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The number of pregnancies in HIV infected women is increasing. In 1998 there were just 185 confirmed cases, which increased to 758 in 2002.1 This probably reflects an increase in incidence as well as an increase in “identification” by the introduction of routine antenatal screening. The success of routine antenatal screening is, however, variable, with the target of 90% of pregnancies being screened being achieved in very few areas. This highlights the need for far more training of both midwives and obstetricians, discussing openly the benefit and need for antenatal testing.
About three quarters of all women, globally, who are infected with HIV come from sub-Saharan Africa.
There has also been an increase in the incidence of tuberculosis, and this resurgence may, in some part, be due to the susceptibility of the HIV infected patient to this disease. Women from sub-Saharan Africa need to be screened thoroughly, and tuberculosis in particular should be considered when they have pyrexia of unknown origin and are known to be HIV positive. Significant pyrexia in pregnancy is known to trigger premature labour, and the cause needs to be identified urgently and effective treatment established as soon as possible.
In utero transmission of tuberculosis leading to congenital infection is rare. Even with vaginal delivery, in cases where the Mother is known to have tuberculosis, transmission has been shown to be postnatal by nosocomial spread. However, there are no specific data on pregnancies complicated by both HIV and tuberculosis with regard to vertical transmission of tuberculosis, and in this situation the risk of in utero transmission may be different.
This case described by Katumba-Lunyenya et al highlights the need for a multidisciplinary approach to women with HIV in pregnancy, whether they are unwell or not. The multidisciplinary team should include:
a consultant in adult infectious diseases or genitourinary medicine
a consultant obstetrician
a consultant in microbiology/virology
a consultant in paediatric diseases
a neonatal consultant
an HIV support worker
It is particularly important to have a consultant microbiologist/virologist who can advise on the most appropriate specimens required and advise on sensitivities, etc.
The role of the HIV support worker/advisor is extremely important as they spend a great deal of time with these women, discussing all aspects of care and in particular confidentiality issues. Their role in being the patient advocate cannot be underestimated.
The obstetrician has an important role to play in explaining that a whole variety of carers will need to know the patient’s HIV status in the best interests of both the mother and the baby. They need to encourage some documentation of the HIV status and plan for delivery in the hand held maternity notes. However, at all times the patient’s wishes have to be respected, but the decision to withhold information must be informed, and consent sought for all relevant information to be held in a separate file and released on a “need to know” basis.
Many women with HIV deliver prematurely; the cause is not known. In this case the mother was clearly unwell, and whether the cause of the pyrexia was intrauterine had to be considered. Although the outcome is devastating for the parents, without an established diagnosis it would have been unwise to attempt to delay delivery by the use of tocolytic drugs.
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