Risiko penularan HIV dari ibu ke bayitanpa intervensi PMTCT
Periode transmisi Risiko
•Kehamilan 5 - 10 %
•Persalinan 10 - 20 %
•Menyusui 10 - 15 %
Total 25 - 45 %
Risiko tertinggi
Risiko penularan masa persalinan
His tekanan pada plasenta meningkat Terjadi sedikit pencampuran antara darah ibu dengan darah bayi
Lebih sering terjadi jika plasenta meradang/ terinfeksi
Bayi terpapar darah dan lendir serviks pada saat melewati jalan lahir
Bayi kemungkinan terinfeksi karena menelan darah dan lendir serviks pada saat resusitasi
Konsep dasar intervensi PMTCT
• Kurangi jumlah ibu hamil dengan HIV positif
• Turunkan Viral Load serendah-rendahnya
• Meminimalkan paparan janin/bayi dengan
cairan tubuh ibu HIV positif
• Optimalkan kesehatan ibu dengan HIV
positif
SC elektif menurunkan risiko transmisi vertikal
hingga 50% pada wanita terinfeksi HIV tanpaARV
hingga 87% pada wanita terinfeksi HIV denganARV (ZDV)
Read JS. Preventing mother to child transmission of HIV: the role of cesarean section. Sex Transm Inf 2000;76;231-232
International Perinatal HIV group, 1999
Konsep dasar intervensi PMTCT
• Kurangi jumlah ibu hamil dengan HIV positif
• Turunkan Viral Load serendah-rendahnya
• Meminimalkan paparan janin/bayi dengan
cairan tubuh ibu HIV positif
• Optimalkan kesehatan ibu dengan HIV
positif
WHO RHL The benefit of elective CS delivery among women
who either received, or did not receive,ZDV.
Unfortunately, the data are insufficient to evaluate the potential benefit of CS delivery for neonates of ARV-treated women with plasma HIV-RNA levels < 1000 copies/ml.
It is unlikely that scheduled CSdelivery would confer additional benefit in reduction of HIV-1 transmission among this group.
PACTG 367 (Shapiro, 2004)In almost 2900 pregnancies found that in all
subgroups of VL
combination ARV therapy was associated with the lowest rates of transmission and with VL <1000 c/Ml
MTCT rates were significantly lower with multiagent vs single-agent ARV (0.6% vs 2.2%) but did not differ by mode of delivery
The European Collaborative Study
Among 4500 women with undetectable VL and after adjusting for ARV therapy during pregnancy, scheduled CS was not associated with additional benefit in reduction of transmission
REKOMENDASI
Perlu dilakukan konseling kepada ibu dan pasangan mengenai manfaat dan risiko persalinan pervaginam dan persalinan dengan SC elektifPersyaratan untuk persalinan pervaginam:
- Ibu minum ARV teratur, atau- Muatan Virus/ Viral Load tidak terdeteksi
Dianjurkan untuk melakukan pemeriksaan muatan virus/ viral load pada usia kehamilan 36 minggu ke atas
Kewaspadaan universal (misalnya cuci tangandan pemakaian alat perlindungan diri) perludilakukan pada semua tindakan obstetri.
Pada dasarnya persalinan Odha dapatdilakukan di semua fasilitas kesehatan.
Pemilihan kontrasepsi pasca persalinanbertujuan untuk mencegah penularan HIV pada kehamilan berikutnya, namun sterilisasibukan merupakan indikasi absolut pada ibudengan HIV
SOGC Clinical Practice Guidelines(No. 101, April 2001)
The available evidence regarding the
prophylactic role of CS applies
only to women
who have not received optimal ARV therapy.
Elective CS (38 weeks gestation) should be offered to HIV-positive women in these specific situations:
SOGC Clinical Practice Guidelines
Women who have not received ARV therapy regardless of the antepartum viral load determination. These patients should be offered appropriate therapy as soon as HIV is recognized. (I)
Women receiving ARV monotherapy regardless of the viral load. Intensification of therapy should be undertaken if time permits. (II-2)
SOGC Clinical Practice GuidelinesPatients with detectable viral load
regardless of the received therapy. (II-2)
Women in whom the viral load determination is not available or has not been done. (II-2)
Women with unknown prenatal care
In HIV-infected women, the higher the plasma viral load, the more likely that HIV will be found in cervicovaginal secretions. However, in many women with undetectable plasma loads, HIV is still often found in such secretions, as reported in an article in the October 17 issue of AIDS (AIDS 2003;17:2169-2176) by , the lead author , Dr Jose Ramon (University of Bati, Italy).
a high CD4 cell count, even in the absence of plasma HIV-1 RNA (as shown in group C), does not necessarily imply the absence of HIV in the cervicovaginal secretions.
Women under HAART treatment were more likely to reach undetectable viral levels in the vagina, even if HIV RNA was detected in the plasma, whereas women under non-HAART treatment were more likely to shed HIV in genital secretions even in the absence of plasma viraemia