PERSALINAN BAGI WANITA HAMIL YANG TERINFEKSI HIV

1
PERSALINAN BAGI WANITA HAMIL YANG TERINFEKSI HIV

• dr. Anita Rachmawati, SpOG
• Bagian Obstetri Ginekologi FK UNPAD/RS Hasan
  Sadikin
• Bandung

2
Risiko penularan HIV dari ibu ke bayi tanpa
intervensi PMTCT
Periode transmisi Risiko Risiko Risiko
Kehamilan 5 - 10
Persalinan 10 - 20
Menyusui 10 - 15
Total 25 - 45
Risiko tertinggi
3
Risiko penularan masa persalinan

• His ? tekanan pada plasenta meningkat
• Terjadi sedikit pencampuran antara darah ibu
  dengan darah bayi
• Lebih sering terjadi jika plasenta meradang/
  terinfeksi
• Bayi terpapar darah dan lendir serviks pada saat
  melewati jalan lahir
• Bayi kemungkinan terinfeksi karena menelan darah
  dan lendir serviks pada saat resusitasi

4
Konsep dasar intervensi PMTCT

• Kurangi jumlah ibu hamil dengan HIV positif
• Turunkan Viral Load serendah-rendahnya
• Meminimalkan paparan janin/bayi dengan cairan
  tubuh ibu HIV positif
• Optimalkan kesehatan ibu dengan HIV positif

5

• SC elektif menurunkan risiko transmisi vertikal
• hingga 50 pada wanita terinfeksi HIV tanpa ARV
• hingga 87 pada wanita terinfeksi HIV dengan ARV
  (ZDV)
• Read JS. Preventing mother to child transmission
  of HIV the role of cesarean section. Sex Transm
  Inf 200076231-232
• International Perinatal HIV group, 1999

6
Konsep dasar intervensi PMTCT

• Kurangi jumlah ibu hamil dengan HIV positif
• Turunkan Viral Load serendah-rendahnya
• Meminimalkan paparan janin/bayi dengan cairan
  tubuh ibu HIV positif
• Optimalkan kesehatan ibu dengan HIV positif

7
WHO RHL

• The benefit of elective CS delivery among women
  who either received, or did not receive,ZDV.
• Unfortunately, the data are insufficient to
  evaluate the potential benefit of CS delivery for
  neonates of ARV-treated women with plasma HIV-RNA
  levels lt 1000 copies/ml.
• It is unlikely that scheduled CSdelivery would
  confer additional benefit in reduction of HIV-1
  transmission among this group.

8
PACTG 367 (Shapiro, 2004)

• In almost 2900 pregnancies found that in all
• subgroups of VL
• combination ARV therapy was associated with the
  lowest rates of transmission and with VL lt1000
  c/Ml
• MTCT rates were significantly lower with
  multiagent vs single-agent ARV (0.6 vs 2.2) but
  did not differ by mode of delivery

9
The European Collaborative Study

• Among 4500 women with undetectable VL and after
  adjusting for ARV therapy during pregnancy,
  scheduled CS was not associated with additional
  benefit in reduction of transmission

10
REKOMENDASI

• Perlu dilakukan konseling kepada ibu dan pasangan
  mengenai manfaat dan risiko persalinan pervaginam
  dan persalinan dengan SC elektif
• Persyaratan untuk persalinan pervaginam
• - Ibu minum ARV teratur, atau
• - Muatan Virus/ Viral Load tidak
• terdeteksi
• Dianjurkan untuk melakukan pemeriksaan muatan
  virus/ viral load pada usia kehamilan 36 minggu
  ke atas

11

• Kewaspadaan universal (misalnya cuci tangan dan
  pemakaian alat perlindungan diri) perlu dilakukan
  pada semua tindakan obstetri.
• Pada dasarnya persalinan Odha dapat dilakukan di
  semua fasilitas kesehatan.
• Pemilihan kontrasepsi pasca persalinan bertujuan
  untuk mencegah penularan HIV pada kehamilan
  berikutnya, namun sterilisasi bukan merupakan
  indikasi absolut pada ibu dengan HIV

12
SOGC Clinical Practice Guidelines(No. 101, April
2001)

• The available evidence regarding the
• prophylactic role of CS applies
• only to women
• who have not received optimal ARV therapy.
• Elective CS (38 weeks gestation) should be
  offered to HIV-positive women in these specific
  situations

13
SOGC Clinical Practice Guidelines

• Women who have not received ARV therapy
  regardless of the antepartum viral load
  determination. These patients should be offered
  appropriate therapy as soon as HIV is recognized.
  (I)
• Women receiving ARV monotherapy regardless of the
  viral load. Intensification of therapy should be
  undertaken if time permits. (II-2)

14
SOGC Clinical Practice Guidelines

• Patients with detectable viral load regardless of
  the received therapy. (II-2)
• Women in whom the viral load determination is not
  available or has not been done. (II-2)
• Women with unknown prenatal care

15

• In HIV-infected women, the higher the plasma
  viral load, the more likely that HIV will be
  found in cervicovaginal secretions. However, in
  many women with undetectable plasma loads, HIV is
  still often found in such secretions, as reported
  in an article in the October 17 issue of AIDS
  (AIDS 2003172169-2176) by , the lead author ,
  Dr Jose Ramon (University of Bati, Italy).

16

• a high CD4 cell count, even in the absence of
  plasma HIV-1 RNA (as shown in group C), does not
  necessarily imply the absence of HIV in the
  cervicovaginal secretions.
• Women under HAART treatment were more likely to
  reach undetectable viral levels in the vagina,
  even if HIV RNA was detected in the plasma,
  whereas women under non-HAART treatment were more
  likely to shed HIV in genital secretions even in
  the absence of plasma viraemia

17

• An increased CD4 cell count and HAART treatment
  were significantly associated with non-detectable
  viral loads both in plasma and in vagina.
• Non-HAART treatment was significantly associated
  with HIV-1 RNA absence in plasma viraemia but not
  in vaginal secretions

18
TERIMA KASIH