In connection with pregnancy and the immunodeficiency disease AIDS, the following situations must be distinguished.
In the first case, the positive test result often hits the pregnant woman and the doctors treating her completely unprepared. If the positive test result is confirmed after a control, the indication for an abortion often arises immediately. Affected women are doubly burdened - on the one hand by the fact of the HIV infection, on the other hand by the necessity of a decision for or against the child.
It is important not to act hastily, but to turn to competent contact points who can help those affected in this difficult situation. The counselling centres, HIV outpatient clinics and hospital departments with experience in caring for HIV-infected pregnant women are all possible options in this regard.
However, even competent counsellors cannot relieve those affected of this serious decision. It must always be made by the woman alone or together with her partner. However, appropriate information and support can simplify the decision-making process.
In recent years, the risk of infection in the unborn child has been reduced from around 30 percent to less than two percent.
For optimal therapy and prevention, it is necessary for HIV-infected pregnant women to be cared for in a centre that guarantees good cooperation between the various medical disciplines. These centres can provide care according to the latest state of knowledge. Close cooperation between the centre and the gynaecologist is one of the most important prerequisites for reducing the risk for the expectant mother and, of course, for the child.
If an HIV-positive woman decides to have an abortion, this must be respected. It is all too understandable that some of those affected are simply overwhelmed in this situation and need all their energies for themselves to cope with the situation.
But the decision to have a child can also be a signal that the woman does not give up and wants to develop further life perspectives, even though she is infected with the immunodeficiency disease. This decision should also be respected.
The (intrauterine) infection of the child occurring in the uterus is possible during the entire pregnancy, but it preferably occurs in the last third, especially during the birth process. Ascending infections through the vagina are also a possible means of transmission.
First of all, the same precautionary guidelines apply as for non-infected persons. Prevention in HIV-positive pregnant women under antiretroviral therapy also includes regular laboratory checks - depending on the medication administered. In addition, precise gynaecological checks must be carried out to exclude infections of the vagina and cervix which could be the cause of premature rupture of the bladder or premature labour.
Since cell changes at the genitals, especially at the cervix, are more frequent in HIV-positive women and can worsen, a regular colposcopy (magnifying glass examination of the cervix) is recommended.
Furthermore, ultrasound examinations of the child should also be part of the preventive programme. However, it is not advisable to have an amniotic fluid puncture.
It is important - parallel to the medical measures - to support the pregnant woman in the psychosocial area. Medical education alone is usually not enough to take away the fears and worries of those affected. The offers of women's groups in the AIDS centres, for example, are suitable for this.
According to the USA recommendations on HIV therapy for pregnant women, treatment during pregnancy should be adapted to the risk. In this respect, the motto is: as much as necessary and as little as possible is treated. The treatment depends on the blood findings and the clinical state of health of the expectant mother.
The drugs administered pose a certain problem, especially as the harmfulness to the fetus of some preparations is not yet sufficiently controlled. There are several treatment options. According to the USA therapy recommendations, a triple combination therapy should be carried out if possible.
However, it must always be considered whether this increases the risk of damage to the child. The switch to a double combination is an alternative in this case. If the immune situation allows the antiretroviral therapy to be interrupted in the first three months, this should be interrupted immediately after confirmation of pregnancy. In order to avoid virus transmission to the child, the active substance zidovudine should be administered from the 32nd SSW onwards. If necessary, quadruple therapy may then be administered.
At present the caesarean section is propagated - if possible in the 37th SSW. A tissue-sparing procedure should be preferred in order to prevent the risk of transmission of the virus from the mother to the child during the procedure as far as possible. Therefore, contractions, premature rupture of the bladder, amniotic infection syndrome and the passage of the birth canal should also be avoided. After childbirth, the newborn receives antiretroviral therapy for prophylaxis.
In the case of a premature bladder jump, a caesarean section with antiviral therapy of the mother should be performed immediately.
Understandably, one would like to know as soon as possible after birth whether the child is infected or not.
Unfortunately, in this situation it is not possible to simply determine the antibodies in the child's blood, because they still originate from the mother. An IgG antibody test is only considered meaningful for children aged 15 to 18 months. The IgA antibody can indicate an infection earlier. In order to determine whether the child is HIV-infected, a search is made for virus components in the blood. If no virus particles are found, the child is considered HIV-negative.
In general, the child should not be breastfed because the HI virus can also be transmitted via breast milk. First of all, the children need further antiviral therapy as prophylaxis, which should be carried out by experienced paediatricians. Regular controls of mother and child are necessary, with special attention to possible side effects of the medication.
Centers for Disease Control and Prevention
American College of Obstetricians and Gynecologists
U.S. Department of Health and Human Services
Written by Mark Riegel, MD
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