Many babies are not infected in utero but become so during parturition. Most mothers at risk of passing on HIV to the next generation (vertical transmission) do not want to know their HIV status, or cannot afford to find out. (If their husband is uninfected, what is the chance of him remaining loyal?) In our section on perinatal HIV (p 34) we comment that anti-retrovirals and caesarean section can prevent vertical transmission but this is not much help if the nearest hospital is 3h away by wheelbarrow, and has only basic drugs. What is needed is much more cost-effective advice.
- Only give blood transfusions if absolutely necessary.
- Avoid any procedure likely to lead to maternal cells contacting fetal blood eg external cephalic version, and amniocentesis.
- In instrumental deliveries, try to avoid abrasions of the fetal skin. Vacuum extractors may be preferable to forceps.
- When you clamp the cord, ensure there is no maternal blood on it.
- Artificial rupture of membranes and episiotomies should be left to the last possible moment, or avoided altogether.
- Avoid fetal scalp electrodes, and doing fetal scalp blood samples.
- If the membranes have ruptured, avoid long labours transmission risk doubles after ruptured for 4h and increases by 2%/h thereafter up to 24h.MET14
- During caesarean sections, open the last layer by blunt dissection, to avoid minor cuts to the baby from the scalpel.
- Rinse the baby after birth; wipe the face away from mouth, eyes, and nostrils.
- Unless there is apnoea, avoid suction catheters to aspirate mucus from the nostrils. The baby's face is likely to be covered with the mother's blood at this stage, and you do not want to force HIV into nostrils.
- Health programmes are likely to end up encouraging breast feeding if there is no satisfactory alternative. Humanized milk is expensive, and may indicate to the mother's neighbours that she is HIV+ve. Using humanized milk might also compound problems by removing the one free method of contraception: lactational amenorrhoea. But studies from Nairobi showed 70% formula fed babies alive and disease-free at 2yrs vs 58% if breast fed. Most transmission occurred in the first 6 months. These babies had access to the city water supply.RCT15 Breast milk transmission was 16%. Also HIV+ve mothers in developing countries who breast feed may die sooner.
- Offer advice on avoiding future pregnancies. This is not an easy area. Encouraging the use of condoms is fine, but many will want the added protection of the Pill. IUCDs promote bleeding, and may increase spread to men. This may also be a problem with the progestogen-only Pill, but note that the latter may cause less ectropion than the combined Pill, and this might be advantageous. Sterilization is the hardest choice, especially when the mother now has no living children because of HIV.
Traditionally, drug therapy for HIV in pregnant patients consisted of mono-therapy with zidovudine in contrast to non-pregnant women treated with combination therapy. Combination therapies are recommended in pregnancy.1 Antiretrovirals are becoming more available in many developing countries but there is a long way to go before all infected mothers will have access to them. Get expert advice.
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