HIV/AIDS and Pregnancy

• Pre-gestational conditions are chronic health conditions present before pregnancy, and can affect the health of both the mother and the fetus

HIV/AIDS

• HIV attacks cells that help the body fight infection, making the person vulnerable to other infections and diseases
• If left untreated, HIV can lead to AIDS (acquired immunodeficiency syndrome)
• There is no cure, but Antiretroviral Treatment (ART) is available
• ART reduces the viral load

Modes of Transmission

• Unprotected sexual intercourse
• Blood contact
• Exposure to body fluids
• Mother to fetus, and through breastmilk

HIV Entry and Replication

• HIV enters the host cell and binds to CD4, CCR5, and CXCR4
• RNA is released with reverse transcriptase
• DNA formation
• Entry to the host nucleus
• The integrase enzyme cuts the host DNA and combines it with viral DNA
• Formation of mixed host and viral DNA
• RNA is made and released from the nucleus via transcription
• Goes to the cytoplasm to find ribosomes for translation
• Release of polyproteins
• Structural and functional proteins, and protease
• Golgi apparatus
• New viruses are released for replication (mostly 5 mutations)

Clinical Manifestation

• Normal T-cell count is 500-1600 cells/mm3
• Common symptoms include fever, fatigue, rash, headache, lymphadenopathy, hair leukoplakia, oral candidiasis, pharyngitis, myalgias, nausea, and diarrhea
• Less than 200 T-cells indicates AIDS
• 10 days post-exposure, viremia levels will decrease and either remains at that level or develops rapidly into an autoimmune disease

Laboratory and Diagnostic Study Findings

• Viral assays can detect infected infants by 6 months
• Enzyme-linked immunosorbent assay can detect infections in children from 18 months
• Immune function tests reveal decreased CD4 and increased CD8 counts

Pregnancy and HIV

• Women identified as HIV positive are advised not to become pregnant until there are better methods to prevent transmission to the fetus
• The virus can be passed through the placenta during separation
• Infants can test positive within the first 6 months and develop clinical manifestations after 1-3 years

Nursing Interventions: Pre-conception Counseling and Education

• Discuss family planning goals, HIV transmission risks during pregnancy and breastfeeding, and the importance of ART or HAART adherence

Nursing Interventions: Antiretroviral Therapy (ART)

• ART adherence: Emphasize the role of consistent ART in suppressing viral load and reducing MTCT risk
• Monitor for side effects, addressing them to encourage adherence
• Adjust ART regimen as needed, based on individual factors and pregnancy stages, collaborating with the healthcare team

Drugs Used for ART

• Enfuvirtide
• Maraviroc
• Nucleoside Reverse Transcriptase Inhibitor
• Non-Nucleoside Reverse Transcriptase Inhibitor
• Integrase Inhibitor
• Protease Inhibitor

Nucleoside Reverse Transcriptase Inhibitors (NRTIs)

• Zidovudine
• Abacavir
• Lamivudine
• Emtricitabine
• Stavudine
• Tenovir
• Didanosine
• (suffix ZALES TD)

Non-Nucleoside Reverse Transcriptase Inhibitors (NRTIs)

• Nevirapine
• Efavirenz
• Etravirine
• Delavirdine
• (suffix VIR in the middle)

Integrase Inhibitors (II)

• Dolutegravir
• Raltegravir
• Elvitegravir
• (suffix TEGRAVIR)

Protease Inhibitors (II)

• Atazanavir
• Darunavir
• Ritonavir
• Lopinavir
• Tipranavir
• Indinavir
• Sequinavir
• (suffix NAVIR:)

Nursing Interventions: Prenatal Care and Monitoring

• Regular prenatal checkups ensure the health of both the mother and fetus
• Viral load monitoring ensures mother's viral load to assess MTCT Risk
• CD4 count monitoring tracks the CD4 cells to assess the mother's potential for opportunistic infections

Nursing Interventions: Postpartum and Delivery Care

• Discuss birth options and the importance of preventing MTCT during delivery (e.g., planned cesarean section for high viral load)
• Administer appropriate prophylactic medications to the newborn to prevent MTCT
• Provide postpartum support and education on breastfeeding options, infant care, and maintaining ART adherence

Nursing Interventions: Psychosocial Support

• Acknowledge the potential for anxiety, depression, and other emotional challenges related to HIV and pregnancy
• Facilitate access to support groups or individual counseling to address mental health needs and build social connections
• Encourage self-care practices and empower informed decisions about health

