- 2x
- 1.75x
- 1.5x
- 1.25x
- 1x, selected
- 0.75x
- 0.5x
- Chapters
- descriptions off, selected
- captions settings, opens captions settings dialog
- captions off, selected
This is a modal window.
Beginning of dialog window. Escape will cancel and close the window.
End of dialog window.
This is a modal window. This modal can be closed by pressing the Escape key or activating the close button.
This is a modal window. This modal can be closed by pressing the Escape key or activating the close button.
Rana Chakraborty, MD, DPhil, reviews treatment options for congenital infections.
| Published:
0 Comments
Emergency Medicine Specialty
Family Medicine & Primary Care Specialty
Internal Medicine Specialty
Obstetrics & Gynecology Specialty
Pediatric & Adolescent Medicine Specialty
Infectious Disease Subspecialty
Maternal-Fetal Medicine Subspecialty
Neonatology Subspecialty
Obstetrics & Gynecology (General) Subspecialty
Pediatric Critical Care Subspecialty
Pediatric Emergency Medicine Subspecialty
Pediatric Hospitalist Subspecialty
Pediatric Primary Care Subspecialty
Mayo Clinic
Download our mobile app
Follow Us
Made with LOVE in Los Angeles | © Copyright 2024
Earn CME Credits
Upgrade to a Premium Account to start earning CME credits.
Past Notes
Aloha.
Good to see everyone.
Thank you, Ali.
And thank you,
Regan, for your talks as
a Segway for this.
And thank you to the organizers
for the invitation.
Real pleasure to be here.
Got no disclosures.
Going to start and do lots of cases
because I know talking
through a participant and making
sense of hearing sensorineural
hearing loss and so on and so forth
can get a little bit dry.
And so I hope that
doing lots of cases might
spark your interest
in this subject.
So let's start with the first
presentation.
Syphilis was diagnosed in a couple,
prompting evaluation of their three
month old infant
in the infant video URL
titers were one in 256
and the confirmatory fluorescent
trap animal antibody test
was also positive.
Physical examination showed intra
oral mucus patches and facial
skin lesions like the patients
shown over here.
And so there's some intra oral
patches and you can see some facial
skin lesions just sort of over here.
Other findings included Rash, a
participant in Magli and
Lymphadenopathy, and
there was also swelling and
limitation of the lower limb
with radiographic features and
really shown over here
whereby you've met
the Met office sites,
there's diminished density
shown over here and
involvement of the metathesis
at the ends of the shaft at the
proximal end of the tibia.
And so with that background, the
child was given a ten
day course of parenteral crystalline
penicillin.
What other investigations would
you prioritize?
And so your options are
liver function tests with a complete
metabolic panel,
an EKG and cardiac
echocardiogram,
a lumbar puncture
or a bone scan.
Okay.
Most of you correctly
picked out that
a lumbar puncture in this situation
would be very much indicated.
So a few words on
congenital transmission of syphilis.
Infants born to women with early
latent syphilis.
And what's early latent syphilis?
Well, that's sort of within 12
months of infection when you still
got non-threatening
Milan antibody titers that are still
positive.
The risks of transmission in that
situation are,
well, there's a 35%
risk of the baby being premature
or stillborn or death
within a year, and
40% often have signs of
congenital disease and show
some of these signs a little later
with late latent syphilis.
And this is remember after you've
had the primary infection, you've
gone through secondary
spark. ARTEMIO
You're in this stage where you are
seropositive with your
non troponin Milan antibody tests,
but now you've gone beyond that 12
month threshold
and the risks and the signs,
10% will manifest with signs
of congenital disease.
And so that's a lot less
than with
early latent syphilis.
And 10% may be stillborn
in most newborns with congenital
disease. They're actually often
free of some of the symptoms, signs
and symptoms that I'm going to talk
about next.
However, with the
stage of late
congenital syphilis and the
manifestations that are also show
that often reflect the vasculitis,
some symptoms may not appear
for more than two years.
And so, as I mentioned,
congenital disease has been divided
into two categories
early, which occurs within the
first two years of life and late
recognized two years
or more after birth.
And so what are these manifestations?
These most often
reflect inflammation,
and they occur within 3 to
7 weeks. Secondary to active
disseminated spirit continue.
And the associated inflammatory
response
you often see, as I mentioned
earlier in the initial case,
the participant majorly
hepatitis, the skin or
lesions and in our case
rhinitis, sniffles, mucous
patches, pseudo paralysis,
inflammation of the lung bones that
I mentioned, including
involvement of the metathesis,
osteoarthritis, pericarditis,
lymphadenopathy, and also anemia
and thrombocytopenia.
Many of these babies are often born
with low birth weight and failure to
thrive.
And so untreated infection
results in intrauterine death.
In 25% of cases,
about 25% die prenatally
and a third have physical
manifestations at birth.
