Infectious
Diseases
General
Screening
|
·
Offer screening to all pregnant substance
users at first visit ·
For high-risk women, repeat testing q 3 months
and/or in third trimester ·
Screen for Hepatitis A Ab,
Hepatitis Bs Ag (HBs Ag) and Ab
(anti-HBs), Hepatitis C Ab
(HCVAb), HIV, VDRL |
General
Prevention
|
·
Advise women about the risks of sharing
needles and drug paraphernalia and benefits of using needle exchanges ·
Advise women with multiple sexual partners
about safer sex practices ·
Refer women for substance abuse treatment
services ·
Refer women with opiate dependence for opioid replacement therapy |
Screening
|
· Hepatitis C antibody (HCV Ab) does not distinguish between acute, chronic or resolved infection ·
If HCV Ab positive, monitor AST and ALT at least once annually ·
If ALT normal, order HCV
RNA to confirm active infection; If HCV RNA is
negative, repeat at least once more to confirm spontaneous clearance of virus ·
For chronic hepatitis C positive patients,
recommend hepatitis A and B vaccines to prevent progression to cirrhosis with
co-infection |
Prevention
of Vertical Transmission
|
·
No known way to prevent vertical transmission ·
Limit the use of fetal scalp clips and other manoeuvres that may place baby in contact with mother's
blood in labour |
Transmission
|
·
Long-term sexual partners of carriers have a
low risk of infection (1-4%) ·
Infection rate is ~3-5% for infants born to hepatitis
C positive mothers, regardless of vaginal or caesarean delivery |
Breastfeeding
|
· No evidence of transmission through breast milk – woman has choice to breastfeed |
Treatment
|
· All patients with chronic HCV should be assessed to determine if may benefit from therapy; treatment is contraindicated during pregnancy ·
Offer treatment after breastfeeding finished |
Neonatal
Testing
|
·
HCV antibody
transferred from mother to infant can last up to 18 months and does not
indicate neonatal infection; if infection has occurred, RNA can be detected
at 1-2 months of age ·
Test for antibody in infant at 18 months, or
RNA at 2 months |
Screening
|
· Screen all pregnant women routinely; check for both HBsAg (indicates infection) and anti-HBs (immunity) ·
Repeat testing before delivery in women with
continuing high-risk behaviours |
Immunization
|
· Canadian Immunization Guide recommends offering Hepatitis B vaccine to all high-risk women during pregnancy ·
Immunize all susceptible pregnant women (HBsAg and anti-HBs negative) who are at increased risk (injection drug
use, high-risk sexual practices) with hepatitis B vaccine (O, 1, and 6 months
schedule preferred); an accelerated schedule is also approved (0, 1 and >
2 months) · For alcohol-dependent and chronic liver disease patients (e.g., persons infected with hepatitis C), higher concentration vaccine and periodic monitoring of anti-HBs titres recommended; booster doses should be given followed by re-checking anti-HBs titre ·
Refer to Canadian Immunization Guide, 7th
edition, 2006 for future details (www.naci.gc.ca)
|
Prevention
of Vertical Transmission
|
If mother is Hepatitis B
surface antigen (HBsAg) positive, treat newborn
with: · Immunoglobulin + vaccine within 12 hours of birth · Booster vaccinations at 1 and 6 months · Test for hepatitis B one month after last vaccination ·
Order the following markers: HBsAg, HBeAg, anti-HBs, anti-Hbe |
Immunization
|
·
Safety in pregnancy unknown ; Canadian
Immunization Guide recommendation is to offer women immunization in pregnancy ·
Immunization recommended for injection drug
users and hepatitis C positive women: drugs and paraphernalia may be
contaminated with hepatitis A (via fecal-oral route) |
Screening
|
·
Offer screening to all pregnant women |
Prevention
of Vertical Transmission
|
·
HIV Medicine is evolving quickly, please
contact local ID expert about appropriate prophylactic antiretroviral therapy
for HIV infected pregnant women to decrease perinatal
transmission |
Antenatal
Treatment
|
· Management of HIV-positive pregnant woman is complex and should occur in centre that offers obstetrics, addiction and HIV treatment ·
Delay treatment until after first trimester to
avoid teratogenic effects |
Intrapartum Treatment
|
· HIV positive women who received no treatment or had inadequate suppression of viral load should receive prophylactic antiretroviral therapy prior to delivery and should be offered a C-Section to decrease risk of perinatal transmission · No evidence for elective C-section for HIV positive women who have received adequate multiple therapy with significant viral load reduction ·
Women who tested negative in the past or have
unknown HIV status in pregnancy, but continue with high-risk behaviours (e.g., injection drug use, sharing needles,
unprotected intercourse with high-risk partner) should be retested and
offered perinatal prophylaxis ·
Refer to guideline in CMAJ
2003; 168(13): 1671-1674 and 1683-1688 (www.cmaj.ca) |
Postpartum
Treatment
|
· Neonate: offer antiretroviral treatment according to the protocol for perinatal prophylaxis · Mother: resume combination antiretroviral therapy based on immunologic and virologic status · Breastfeeding: contraindicated if HIV positive status ·
See guideline in CMAJ
2003; 168(13): 1671-1674 (www.cmaj.ca) and
contact local ID expert for advice about management |
Screening
|
·
Mantoux testing
recommended for all patients who use injection drugs, are HIV positive,
homeless or imprisoned within the last 12 months |
INH Prophylaxis
|
·
INH prophylaxis recommended
if tuberculin positive on Mantoux screening with no
evidence of active tuberculosis (Tb) ·
Can wait until 2-3 months postpartum to treat
latent tuberculosis due to increased risk of INH-induced
hepatitis in pregnancy (INH not teratogenic) ·
Breastfeeding should be encouraged (low
concentrations in breast milk) · For adults, order baseline liver enzymes (AST, ALT and bilirubin) and monitor ALT, AST for patients with a history of alcohol abuse, age ≥35 or pre-existing liver disease ·
Monthly clinical monitoring is recommended ·
INH should be given
for 9 months at a dose of 300 mg daily ·
Vitamin B6
(pyridoxine) should be added during pregnancy (dose: 25 mg
daily) ·
Administer under direct observation if woman
is highly unstable |