Transcript Powerpoint

Women and Adolescents
Case Presentations
Vivian M Tamayo-Agrait, MD, FACOG, AAHIVMS
Department of Obstetrics and Gynecology
University of Puerto Rico
Faculty, Florida/Caribbean AETC
Disclosures of Financial Relationships
This speaker has no significant financial
relationships with commercial entities to
disclose.
This speaker will not discuss any off-label
use or investigational product during the
program.
This slide set has been peer-reviewed to ensure that there are no
conflicts of interest represented in the presentation.
Case #1: Pregnant perinatally infected adolescent
• This is the case of a 17 years old G1P0
adolescent with history of HIV diagnosed
at 2 y/o who comes referred from a
Pediatrics Immunology Clinic due to a
positive pregnancy test.
• Past medical history: Bronchial asthma,
lipodystrophy, major depression, suicidal
attempt
Case #1: Pregnant perinatally infected adolescent
• Past ARV experience:
– AZT and ddI (1997-1998): changed due to viremia
– Lamivudine/AZT/ritonavir: ritonavir d/c due to nausea
– Nelfinavir/AZT/3TC (1998-2000): changed due to
viremia
– Efavirenz/d4T/ddI (2000-2002)
– Lopinavir/ritonavir, 3TC/d4T (2002-2004): changed to
due viremia
– Atazanavir/tenofovir/T-20 (2004-2006): d/c due to poor
commitment with treatment
– Atazanavir/ritonavir/tenofovir/3TC: treatment at initial
visit
Case #1: Pregnant perinatally infected adolescent
• Patient brings results of three previous
resistance tests (genotypes) that showed
the following mutations:
– 2001: I84V, M46I, L90M
– 2006: no mutations detected
– 2007: no mutations detected
Case #1: Pregnant perinatally infected adolescent
• At initial visit, patient reported poor
adherence with her ARV therapy.
– Latest labs:
• CD4 count: 393 (31%)
• HIV RNA viral load: 85,826 copies/mL
• Patient was continued on current therapy and
genotype was ordered which showed the
following:
Case #1: Pregnant perinatally infected adolescent
Case #1: Pregnant perinatally infected adolescent
• Based on these results, patient was started on
Lopinavir/ritonavir, raltegravir, etravirine,
3TC/AZT
• Importance of good adherence was stressed
for both maternal and fetal reasons.
• Follow-up labs after 2 weeks on treatment
showed:
– CD4 count: 476 (31%)
– HIV RNA viral load: 5617 copies/mL
Case #1: Pregnant perinatally infected adolescent
• Labs after 2 months on new regimen showed:
– CD4 count: 530 (36%)
– HIV RNA viral load: 115 copies/mL
• The patient’s pregnancy was complicated by
delivery via emergency cesarean section at 28
weeks gestational age (WGA) due to
eclampsia.
• She delivered a baby girl, weight 3 lbs.
– The baby has been followed up at the
Pediatrics Immunology Clinic and is
confirmed negative.
Case #1: Pregnant perinatally infected adolescent
• After delivery, patient was lost to F/U for more
than a year.
– Patient had discontinued all her medications
– She had abandoned care at her
Immunology Clinic
– Had a new sexual partner
• Adherence to medications stressed in all visits
• Injectable contraception (depot
medroxyprogesterone) started
• Consistently shows poor compliance with
treatments and appointments
Case #1: Topics for discussion
• Adherence difficulties in perinatally
infected adolescents
• Managing multi-drug resistance during
pregnancy
• Contraceptive alternatives for HIV
infected women/adolescents
Case #2: Pregnancy complicated by multiple comorbidities
• This is the case of a 42 years old G4P2012
woman with history of HIV diagnosed 2 years ago
(heterosexual contact), Diabetes Mellitus type 2,
chronic hypertension referred for prenatal care
(PNC).
• Had 2 prior PNC visits with another provider, but
failed to report her serostatus to him.
• This is a desired pregnancy, since she has a new
sexual partner (who is HIV negative) who has no
children.
• Comes to the first visit in our clinic at 12 WGA.
Case #2: Pregnancy complicated by multiple comorbidities
• Current medications:
– Efavirenz/tenofovir/emtricitabine (since HIV
diagnosis) discontinued medication on her own
when she found out she was pregnant
– Metformin 500mg twice daily
– Methyldopa 250mg twice daily
• Baseline:
– CD4:368 (29%)
– HIV RNA viral load: 6376 copies/mL
– HgA1c: 8.5%, glucose=230 mg/dL
– BP= 170/95
Case #2: Pregnancy complicated by multiple comorbidities
• Patient was admitted for metabolic
control with insulin and optimization of
anti-hypertension medication.
• She was immediately started on
Lopinavir/ ritonavir and 3TC/AZT.
• Pregnancy ended at 17 WGA due to a
spontaneous abortion.
Case #2: Pregnancy complicated by multiple comorbidities
• Post expulsion follow up:
– Still desires another pregnancy
– Oriented about all the co-morbidities that
might also complicate a future pregnancy
• Advanced maternal age
• Chronic hypertension
• Diabetes type 2
– Continued on same ARV regimen,
antihypertensive medications and was
switched back to an optimized dose of
metformin
Case #2: Pregnancy complicated by multiple comorbidities
• Post expulsion follow up:
– Continues with undetectable viral load with
current regimen
– Following metabolic and blood pressure
control closely
– Recommended folic acid supplementation
– Home insemination techniques and benefits
explained to the couple
Case #2: Topics for discussion
• Importance of pre-conceptional
counseling
• Managing co-morbidities in HIV infected
pregnant women
• New recommendations about 1st
trimester use of efavirenz
• Barriers to disclosure of HIV serostatus
to HCP
• Reproductive alternatives for HIV
serodiscordant couples
#3: Preconceptional counseling for sero-discordant couples
• A serodiscordant couple (male HIV+, woman HIV-)
is referred to our clinic for counseling on
reproductive alternatives.
• Woman: 30 years old G2P1A1, without history of
any systemic illness.
• Man: 35 years old, with history of HIV diagnosed 7
years ago due to past history of IVDA. He is ARV
naïve and receiving continuous care at his local
Immunology Clinic
• No fertility problems suspected (both have
children with previous partners)
#3: Preconceptional counseling for sero-discordant couples
• Baseline evaluations (woman):
– Rapid HIV test: negative
• Baseline evaluations (male):
– CD4 count: 825 (40%)
– Viral load: 3823 copies/mL
– Hepatitis profile: negative
– Semen analysis: normal
#3: Preconceptional counseling for sero-discordant couples
• Recommendations:
– Infected partner should begin an effective ARV
treatment
– Timed intercourse and artificial insemination
techniques (ideally including sperm washing)
were discussed, including risk, benefits and
costs
– Couple referred to a Reproduction/Infertility
specialist
– PreP and PEP recommended prior and after
insemination
– Folic acid supplementation
Case #3: Topics for discussion
• Reproductive alternatives for
serodiscordant couples
• Treatment as prevention
• PreP and PEP and their role in assisted
reproduction