These clinical manifestations of
early syphilis include, as I
mentioned, low birth weight, the
skeletal abnormalities
on the macula popula rash.
And so we've already spoken about
the involvement of the
of the long burns.
There's also rhinitis Karissa
and snuff also shown
in this infant here
with muscles
being this profuse
nasal drainage that can also
become serous thank goodness and
later bloody and that can
appear anytime from one week
to his latest three months, like in
our case.
And then the skin can become red
glazed with these fissures.
Or God said, that
begin to develop
and that appear oftentimes at the
angles of the mouth
and around the nose and also present
in the anus.
And these lesions
form these radial scars called
irrigates,
but they're also manifestations in
congenital syphilis that remind me
of secondary syphilis.
And I've also managed
adolescents and young adults
in my career with
second with with syphilis.
And so some of you may be familiar
with the disseminated
rash, which often involves the palms
and also the soles.
And that can also be manifested over
here with congenital
syphilis as shown over here.
And you often get this
discriminating macular popular
lesions, which
are also present, and also these
punched out lesions shown
in the ears in this newborn.
Now let's talk a little bit about
late congenital syphilis.
Feels odd in 2022 to
be even talking about this.
But as early mentioned, those
numbers that we're seeing
epidemiologic are just astronomical
in terms of new cases of
congenital syphilis and how
virtually every state is now
affected. Now, unfortunately, my
suspicion is that a number of cases
are going to be missed.
And so it may be worthwhile thinking
about like congenital syphilis.
Sadly, in 2022,
here in the United States,
most of this reflects vasculitis.
And so we've moved away from the
inflammation that we were talking
about, the dramatic generalized
act, activation and inflammation.
And we've moved to vasculitis
and really sort of
the impact on the teeth.
And here it starts with the
developing tooth buds,
often in the upper incisors,
which you can you can see become
democratic or peg shaped.
You can I hope you can appreciate
that here.
And then later on, you can
also develop these cusps
that are shown over here.
And these are the old classical
mulberry molars.
And you see multiple cusps over
in the molars over here.
You can also later on
see perforation
of the heart palate as shown
in this case,
and then interstitial keratitis,
which can appear as photophobia
or blurred vision in one
eye and then can become bilateral
and can stop anytime between 5
to 20 years
and eventually.
The other thing is, although
we I mentioned congenital
CMB also now
worth thinking about syphilis as a
potential untreated pattern
and untreated congenital
syphilis as a potential
cause,
which can be either unilateral or
bilateral if it's missed.
And so that triad that was described
hundreds of years ago
by Dr. Hutchinson
incorporates interstitial keratitis.
The teeth, the dental abnormalities
and the deafness
are also other manifestations,
including the saddle nose shown
over here, the protuberance,
mandl, mandible.
There can also be mental
retardation, optic nerve atrophy
and seizure disorders
and also the bone and joint
involvement that I've spoken about,
including submissions
illustrated here and hypertrophy
of the stunning clavicle.
The joints, Clayton's
joints, again described
hundreds of years ago
involves Hydra throws
disorder of the knee knee joints,
basically where
there's painless sinusitis
with collections of fluid in
the joint capsule.
And so these are this is a summary
of the late manifestations of
congenital syphilis.
We've talked about Hutchinson's
triad frontal bossing
prominence of the forehead,
the subtle nose defects in
the heart, palate, gluttons, joints,
saber shins, short
maxilla and protruding mandible
all worth still looking for
in pediatric practices.
And the I've
put these up really just to remind
myself and
your cells about how
we move from a process of
generalized activation
into
into vasculitis
as shown with this individual
here again with the destruction
of the nasal ridge, the impact also
of of of his teeth.
And also cataracts,
which you can't see at which you may
be able to appreciate just over here
in his right eye.
Okay.
It's 2 a.m.
and you're asked to manage a two
kilo full term infant
born a few hours earlier to a
28 year old female by normal
vaginal delivery.
Mom received no prenatal care and
admits to marijuana and crack
cocaine usage during pregnancy.
She reports previously being treated
for genital herpes in the previous
pregnancy and chlamydia two
years ago.
On examination, you note fissures
at the angles of the mouth and nose
and bloody nasal discharge and
cough.
Diffuse macular, pambula rash,
generalised lymphadenopathy and
hepatic spleen and majorly an
and PR on blood obtained from
the baby is reported as one
in 128.
Maternal OPR was also one in
128. How would you manage this baby?
A one broken penicillin.
How about dose as a single dose
or oral doxycycline at
the dose mentioned for 14 days,
obtain a lumbar puncture and begin
treatment with aqueous crystalline
penicillin. G And that dose
for a 10 to 14 day course
ceftriaxone to complete a 10
to 14 day course.
