Women and Adolescents Case Presentations

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


• 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


• 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


• 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:



• 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


• 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.


• 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.


• 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


• 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.


• 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


• 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


• 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)


• 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


• 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


• Reproductive alternatives for serodiscordant couples

• Treatment as prevention

• PreP and PEP and their role in assisted reproduction

Women and Adolescents Case Presentations

Documents

history of hiv

hiv rna viral load

initial visit case

poor adherence

cd4 count

following mutations

pediatrics immunology

poor compliance