hiv in pregnancy; usmle rx vs usmle world, plz hlp - resi_hopeful

[ArchivalUser]

A 28-year-old G2P1 woman comes to the clinic 9 weeks after missing her period and suspects that she is pregnant. Urine pregnancy testing is positive, and ultrasound confirms a viable intrauterine pregnancy. She has no acute complaints. Her medical history is significant for HIV infection diagnosed 1 year ago. Her only medication is prenatal vitamins. Her most recent CD4+ cell count 1 month ago was 395/mm³ (normal: 500-1500/mm³), and her HIV viral RNA load was 6800 copies/mL. She has no history of opportunistic infections. Her temperature is 37.6°C (99.7°F), blood pressure is 128/84 mm Hg, and pulse is 78/min.
Which of the following is the best next step in management?

A.Begin three-drug antiretroviral therapy now; advise a cesarean section and exclusively bottle feeding
B.Begin three-drug antiretroviral therapy now; advise vaginal delivery and the avoidance of breast-feeding for 6 months after delivery
C.Begin zidovudine prophylaxis in the third trimester; advise a cesarean section
D.Begin zidovudine therapy in the third trimester only if her HIV viral RNA load at that time is >10,000 copies/mL
E.Recheck her HIV viral RNA load every 3 months; begin three-drug antiretroviral therapy when her HIV viral RNA load is >10,000 copies/mL; advise vaginal delivery
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The correct answer is A. 75% chose this.
All pregnant women should be started on triple therapy regardless of viral load or CD4+ count to reduce the risk of vertical transmission. Triple therapy should include zidovudine but not efavirenz as this medication is associated with neural tube defects when used in the first trimester. Numerous factors are associated with increased risk of vertical transmission, including high maternal levels of viremia, a low maternal CD4+ cell count, vaginal delivery, sexually transmitted disease during pregnancy, prenatal smoking, and breast-feeding. HIV-positive women should be advised to undergo cesarean delivery because it carries lower rates of transmission. Because of detectable levels of HIV in maternal breast milk, breast-feeding should be avoided totally.
B is not correct. 6% chose this.
All pregnant women with HIV infection should be started on a three-drug antiretroviral regimen on becoming pregnant to decrease vertical transmission, as well as to decrease overall maternal viral load. Vaginal delivery carries a higher rate of transmission and should be avoided if possible. Because of detectable levels of HIV in maternal breast milk, breast-feeding should be avoided throughout the postnatal period.
C is not correct. 14% chose this.
Zidovudine is a nucleoside reverse transcriptase inhibitor and is a commonly used drug in highly active antiretroviral therapy (HAART). Zidovudine therapy as a single agent has been shown to reduce vertical HIV transmission rates, especially in sub-Saharan Africa where there is limited access to antiretroviral medication. However, the goal of therapy is to lower the maternal HIV viral load as much as possible, and in this regard a three-drug regimen is superior to a single-agent regimen. Cesarean delivery carries lower rates of transmission compared with vaginal delivery and should be advised.
D is not correct. 2% chose this.
Zidovudine therapy as a single agent has been shown to reduce vertical HIV transmission rates independent of HIV viral load. However, the goal of therapy is to lower the maternal HIV viral load as much as possible, and in this regard a three-drug regimen is superior.
E is not correct. 3% chose this.
It is appropriate to follow maternal HIV viral loads during pregnancy; however, therapy should not be withheld on the basis of the results. The goal of therapy is to lower the maternal HIV viral load, and in this regard a three-drug regimen is appropriate. In addition, vaginal delivery carries a higher risk of maternal transmission and should be avoided if possible.
Bottom Line:
Strategies for reducing vertical HIV transmission include lowering the maternal viral load with a three-drug antiretroviral regimen, cesarean delivery, and the avoidance of breast-feeding.

[ArchivalUser]

usmle world states:

if pt already on zidovudine...she shud resume

if not on zido yet...she shud start at 12-14 weeks...


usmle rx....said start now...

any one wanna add

[ArchivalUser]

When should a pregnant woman with HIV begin to take HIV medicines?


It depends on a woman’s individual situation. The following information provides general guidance on when to start HIV medicines during pregnancy and what HIV medicines to use. The information is based on guidelines from the U.S. Department of Health and Human Services.

Women who are already taking HIV medicines when they become pregnant
Some women with HIV may be taking HIV medicines for their own health before they become pregnant. They should continue taking HIV medicines throughout their pregnancies. The HIV medicines will protect the women’s health and also prevent mother-to-child transmission of HIV.

A woman’s HIV regimen may change during pregnancy. For example, it may be necessary to change the dose of an HIV medicine because pregnancy affects how the body processes medicine. Pregnancy may increase the risk of certain side effects from HIV medicines. A change in HIV medicines may be necessary, but women should always talk to their health care providers before making any changes.

Pregnant women with HIV who are not yet taking HIV medicines
Some women with HIV may not be taking HIV medicines when they become pregnant. For these women, when to start taking HIV medicines during pregnancy depends on several factors.

Women who have a low CD4 cell count or symptoms of HIV infection should start HIV medicines as soon as possible in pregnancy.
These women should begin to take HIV medicines as early as possible in pregnancy to protect their health and to prevent mother-to-child transmission of HIV. Treatment with HIV medicines is recommended for everyone with HIV, but the recommendation is strongest for those who have a CD4 count less than 350 cells/mm3; symptoms of HIV disease; high HIV viral loads; or certain conditions, such as AIDS or certain HIV-related illnesses and coinfections. HIV-infected women in these circumstances should start taking HIV medicines as soon as possible in pregnancy.

In women who have a high CD4 cell count and no symptoms of HIV, there is less urgency to start HIV medicines as soon as possible in pregnancy. These women may consider waiting until after the first trimester of pregnancy (12 weeks of pregnancy) to begin taking HIV medicines to prevent mother-to-child transmission of HIV. To make this decision, women and their health care providers consider a woman’s CD4 count and HIV viral load, any pregnancy-related conditions such as nausea and vomiting, and the benefits versus the risks of waiting until after the first trimester of pregnancy to start HIV medicines to prevent mother-to-child transmission of HIV.

SOURCE: NIH.GOV
http://aidsinfo.nih.gov/education-materi...-pregnancy

Both UW and USMLE RX are correct depending on the cinical situation.

[ArchivalUser]

great thanks alexa!!!!