PMCT
Prevention of mother to child transmission
Moderator – SCS Dr. Myo Nyi Nyi
Roll No. – 183,185
Contents
Definition
Methods of transmission of HIV
Risk factors
Effects of HIV on pregnancy
Interventions for HIV
Management of HIV infected mothers and babies
Definition
What is MCT?
Mother to child transmission of HIV (MCT) is vertical or
perinatal transmission of HIV from an infected mother to her
infant.
What is PMCT?
Prevention of mother to child transmission of HIV (PMCT) is
a comprehensive approach to prevent HIV infection in infants
through vertical transmission.
Mother to child transmission
Methods of vertical transmission-
Intrauterine transmission (late 3rd trimester)
Intrapartum transmission
Transmission during breastfeeding
Risk factors for vertical transmission of HIV
Advanced maternal HIV disease
High maternal plasma viral load
Low CD4 lymphocyte counts
Prolonged rupture of membranes (>4 hours)
Chorioamnionitis
Preterm delivery
Coexisting viral infections (Hepatitis C, Herpes)
Breastfeeding doubles transmission rate
Effects of HIV on pregnancy
• Increased incidence of miscarriage
• Stillbirth
• Perinatal & neonatal mortality
• IUGR
• Low Birth Weight
• Preterm delivery
Screening
Routine antenatal screening has increased detection rates
Treatments have dramatically increased life expectancy.
Pregnant women should be offered screening for HIV early
in pregnancy because appropriate antenatal interventions
can reduce mother to child transmission of HIV infection
from 25–30% to less than 2%
Four interventions for PMCT
VCCT (Voluntary Counseling and Confidential testing)
ART given antenatally and intrapartum to the mother and
to the neonate for the first 4–6 weeks of life.
Delivery by elective caesarean section in the presence of a
high viral load.
Avoid breast feeding
These 4 interventions reduce the risk of transmission.
Voluntary Counseling and Confidential testing
Counseling is an essential part of PMCT program to provide
Pre-test counseling for HIV testing
Partner counseling
Post-test counseling for HIV positive pregnant women
Choosing ART treatment
Safe delivery options
Appropriate infant feeding practice
A positive HIV antibody test result should be given to
the woman in person by an appropriately trained health
professional; this may be HIV physician or obstetrician.
The issue of disclosure of the HIV diagnosis to her
partner should be handled with sensitivity and she
should be reassured that her confidentiality will be
respected.
Aim of ART
Providing ART to all pregnant and breastfeeding women
living with HIV serve three synergistic purposes;
improving the mother's health
preventing mother-to-child transmission of HIV
preventing the transmission of HIV from mother to
sexual partners
When to start ART
To determine the optimal time to start ART, the following must
be considered.
• ART that are contraindicated in pregnancy (especially 1st
Tri)
• Risk of congenital abnormality of ART
• Risk of vertical transmission to the infant
viral load >100,000 HIV RNA copies/mL – within the first
trimester
baseline viral load of 30,000–100,000 HIV RNA copies/mL - at
the start of the second trimester, or as soon as possible
What to start (BHIVA)
Recommended and alternative agents in pregnancy
Recommended Alternative
NRTI backbone Abacavir/lamivudine Tenofovir alafenamide/
TenofovirDF/ emtricitabine (after the
emtricitabine first trimester)
Zidovudine/lamivudine
Third agent Efavirenz Rilpivirine
Atazanavir/r Darunavir/r
Raltegravir 400 mg bd
Dolutegravir (after 6
weeks gestation)
In Myanmar
Management of HIV infected mother
Antenatal management
Early booking visit in a known case
Pre-conceptual counseling for women with ART
Multidisciplinary care
Screening for congenital malformation by anomaly scan
at 18-21 weeks
Investigations
CD4 cell count- a minimum of one CD4 cell count at
base line and one at delivery.
HIV viral load - 2-4wks after commencing ART, at least
once every trimester, at 36 weeks and at delivery.
Do not require any additional baseline investigations
compared with non-pregnant HIV positive women,
except routine investigation at AN clinic.
