Pre-pregnancy counseling critical for patients
Prospective parents should know all the risks
One of the most important reasons clinicians should be open to assisting their HIV patients with planned pregnancies is that they can help patients reduce risk by providing counseling that clarifies all options and consequences.
"I just think the most important thing is to prepare HIV-positive women for the fact that there is always the potential for the child to become HIV-positive," says Rani Lewis, MD, associate professor of obstetrics and gynecology in the Division of Maternal Fetal Medicine at Vanderbilt University in Nashville, TN.
Before attempting pregnancy, HIV-infected women should consider improving their insurance coverage, stop all risk behaviors (including drug use), and prepare for the difficulties that would arise with an HIV-infected infant.
"The thing that would change things the most for the couple is if the child becomes HIV-infected," Lewis says. "Neonates have such a miserable immune system anyway, and HIV-infected neonates have a very short life span."
On the other hand, if the infant is born HIV-negative, the HIV-infected parent or parents must face the possibility of not living to see their child reach adulthood. Rebecca Denison, who was diagnosed with HIV infection in 1990 and later gave birth to twins, says she often talks with HIV-infected women about the issue of whether they will live to raise their children. But she feels this is issue is something all parents need to address.
"Every parent has a responsibility to think about what happens if I’m in a car crash tomorrow," Denison says. "We need wills because we’re parents; the fact that I’m positive means that maybe I placed greater urgency and responsibility on doing those things."
Denison has put together photo albums and audio tapes, including some in which she sings lullabies, for her daughters.
From a medical standpoint, clinicians need to advise HIV patients about strategies that will protect their own health and that of their child. If the pregnancy is unplanned, some physicians will suggest the woman have an abortion, but that shouldn’t be the knee-jerk reaction to every pregnancy an HIV-infected woman has, says Stanley J. Bodner, MD, FACP, associate clinical professor of medicine at Vanderbilt University School of Medicine in Nashville, TN.
Bodner has participated on a committee of the Triangle AIDS Leadership Alliance Mid-America that has developed guidelines for clinicians treating HIV-infected women who are or desire to become pregnant. The guidelines, titled "HIV Infection and Having A Baby Timeline," are expected to be published in 2001.
According to Bodner, Lewis, and the guidelines, here are some of the steps clinicians should take when advising HIV-infected women about pregnancy:1
• HIV management: The first step is for an HIV specialist to be involved with prenatal care so antiretroviral treatment can be adjusted to accommodate the pregnancy.
• Counseling: The pregnant woman, her partner, and sometimes the larger family should be counseled by an obstetrician and obstetric team nurse, and the obstetric team should be in early contact with the HIV specialist.
Initial counseling should give patients accurate information about HIV, including side effects of treatment, how to reduce the risk of mother-to-fetus transmission, and how the prospective mother might expect to live to see her child reach adulthood. Clinicians also may describe various scenarios to the prospective parents to help them see the situation realistically.
If the couple is serodiscordant, then they would be advised of various options for achieving pregnancy while reducing risk of transmitting the virus to the uninfected partner.
• First-trimester care: The team would include an obstetrician/gynecologist, an infectious disease expert, and a pediatrician. Each professional involved with the woman’s prenatal care would maintain strict confidentiality.
The team would plan how to use antiviral therapy and would monitor the patient’s viral load count and CD4 cell count.
Watch out for toxoplasmosis
• Second-trimester care: Every three months, the team obtains the patient’s viral load and CD4 cell count.
The infectious disease specialist should attend to both standard infectious disease concerns regarding pregnant women and special issues related to HIV opportunistic infections. This includes surveillance for perineal Group B Streptococcus agalactae colonization, prior rubella and varicella exposure and immunization, maternal genital herpes simplex infection, and S. agalactae vaginal colonization. HIV-infected women with CD4 lymphocyte counts under the 100-200 range who are not taking toxoplasmosis prophylaxis may have maternal risk of toxoplasma infection. All pregnant women who are HIV-infected should avoid cats and cat litter.
Lewis also recommends that HIV-infected pregnant women avoid having an amniocentesis because that could increase the likelihood of transmitting HIV to the infant.
"We would recommend they don’t automatically go to an amniocentesis, because interrupting the bag of water significantly increases the risk that the baby would get HIV," Lewis says.
• Third-trimester care: At this point, the obstetrician discusses the importance of an elective cesarean section prior to labor for women who have HIV-RNA levels of greater than 1,000 virions, to reduce the risk of infecting the infant. The infectious disease specialist should obtain a 35-37 week HIV viral load test.
The obstetrician also might discuss with the woman the possibility of sterilization, possibly to accompany the cesarean. The obstetrician also should advise the woman to use infant formula and avoid breast-feeding.
Balancing health vs. bonding experience
"Breast-feeding is very strongly associated with the baby becoming infected," Lewis says. "In the United States, where we have alternate forms of nutrition for babies, I think increasing the risk to the baby’s health for the benefit of the maternal-infant bonding experience is probably not worth it."
The pediatrician and other team members should plan to have the antiretrovirals zidovudine, lamivudine, and nevirapine present at the birth in oral infant pediatric syrup formulations. The obstetrician also should have intravenous zidovudine available to administer during delivery, and the ID specialist should provide a single 200 mg dose of nevirapine to the woman on the morning of the planned cesarean.
Lewis recommends alerting the patient to some potential birth complications, such as problems with a small gestational age or decreased amniotic fluid volume. "So as the amniotic fluid around the baby goes down, the chance that the baby can suffer interfetal demise goes up," she says.
• Newborns: The birthing team should follow usual universal precautions and examine the newborn for mitochondria toxicity, birth defects, and other problems. The infant should be tested using a polymerase chain reaction (PCR) DNA test at six to eight weeks and again at five or six months. Because all babies born to HIV-infected women have positive ELISA HIV antibody tests, the PCR-DNA test is required, and the infant is considered negative after a second negative HIV test. All babies born to HIV-infected mothers should be prescribed sulfamethoxazole-trimethoprim for Pneumocystis carinii pneumonia prophylaxis until tests show that the baby is not infected with HIV.
Reference
1. Rhame F, Bodner S. "HIV Infection and Having A Baby Timeline." (Expected publication in 2001.)
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