Perinatal transmission audit recommendations

Submitted by Paul Decle on Sun, 07/08/2011

Authors: Guide information
NSHPC, AIAU, CHIVA

Date of preparation: July 2009
Date reviewed: February 2011
Next review date: February 2012

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Contents

Antenatal care
Around the time of delivery
The postnatal/neonatal period
Other issues

During the care of a pregnant woman and her baby BHIVA pregnancy guidelines should be followed
http://www.bhiva.org/cms1221368.asp.

In addition recommendations have been made from the audit Perinatal Transmission of HIV in England 2002-2005, NSHPC, AIAU and Children’s HIV Association collaboration, October 2007. Key recommendations from the executive summary of this audit are tabulated below.


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Antenatal care

1. All pregnant women should be recommended an HIV test at the time of booking; any woman who declines the test at first offer should be recommended it on at least one more occasion, preferably during the second trimester and by a member of the team with specialist training.
2. Positive test results should normally be given in person within 2 weeks of testing.
3. For women booking or being tested after 20 weeks, blood samples should be marked urgent for rapid testing. This is particularly important if there is an increased likelihood of preterm labour (see Recommendation 11, below). Women tested at 28 weeks or later should be offered point of care testing, or rapid testing within 24 hours.
4. Dates and details of test discussions, who these involved, decisions, samples taken, and when results were available and were given, should be recorded.
5. Local protocols should ensure that there is a clear line of designated responsibility for communicating positive results and following up late results; these should make provision for staff absence for any reason.
6. HIV positive women should have an STI screen as early as possible during pregnancy and this should be repeated at around 28 weeks.
7. HIV positive pregnant women should be screened for Hepatitis C.
8. All antenatal notes (including screening results) for any woman transferred from one unit to another, should be forwarded to the appropriate clinical lead midwife. If any screening test results are missing, the relevant test should be recommended to the woman at the new unit.
9. Amniocentesis should normally only be carried out after a women’s HIV status has been established.
10. CD4 and viral load results should normally be available within 2 weeks of the woman being informed of her diagnosis; however, if delivery is imminent, treatment decisions should not be delayed pending these results.
11. Women’s individual circumstances should be considered so that ART can be started at an appropriate time, depending on gestation at diagnosis, previous obstetric history, and other relevant considerations. For example a woman who has previously delivered at 28 weeks ideally needs to be on ART by 20 weeks gestation.
12. Resistance testing should be undertaken on all HIV infected women and repeated according to current guidelines. For women presenting at 20 weeks or later, samples for resistance testing should be fast-tracked and ideally should be available within 2 weeks, and certainly within 4 weeks. Empiric treatment should not be delayed pending resistance results for women who have indications for starting ART immediately.
13. HIV positive women presenting on complex therapies or with co-morbidities or STIs require urgent individualised treatment and close monitoring, including therapeutic drug monitoring and adherence support as necessary.
14. If the maternal viral load response to HAART is sub-optimal (less than 1 log drop in 2 weeks, or still detectable at 36 weeks gestation), appropriate action should be taken and expert advice sought if necessary.
15. Adverse social circumstances and complex problems must be properly documented. Women identified with complex social needs require early multidisciplinary discussion that includes a member of the paediatric team, and appropriate referral and support. Duty of confidentiality should not compromise duty of care.
16. Early involvement of Social Services is essential if there are serious concerns about a woman’s mental health, or if potential child protection issues are identified.


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Around the time of delivery

17. All staff who need to know about a woman’s HIV status in order to ensure appropriate care of both woman and infant should have access to the relevant information. Labour wards and neonatal units should be aware in advance of diagnosed women who are due to deliver, and have prompt access to each woman’s birth plan. Local protocols should identify a designated staff lead to ensure this. If HIV results are recorded electronically, labour ward staff should also check the status of all women presenting in labour.
18. Rapid/same day tests should be recommended to women who present in labour with unknown HIV status, including those who arrive unbooked and those who previously declined an HIV test.
19. If an HIV infected woman was diagnosed but declined further care, labour ward staff should be informed so that labour and delivery can be managed appropriately and prophylaxis provided for the infant. Local protocols should set out how to achieve this.
20. Current screening guidelines on Hepatitis B and syphilis screening for all women presenting unbooked and in labour should be adhered to, using appropriate rapid methods.
21. BHIVA guidelines for the active management of all modes of delivery should be followed.
22. All infected women should continue taking ART during labour; in most cases this will be their usual oral regimen according to their established daily schedule. Where monotherapy with ZDV (AZT) has been selected, an intravenous infusion should be administered during labour. Units should ensure intravenous and oral drugs are available.



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The postnatal/neonatal period

23. Every effort should be made to ensure that there is no delay in starting neonatal ART. The timing of initiation of ART should be recorded, along with the reason for any delay. In any case where there is an increased risk of transmission triple therapy should be considered.
24. In cases where the birth plan had been for single drug infant prophylaxis, but problems arise during delivery that increase the risk of transmission, there should be early consultation with the paediatric team to decide whether triple therapy for the infant is required.
25. Infant HIV diagnostic samples should be sent in accordance with BHIVA guidelines, minimally at day 1 and 6 weeks of life. Dates, tests and results should be recorded; results should be reviewed within two weeks. This is to clarify the likely timing of infection and to enable early modification of treatment if a child is infected.
26. Educational and social support to enable every mother to formula feed her infant safely should be provided.
27. As with other routine antenatal serology, maternal HIV status should be recorded in neonatal notes. Prompt consideration should be given to testing any newborn infant whose mother’s HIV status is unknown (and especially if she repeatedly declined the test).

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Other issues

28. When an infant / young child is diagnosed with HIV, the diagnosing paediatrician should seek permission from the mother to inform the relevant obstetric unit that they delivered an infected infant to an undiagnosed woman, in order that procedures can be reviewed and revised.
29. Every Trust that provides care for HIV infected pregnant women should have a designated HIV lead for obstetrics and for paediatrics.
30. If a mother is identified on antenatal screening as HIV infected, every effort should be made to test her partner and any children.
31. At the next policy review, the DH should consider classifying HIV prophylaxis for prevention of mother to child transmission, and appropriate support in pregnancy and for her infant, as emergency care. As such, care should be free, regardless of immigration, asylum or residence status.

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