Antenatal care

Good antenatal care is important for any woman expecting a baby. For women with HIV, it is essential, in order to maximise the chances of preventing mother-to-child transmission. Especially for women who have been diagnosed during pregnancy, there may be a "complex mix of emotional, psychosocial, relationship, economic and even legal issues that arise directly out of the HIV diagnosis".¹

Recently diagnosed women may only have a short time to build a relationship of trust with the healthcare team, and to gather information to make informed choices. The BHIVA/CHIVA guidelines emphasise that prevention of MTCT can only be achieved if the woman 'embraces the medical interventions appropriately', and recognise that social and other factors can prevent her from doing so. They recommend a very early assessment of every woman's circumstances, and identification and careful follow-up with patients who refuse medical advice or care, or who fail to attend further outpatient appointments.

The multidisciplinary antenatal team may include counsellors, psychologists, social workers, community midwives, patient advocates and others, as well as an HIV clinician, obstetrician, specialist midwife and paediatrician.

In addition to the HIV-positive women’s medical care, support and advice should be offered in antenatal clinics on issues such as:

• Welfare – for example, housing, finances, drug use.
• Immigration – including eligibility for NHS treatment.
• Serodiscordance – advice for newly diagnosed women whose partners are HIV-negative on avoiding onward transmission.
• Advice on feeding their baby.
• Adherence to treatment during pregnancy and after the birth.

Women usually receive significant individualised support during their pregnancy, but this tends to concentrate on HIV-related issues and there may be an expectation that some of the more basic antenatal preparation will be delivered by generic antenatal services. This may not always be appropriate or welcome – for example, these services will not cover disclosure of HIV status, and the discussion of mode of delivery will not take the HIV-positive woman’s situation into account. Generic classes usually include strong promotion of breastfeeding and discourage the taking of medication during pregnancy; this can directly contradict the advice a woman with HIV is receiving and potentially cause feelings of awkwardness or confusion.

The presence of a genital infection can – because it can result in the increase of HIV replication and therefore a higher viral load in genital secretions, and/or cause ulceration or inflammation – significantly increase the risk of mother-to-child transmission of HIV. The BHIVA/CHIVA guidelines suggest it is prudent to screen all pregnant HIV-positive women, as early in the pregnancy as possible, for genital infections, and to repeat the screening at 28 weeks of pregnancy.¹

The successful treatment of any genital infection is particularly important if the woman is planning to have a vaginal delivery.

Amniocentesis should not be carried out before the woman's HIV status has been established.²

The BHIVA/CHIVA guidelines recommend that healthcare staff discuss testing for Down’s syndrome with all women during the first three months of pregnancy. Ideally, this should be done using the most specific and non-invasive tests: nuchal translucency (looking at the fluid space at the back of a baby’s neck) with serum screening (a test on the mother’s blood), with appropriate counselling. This should reduce the need for more invasive procedures.¹

The guidelines suggest that women considering invasive genetic screening should be given counselling at a specialist foetal medicine unit.

Earlier studies suggested that there was a higher incidence of HIV mother-to-child transmission if an amniocentesis (where a fine needle is inserted through the mother's abdomen and into the fluid surrounding the foetus) was carried out, and that efforts should be made to avoid this procedure if possible.³ However, these were done before the widespread use of HAART and more recent studies have shown no increased transmission rates in women having an amniocentesis compared to those who did not.⁴

It is recommended that, wherever possible, if a woman has started HIV treatment but does not yet have an undetectable viral load, the amniocentesis is delayed until the maternal viral load becomes undetectable. Where women are not yet on treatment, it may be advisable to administer treatment to cover the procedure. Some treatments cross the placenta better than others (NNRTIs do so more effectively than protease inhibitors and adding a single 200mg dose of nevirapine to an existing regimen should be considered). Every effort should be made to avoid inserting the needle through the placenta.¹