Or call the ID Division Director
for the number of the local
alchemist in order to order mercury
treatment.
Okay.
And nearly all.
A few folks once to only use a
mercury. That's okay.
But yeah.
96% of you.
It's worth remembering, too,
about the lumbar puncture and
the dosage and generally that
we target 10 to 14 days in
terms of treatment.
So treatment of congenital syphilis
is run that with
that dose and for 10 to 14 days
thing with prochain penicillin is
and it is a potential alternative
but you don't get adequate CNS
concentrations
and therefore if they're not
achieved consistently, you may not
be treating neuro syphilis
adequately
for older children above age
four weeks. We generally go for a
high dose of 200000 to
300000 units
divided. Q6 610 to 14
days.
Okay.
A 25 year old pregnant woman
underwent fetal ultrasonography
at 26 weeks gestation.
Her obstetric history was notable
for a febrile illness in the first
trimester.
Ultrasound images showed ventricular
dilatation in the fetal brain.
In addition, there was severe
intrauterine growth restriction
following a hard drive in the US and
increased peak systolic velocity of
the middle cerebral artery on
ultrasonography.
A follow up MRI revealed
ventricular
and cerebellar hyperplasia.
Which infectious pathogens would you
investigate for?
One Hepatitis A, B,
C, HSV
an HIV
Cytomegalovirus Toxoplasma
Gondii Parvovirus
B19 Lymphocytic
Carrier Meningitis Meningitis
Virus L CMB
and Syphilis Toxoplasma
Gondii Parvovirus B19
CMV and Zika Virus
or Syphilis Zika
CMB and Toxoplasma Gondii.
Okay.
Thank you for your responses.
And most of you have opted
given the description
to look for CMB Toxoplasma
Positive B 19 and L
CMB and syphilis.
The other options are
still reasonable, perhaps not.
Maybe option one,
but based on the clinical
presentation.
But certainly CMV would have been
pretty high in terms of
diagnostic testing.
And so a woman
had a normal vaginal delivery of a
male baby weighing
2500 grams.
On the second percentile,
lance was 45 centimeters.
That was less than the second
percentile. The head circumference
was less than the first percentile.
Baby hands, as
you can see here in the
picture, non blanching,
macula rash as well as papules
and fatigue covering his
entire body.
A participant in Magli was also
present
and a lab investigation revealed
anemia and thrombocytopenia.
Tests of parvovirus, b19
and Rubella with negative
CT scanning of the newborns
brain.
Newborns brain showed ventricular
dilatation and Perry ventricular
calcifications.
And that's sometimes important
as I'll show with a little summary
table later.
Maternal serum Immunoassay was
positive for CMB, IG
and AGM and immunohistochemical
testing of the placenta was also
positive for CMB
as shown over here.
I don't know if we can quite
illustrate some outside inclusions.
This was from a colleague of mine,
Dr. Elizabeth Anning,
who who helped provide the slide
and
look. And both Elizabeth
and I do have an ongoing interest in
our lab looking at
CMB and its pathogenesis
in the Mother Infant Diet,
PCR testing of infants urine.
This was obtained at less than three
weeks of age.
Revealed CMB
Urine Positivity for CMB DNA
by PCR.
And so the newborn was treated with
onsite review and
follow up visit.
11 months the child had
sensorineural hearing loss in the
right ear, epilepsy,
spastic, quadruple paresis and
developmental delay
similar to the child's
in the illustration here
note here the severe microcephaly
and the lower limb spasticity.
A few words on congenital CMB.
In the main, it can be asymptomatic
or symptoms can include is just
described entry
growth restriction, hematologic
abnormalities, sensory neural
and developmental disorder,
essentially neural hearing loss and
developmental disorders
that can range in severity.
It can also be associated with extra
medullary hematopoietic is
the dermal hematopoietic.
This can occur in utero as
a result of severe anemia and
that can explain the rash that you
sometimes see that you saw in our
case here
also can be associated with
congenital rubella,
parvovirus as well.
And about 10% of
infants with congenital CMB
exhibit clinical findings that are
going to be evidence of birth.
But for a large number, which is why
screening is really critical,
you really have to
look very, very closely.
Otherwise you'll miss children
who have sensorineural hearing loss
and were exposed to CMV
in utero.
But as we've already mentioned, the
particular thrombocytopenia hepatic
spleen and majorly microcephaly, the
intracerebral calcifications which
are typically pre ventricular
calcification, sensorineural
hearing loss, credit
chorea, retinitis and developmental
delays will go along with this.
As I mentioned, this is the
leading cause of non-genetic
sensorineural hearing loss in the
U.S. But look out for
syphilis.
Given the alarming rise in numbers
about 0.5 to 1%
of all life born infants are
infected in utero and excrete
CMB at birth.
