dr. Anita Rachmawati, SpOG Bagian Obstetri Ginekologi FK UNPAD

dr. Anita Rachmawati, SpOG
Bagian Obstetri Ginekologi FK UNPAD/RS Hasan Sadikin
Bandung
Risiko penularan HIV dari ibu ke bayi
tanpa intervensi PMTCT
Periode transmisi
•Kehamilan
•Persalinan
•Menyusui
Total
Risiko tertinggi
5
10
10
25
Risiko
- 10 %
- 20 %
- 15 %
- 45 %
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 tanpa
ARV
 hingga 87% pada wanita terinfeksi HIV dengan
ARV (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 elektif
 Persyaratan 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 tangan
dan pemakaian alat perlindungan diri) perlu
dilakukan pada semua tindakan obstetri.
 Pada dasarnya persalinan Odha dapat
dilakukan di semua fasilitas kesehatan.
 Pemilihan kontrasepsi pasca persalinan
bertujuan untuk mencegah penularan HIV
pada kehamilan berikutnya, namun sterilisasi
bukan merupakan indikasi absolut pada ibu
dengan 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 Guidelines
 Patients 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
 An increased CD4 cell count and HAART treatment were
significantly associated with non-detectable viral loads
both in plasma and in vagina.
 Non-HAART treatment was significantly associated with
HIV-1 RNA absence in plasma viraemia but not in vaginal
secretions