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