All pregnant and breastfeeding women living with HIV
should initiate ART and remain on lifelong treatment,
regardless of clinical stage or CD4 count.
Antiretroviral therapy is usually commenced between 28
and 32 weeks gestation.
An HIV viral load should be performed 2–4 weeks after
commencing ART, at least once every trimester.
In women commencing ART in pregnancy, liver function
tests (LFTs) should be performed as per routine initiation
of ART and then with each routine blood test.
Mode of delivery (Safe delivery)
For women with plasma viral load <50 copies/ml at 36 weeks
of gestation and in the absence of obstetric complications, a
planned vaginal delivery should be supported.
It is important to avoid such obstetric interventions as:
Amniotomy
Episiotomy
Instrumental delivery (vacuum, forceps)
Fetal blood sampling
Fetal scalp monitoring
A caesarean delivery is recommended if viral load is >50
copies/ml at or beyond 36 weeks gestation.
As the risk of transmission is higher in women with
hepatitis C coinfection, a caesarean delivery should also be
recommended.
Elective caesarean section should be performed before the
onset of labour or membrane rupture. It can reduced MTCT.
The benefit and risks of vaginal delivery versus elective
caesarean section and risk of complications from operation
should also be considered.
Early cord clamping is recommended. Baby should be
bathed immediately after the birth.
Minimize risk of postpartum hemorrhage
• Active management of 3rd stage by giving oxytocin.
• Use controlled cord traction.
• Carefully repair genital tract laceration
• Carefully remove all products of conception
Management of infants
All infants born to women who are HIV positive should be treated
with antiretroviral therapy from birth.
HIV antibodies test is detectable in most neonates because of
maternal antibodies crossing the placenta.
Testing immediately after birth does not provide reliable result due
to presence of maternal antibodies in baby
For this reason, direct viral amplification by PCR is used for
diagnosis of infant infection.
Tests are carried out at birth, then at 3 weeks, 6 weeks and 6
months.
Infant PEP should be started within 4 hours of delivery
Two weeks of zidovudine monotherapy
• If woman has been on ART for > 10 weeks
Very low risk • maternal viral load is <50 HIV RNA copies/ml at or after
36 weeks
Extend to 4 weeks of zidovudine monotherapy
• If the maternal ART <10 weeks,
Low risk • the infant is born prematurely (<34week) and
• maternal viral load is < 50 HIV RNA copies/ml
Combination PEP (zidovudine, lamivudine, nevirapine)
High risk • if maternal HIV viral load is >50 HIV RNA copies/mL
on day of birth
Infant PEP should not be given beyond 2 weeks for VERY
LOW-RISK or 4 weeks for LOW-RISK infants even if the
infant is breastfed.
Infant feeding
The safest way for a mother living with HIV to feed her
baby is bottle-feeding using formula milk.
But formula should be AFASS
Affordable
Feasible
Acceptable
Sustainable for mother
Safe for infant
Women who are virologically suppressed on ART with good
adherence can choose to breastfeed.
But she should be informed that low risk of HIV transmission to baby
still present through breastfeeding.
Exclusive breastfeeding for first 6 months, introducing
complementary food thereafter, and continuing breastfeeding for 12
months, weaning gradually within 1 month.
Mixed feeding may irritate the baby's tummy and increased the risk of
HIV infection.
Postpartum care
Anti retroviral therapy
• All women are recommended to continue ART and refer to HIV
physician.
Postnatal follow up
• All women should be reviewed within 4-6 weeks.
Mental health assessment and support
Contraception
• Many ART interact with hormonal contraceptives, resulting in
reduced contraceptive efficacy. Contraception such as condoms
and IUCDs should be recommended.
Cervical cytology
• Women with HIV infection are more likely to have HPV 16 or
18 infection and have a higher prevalence and incidence of CIN.
For this reason, annual cervical cytology is recommended.
Testing of partner and older children should be completed.
References
Obstetrics by Ten Teachers (20th Edition)
BHIVA Guidelines for management of HIV in pregnancy and
postpartum (2018)
Guidelines for the clinical management of HIV infection in
Myanmar (5th Edition)
THANK YOU!!
