high morbidity and mortality.1 Transmission can occur through sexual intercourse, intravenous drug use, transfusion of blood or blood products and vertically, from mother to child during pregnancy and breastfeeding.2 All pregnant women are screened for HIV to enable those with a positive diagnosis to take up interventions that reduce the risk of mother-to-child transmission and improve their health. Recently, studies in resource rich countries have reported vertical transmission rates of less than 2%. This can be attributed to effective use of highly active antiretroviral therapy (HAART) regimes, leading to low or undetectable plasma viral loads, appropriate management of delivery and avoidance of breastfeeding.3Some studies have suggested women using HAART in pregnancy are at increased risk of obstetric complications, including gestational diabetes4,5 and pre-eclampsia.6, European studies have consistently demonstrated an association between HAART and preterm delivery but the mechanism by which this occurs is unclear.8 Preterm prelabour rupture of membranes (PPROM) complicates 3% of pregnancies, accounting for nearly a 1/3 of all preterm births and is a major contributor to perinatal morbidity and mortality.13 Investigations have shown that in term pregnancies complicated by HIV, a duration of rupture of membranes greater than 4 hours increases the risk of intrapartum vertical transmission 14-15. However in PPROM, the risk of transmission must be weighed against the great risks of prematurity. Before 32 to 34 weeks, expectant management is preferred for patients with well controlled HIV 9. Very low rates of vertical transmission have been demonstrated among women taking HAART10 with no protective effect of elective caesarean section but published data is limited. In 2006, the policy at Kings college hospital was changed to conservatively manage those with PPROM and low or undetectable viral loads. These pregnancies were allowed to continue until 32 weeks gestation. Those women with prelabour rupture of membranes (PROM) were still induced immediately but labour was allowed to continue beyond four hours. 3. Mode of delivery Bhiva guidelines recommended Vaginal delivery for women on HAART with a viral load <50 HIV at 36 weeks. In women in whom a vaginal delivery has been recommended and labour has commenced obstetric management should follow the same guidelines as for the uninfected population. Vaginal Birth after Caesarean section should be offered to women with a viral load <50c/ml. Mode of deliver over the last 5 years % of women receiving routine HIV tests Fetal outcomes in HIV pregnancies compared to the general KCH Population % % During the last 5 years caesarean sections were only undertaken for obstetric reasons. We are continuing to increase our vaginal deliveries and have even had a planned home birth. 4. Management of Spontaneous Rupture of Membranes Bhivarecommends that In all cases of term pre-labour spontaneous rupture of the membranes delivery should be expedited, either by induction If viral load is < 50 or LSCS if ≥1000. The management of PPROM at >34 weeks is the same as term with the addition of group B streptococcus prophylaxis if <37 weeks. When PPROM occurs at < 34 weeks a more conservative approach is taken- steroids should be administered, virological control optimised and and there should be an MDT discussion about the timing of delivery. 8 Conclusions Timing of diagnosis At kings we are 100% compliant with Bhiva guidelines. There were no incidences of vertical transmission, even in those with prolonged and pre term ruptured membranes. Overall, there was no difference in maternal or foetal outcomes apart from the slightly higher placenta previa rate between those diagnosed with HIV and the local pregnant population. This data supports the conservative approach advocated by BHIVA in those with HIV as long as the viral load is low or undetectable. From our data over 5 years there were nine women with PPROM. They were managed conservatively with caesareans only for obstetric reasons. The pregnancies were prolonged anywhere between 1 to 16 weeks. There were 61 women who had PROM. All women but one (who was unbooked) were on HAART. Viral load was undetectable in all but five women (50-100 copies/ml). The delivery