HIV in the Pregnant Patient

Today we go into part 2 of our HIV series, this time focusing on pregnancy and HIV. Check out ACOG CO 752 (Prenatal and Perinatal HIV Screening) and CO 751 (Labor and Delivery Management of Women with HIV).

However, we have to give a major shout out to the OBG Project — their editors have put out an awesome summary of HIV in pregnancy and preventing vertical transmission: Check it out here.

(c) OBG Project

One of the important CREOG points on HIV in pregnancy includes drug interactions. Methergine is metabolized by CYP3A4 enzymes, which may be inhibited by certain antiretrovirals. Thus, methergine should be avoided if possible if encountering postpartum hemorrhage.

Lastly, we wanted to drive home the point again about patient autonomy, especially regarding risk of cesarean delivery. We put the ACOG CO text below for you to chew on!

ACOG CO 751

HIV in the Non-Pregnant Patient

We jump back to our STI saga to cover HIV today. ACOG PB 167 and CO 596 make for supplementary reading for this show.

The CDC and USPSTF recommend at least one-time HIV screening in most women. The CDC goes further to recommend up to annual screening in certain high-risk groups, including IV drug users, > 1 sex partner annually or known sex partner with HIV, those who exchange sex for money or goods, and MSM.

Screening is important, because almost 25% of new cases occur in women, and heterosexual intimate contact is the most common form of disease spreading. ACOG subscribes to a philosophy of “opt out” testing, by which HIV screening should be considered routine, with the patient able to opt out. Physicians need to document the reason for this in their notes. Screening tests are broken into rapid and confirmatory. A positive rapid screen should always be followed with a confirmatory test, as the rapid screens have high sensitivity, but lower specificity.

GYN care may vary somewhat with positive HIV status. For Pap smears, PB 167 describes an appropriate algorithm for dealing with initial screening and some positive results:

ACOG PB 167

ACOG PB 167

We spend some time reviewing the treatment of other STIs in the podcast briefly, all of which are reviewed in PB 167 as well. Highlights include:

  • Using 1 week rather than single-dose metronidazole treatment for trichomonal infections

  • Re-testing any positive GC/CT testing result at 3 months, due to high risk of re-infection

  • Screening for most STIs at entry to care for HIV-affected patients.

Birth control is also another important topic for HIV-affected patients. ACOG and the CDC recommend use of dual-contraception — that is, a barrier method and a hormonal method — to prevent viral spread. Certain forms of hormonal contraception may be affected by antiretroviral drugs:

  • CHCs: The NNRTI non nucleoside reverse transcriptase inhibitor efavirenz and certain protease inhibitors (-navir) may decrease efficacy of combined methods by reducing contraceptive hormone levels; however, they are considered US MEC Category 2.

    • The exception to this rule is fosamprenavir, as CHCs also lead to decreased levels of this protease inhibitor (US MEC 3).

  • Etonogestrel implant:  Similarly to CHCs, there are theoretical risks in decreased contraceptive effectiveness for patients on efavirenz; however, the implant remains US MEC 2.

  • DMPA: MEC category 1 for all users, except for those on fosamprenavir; there is limited evidence DMPA decreases fosamprenavir levels like CHCs (US MEC 2).

  • IUDs: MEC category 1 for all users!

  • Emergency contraception: for oral medicatons such as levenorgestrel and ulipristal, these should be offered to HIV-affected women as the benefits of emergency contraception are considered to outweigh the risks in this group. Similarly to CHCs, there is theoretical risk of decreased efficacy of these methods among women taking efavirenz.

Finally, in a preview to our next episode, we talk about preconception counseling for HIV-affected patients. The goal for any patient with HIV is to achieve a negative viral load, and for OB-GYNs, this is important to limit vertical transmission. Efavirenz has been associated with neural tube defects, so should be avoided in pregnancy if possible.

Conceiving is safest through artificial insemination. However, if natural conception is desired. OB-GYNs should discuss limiting unprotected intercourse to ovulatory times, and using pre-exposure prophylaxis for the patient, or her partner, in serodiscordant couples. This generally involves a daily regimen of tenofovir/emtricitabine (Truvada) for 1 month prior to, and 1 month after, conception. Risk reduction is estimated to be somewhere between 63-75%, and the best-available data suggests this is likely safe.

Pelvic Inflammatory Disease & Tubo-ovarian Abscess

Before we get to the meat of today’s topic… we’re pleased to announce a partnership with the OBG Project. They have excellent resources, and a new product called OBG First. PGY-4 residents can get OBG First for one year for absolutely free — check out the website and follow the instructions, and a coupon code will get sent to your inbox.

And now for PID! The CDC guidelines, as always, are super helpful further reading.

The diagnosis of PID can be challenging. In the absence of other causes, one of the following three findings must be present:
- Cervical motion tenderness
- Uterine tenderness
- Adnexal tenderness

There are several additional criteria that can enhance the specificity of diagnosis:
- Oral temp > 101 F (38.3)
- Abnormal cervical mucopurulent discharge or friability
- Presence of abundant WBC on saline microscopy of vaginal fluid
- Elevated erythrocyte sedimentation rate
- Elevated C-reactive protein
- Laboratory documentation of cervical infection with N. gonorrhoaea or C. trachomatis

Even more specific criteria include certain other tests, including:
- Endometrial biopsy with histopathologic evidence of endometritis
- TVUS or MRI showing thickened, fluid-filled tubes with or without free fluid, or tubo-ovarian complex
- Laparoscopic findings of PID (remember Fitz-Hugh-Curtis?)

We review indications for hospitalization versus outpatient treatment for PID, but the big ones to remember include:
- Inability to exclude other surgical emergencies
- Pregnancy
- Severe illness
- Inability to tolerate or follow outpatient therapy,
- Failed response to outpatient therapy in 48-72 hours.

Finally, we go over treatments for PID, straight from the CDC:

CDC STD 2015 Guidelines.

CDC 2015 STD Guidelines.

And remember:
- Clinical follow up should be arranged in 48-72 hours after hospitalization or after initiation of outpatient therapy, to ensure response.
- Tubo-ovarian abscess < 10 cm rarely need surgical intervention. However, percutaneous drainage is an option that often does help to expedite response to therapy.

Further reading from the OBG Project:
- Unexplained Pelvic Pain
- CDC treatment guidelines
- The ABCs of PID Diagnosis

Gonorrhea and Chlamydia

Though CREOGs are over, we hope you continue to study with us! On today’s episode we tackle chlamydia and gonorrhea.

The most helpful resource we mention on today’s episode comes from the CDC’s 2015 STD Treatment Guidelines. They even have a free smartphone app, which is very handy for use in your emergency department or clinic/office setting.

Gonorrhea is caused by the gram negative diplococcus Neisseria gonorrhoeae. Chlamydia is an obligate intracellular gram negative pathogen. Below we’ve created our own guides to treatment based on the CDC recommendations. Happy listening!