dr. Anita Rachmawati, SpOGBagian Obstetri Ginekologi FK UNPAD/RS Hasan Sadikin

Bandung

Risiko penularan HIV dari ibu ke Risiko penularan HIV dari ibu ke bayi tanpa intervensi PMTCTbayi tanpa intervensi PMTCT

Periode transmisiPeriode transmisi RisikoRisiko•Kehamilan 5 - 10 %•Persalinan 10 - 20 %•Menyusui 10 - 15 %

TotalTotal 2525 -- 45 %45 %

Risiko tertinggi

Risiko penularan masa Risiko penularan masa persalinanpersalinan

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 Konsep dasardasar intervensi intervensi PMTCTPMTCT• 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

ARVhingga 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;231-232International Perinatal HIV group, 1999

Konsep Konsep dasardasar intervensi intervensi PMTCTPMTCT• 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 RHLWHO RHLThe 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)PACTG 367 (Shapiro, 2004)In almost 2900 pregnancies found that in all subgroups of VLcombination 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 StudyThe 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 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

terdeteksiDianjurkan 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 GuidelinesSOGC Clinical Practice Guidelines(No. 101, April 2001)(No. 101, April 2001)

The available evidence regarding the prophylactic role of CS applies only to womenwho 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 GuidelinesSOGC Clinical Practice GuidelinesWomen 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 GuidelinesSOGC 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

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