interval was greater than four hours ranging from 5 to 37 hours. In our population, the duration of ruptured membranes did not increase the risk of vertical transmission as long as the viral load was less than 50 copies/ml. There were no cases of vertical transmission and no associated major neonatal morbidity. Maternal Outcomes: There was no statistically significant difference in the incidence of gestational diabetes and pre eclampsia between those diagnosed with HIV and those who were not. There was a significant increase in the number of Placenta Previa cases 1.26% (95%CI 0.43% -3.64%) in HIV pregnancies compared to the general KCH population 0.24% (95% CI 0.14% – 0.4%) p<0.05.This is probably related to the higher number of previous caesarean sections in the HIV positive group. References • 1.Health Protection Agency; UK National Screening Committee. Infectious Diseases in Pregnancy Screening Programme 2007/08 Annual Report and 2005–2007 Surveillance Data. London: HPA; • 2. Health Protection Agency. HIV in the United Kingdom: 2009 Report. London: HPA; 2009 • 3. Townsend CL, Cortina-Borja M, Peckham CS, De Ruiter A, LyallH,Tookey PA. Low rates of mother-to-child transmission of HIV following effective pregnancy interventions in the United Kingdom and Ireland, 2000–2006. AIDS 2008;22:973–81 • 4. Watts DH, Balasubramanian R, Maupin RT Jr, Delke I, Dorenbaum A, Fiore S, et al. Maternal toxicity and pregnancy complications in human immunodeficiency virus-infected women receiving antiretroviral therapy: PACTG 316. Am J ObstetGynecol 2004;190:506–16. • 5.Wimalasundera RC, Larbalestier N, Smith JH, de RA, McG Thom SA, Hughes AD, et al. Pre-eclampsia, antiretroviral therapy, and immune reconstitution. Lancet 2002;360:1152–4. • 6. MattarR,Amed AM, Lindsey PC, Sass N, Daher S. Preeclampsia and HIV infection. Eur J ObstetGynecolReprodBiol 2004;117:240–1. • 7 Kourtis AP, Schmid CH, Jamieson DJ, Lau J. Use of antiretroviral therapy in pregnant HIV-infected women and the risk of premature delivery: a meta-analysis. AIDS 200712;21:607–15. • 8 British HIV Association Guideline The management of HIV in pregnancy. http://www.bhiva.org/documents/Guidelines/Pregnancy/Pregnancy_Guidelines_for_Consultation120125.pdf • 9. RCOG Green Top Guideline No.39;2010 • 10. Townsend CL, et al. Low rates of mother-to-child transmission of HIV following effective pregnancy interventions in the United Kingdom and Ireland, 2000–2006. AIDS 2008;22:973–81 • 11. National Study of HIV in Pregnancy and Childhood. National surveillance data available at. National Sudy of HIV in Pregnancy and Childhood, 2011 (Accessed December 21, 2011 www.nshpn.ucl.ac.uk). • 12. Townsend CL, Cliffe S, Tookey PA. Uptake of antenatal HIV testing in the United Kingdom: 2000-2003. J Public Health 2006;28(3):248-252. • 13. Robert M Ehsanipoor, Carol A Major,Herpes simplex and HIV infections and preterm PROM, ClinObstetGynecol, 2011 vol. 54 (2) pp. 330-6 • 14. Aagaard-Tillery KM, Lin MG, Lupo V, BuchbinderA,Ramsey PS. Preterm premature rupture of membranes in HIV infected women: a novel case series. Infect DisObstetGynecol 2006: 53234. Published online 2006 April 20 • 15. Jesus R Alvarez, Arlene Bardeguez, Leslie Iffy, Joseph J Apuzzio,Preterm premature rupture of membranes in pregnancies complicated by human immunodeficiency virus infection: a single center's five-year experience, Matern Fetal Neonatal Med, 2007 vol. 20 (12) pp. 853- • 16.Minkoff H, Burns DN, Landesman SH, et al. The relationship of the duration of ruptured membranes to vertical transmis- sion of human immunodeficiency virus. American Journal of • Obstetrics and Gynecology. 1995;173(2):585–589. Objectives We conducted a 5 year retrospective observational study of maternal and foetal outcomes of pregnant women found to be HIV positive at Kings college hospital. This included a a sub analysis of patients with PPROM and an assessment of adherence to the BHIVA guidelines. Methods An annual retrospective observational study was undertaken using patient notes and electronic databases, from both the HIV medical service (at theCaldecotcentre) and the Kings obstetric service. Data was collected for all women found to be HIV positive who booked between January 2007 and December 2011. Viral load at delivery following antiretroviral therapy