Nursing Management

• Prevent opportunistic infections
• Provide adequate nourishment
• Foster healthy growth and development
• Assist familial needs
• Education

Nursing Management for Pedia Client

• Prevent opportunistic infections
  • Assess for signs of opportunistic infections
  • Prophylaxis 6 hrs after delivery
  • 4 - 6 weeks of short course therapy
• Assist in identifying neonates at risk
• Administer prescribed medications
• Administer immunizations against those of childhood

Nursing Management to provide adequate nourishment

• Offer high calorie and protein
• Provide mouth care
• Monitor weight and height

Nursing Management to Foster Healthy Growth and Development

• Assist the child in maintaining self-esteem, and enhance growth and development
• Facilitate verbalization of thoughts and feelings while also supplying support and assist them in developing mechanisms for coping
• Assist the child and family with the grieving process
• Assists the family in meeting needs
• Educate

Anemia

• Lack of hemoglobin that carries oxygen throughout the body
• Normal level is 12-15.05 g/dL

Types of Anemia

• Iron deficiency
• Folate deficiency
• Vitamin B12 deficiency

Symptoms of Anemia

• Dizziness
• Pale skin, lips, and nails
• Fatigue or tired
• Shortness of breath
• Rapid heart rate
• Trouble concentrating

Risk factors for the pregnant.

• Pregnant with multiples (more than one child)
• Have had two pregnancies close together
• Excessive vomiting due to morning sickness
• Pregnant teenager
• Inadequate consumption of foods with iron
• Previous history of anemia

Anemia Risk Factors in Pregnancy

• Severe or untreated iron-deficiency anemia can increase the risk of:

  • A preterm or low-birth-weight baby
  • Blood transfusion
  • Postpartum depression
  • Baby with anemia
  • Child with developmental delays

• Untreated folate deficiency can increase the risk of:

  • Preterm or low-birth-weight baby
  • Baby with a serious birth defect of the spine or brain (neural tube defects)

• Untreated vitamin B12 deficiency can increase the risk of having a baby with neural tube defects

Laboratory Test

• Hemoglobin count (12 - 16 g. per deciliter)
• Hematocrit count

Treatment of Anemia

• Iron supplement
• Folic acid supplement

Nursing Intervention

• Advise eating iron-rich and folate-rich foods
• Monitor Hemoglobin and Hematocrit levels
• Evaluate for various signs of anemia

Rh Sensitization

• Condition that material immune system develops antibodies against Rh positive cells
• Rh factor (Rhesus)
• Rh Sensitization occurs when a Rh negative person bodily produced anti-bodies to attack that a Positive blood
• Incompatibility, a mother is Rh negative and her fetus is Rh-positive
• Alloimmunization: and immune responsibility buddy to foreign antigen Hemolytic disease and newborn: a serious illness

Rh Positive vs Rh Negative

• Positive: D antigen
• Negative: lacking D antigen
• Fetal growth, her immune system is invaded
• The placenta causes the fetus's blood cell destruction

Causes of Cell Destruction

• Childbirth
• Abortion
• Miscarriage
• Prenatal Testing

Result of antibodies

• Minimal effect during the first pregnancy
• Harmful effect during the second pregnancy
• Placental Separation : Active exchange of maternal and fetal blood
• Antibodies form during first 72 hours after birth

Diagnosis

• Blood Typing
• Coombs test: normal is 0, minimal is 1:8
• Repeated at week 28 of pregnancy.
  • If there is not sensitization then there is no need until after delivery blood test
  • If first titer reveals 1:16 or higher, must perform fetal monitoring every 2 weeks

Middle Cerebral Artery Doppler Velocimetry

• A technique of predicting when anemia is present or when red blood cells are being destroyed
• Artery velocity:
  • High = no anemia
  • Low = RBC destructions
• If Rh positive on newborn: conduct blood to see if the mother was sensitized during late pregnancy or childbirth

Rh D Treatment

• Anti D immunoglobulin prevents anti D alloimmunization estimated 25 to 30% of fetuses from a immunized pregnancies will have modern to modern hematolytic anemia and without management up to 25% will developed drops

• RhIG is given again by injection to the mother during 28th weeks of pregnancy and in the first 72 hours after birth

• Further prevent forming natural antibodies

• Passive antibody (disappear after 2 months)

• Close monitoring

Role of a Nurse

• Preconception counseling for all mothers of Rh negative histories
• Education
• Diagnostic findings
• Testing