Intrauterine fetal infection
can occur in women with no
preexisting immunity,
and that's really the big set up
where they live where you've got
a population has not had
CMB seropositivity
and in
in childbearing
age oftentimes
if they do acquire
CMB when
they're not in
the first trimester when sometimes
they may not even be aware of
pregnancy, that's
the time that the baby's most
vulnerable.
It can also happen during
reactivation, and that often is
a reflection
of of the virus
coming back in pretty large viral
load.
And there's also an association with
a different infection
with a different viral strain during
pregnancy.
But generally we see more severe,
equally in those
with primary infection
in the first half of gestation.
A few words on treatment.
So those neonates with symptomatic
congenital CMB
appear to have improved audio, logic
and neurodevelopmental outcomes
by two years of age when treated
with oral vanguard, value and cycle
available for six months.
Oral drug exposure
following a dose of outgoing
cycle of ear is the same as that
chief by IV,
and generally the pro-drug is
absorbed very well.
Even after first pass metabolism.
You do have to look out for
neutropenia in about 20%
of infants treated and monitor
their transmit disease
monthly during the course of
treatment.
Antiviral therapy should generally
be limited to patients with
moderate to severe symptomatic
congenital CMB
who are able to start treatment
within the first month of life.
So the third case,
the 27.
Oh, sorry.
Well, 27 year old pregnant
woman.
Gravitate to power.
One developed the February of
illness at 15 weeks gestation
associated with headache, upper
respiratory symptoms and sub
mandibular lymph node swelling.
Symptoms resolve spontaneously.
Family members at home included a
two year old male and
five cats, including two kittens.
At 17 weeks, ultrasound,
ultrasound images and an MRI
showed ventricular dilatation
in the fetal brain hydrocephalus
and intracellular cerebral
calcifications.
Toxoplasma, IgG and IgG
were positive.
PCR of the amniotic fluid detected
Toxoplasma DNA.
She was started on oral spa
in mice and members.
She's a 15 weeks gestation.
Clinical manifestations in the
neonate included by bilateral
carrier retinitis
hydrocephalus and intracerebral
calcifications.
The infant had high titers for
Toxoplasma.
The infant was started on three
method mean and subsidising with
leucovorin.
A little bit on some of the
characteristics.
And this is from a recent report
from emerging infectious diseases.
When you look for ventricular
amygdala in some of the
associations, you often see this
with L CMV.
You can also see it with Toxoplasma
and Zika virus.
Calcifications are often
prominent as well, associated
with all CMB and Toxoplasma.
Microcephaly can be seen in
CMB, as you know, and Zika virus
and retinopathy is often
shown with L, CMB
and also CMB and
toxoplasmosis.
So a few words on congenital
toxoplasmosis.
It has that classical triad of
Corio, retinitis,
cerebral calcifications and
hydrocephalus, and all of this is
very suggestive of the diagnosis.
Here you can see the presence of
cysts and brain tissues
from any and staining
and the cysts.
This is sort of a larger cyst
showing
greater magnification.
You can see severe chorea, retinitis
and also central, some
healing in this infant,
either from the involvement
of their eyes.
However, you don't really see all
three cases and therefore the triad
is most likely to be seen in infants
where you may have one or two
signs suggestive of
congenital Toxoplasma.
Additional signs include the micro
microcephaly.
As I mentioned from the previous
slide seizures, hearing loss,
strabismus, macular, popular rash,
generalized lymphadenopathy have
participant imagery.
Pneumonia, anemia, fatigue
and thrombocytopenia.
And oftentimes with the
meningoencephalitis,
you can see very, very high protein
concentrations similar
to what you might see in tuberculous
meningitis.
So few words on treatment.
Inspiring medicine is
the treatment of choice
and innately
this is
preferred during embryogenesis,
but it doesn't reliably treat the
fetus if there's or if
intrauterine infection has already
occurred because it
doesn't cross the placenta
particularly well.
And so therefore, by about 18
weeks of gestation,
if you've detected the possibility
of congenital toxoplasmosis
or if the mother has acquired
infection in the third trimester,
the drugs of choice of pyrimethamine
and sulfur dioxide and leucovorin,
given how well they cross the
placenta.
Pyrimethamine.
This is the dose.
And then basically
you're providing it for two days
and then for six that one particular
dose and then six months
at a different US
to complete a 12 month course.
Sulfa dies in similarly
is given 1212 months
and folic acid leucovorin
is given and folic acid
isn't really a substitute for food
intake acid.
With high CSF protein
concentrations.
Steroids are often indicated
at the dose mentioned here,
usually twice daily until your
CSF proteins are less than one
gram per deciliter, or you're
seeing resolution of the
carrier retinitis.
Steroids can also
be used
within 72 hours of
initiating treatment for anti total
and for Toxoplasma.
Okay.
The next case,
it's 2003.
A mother was diagnosed with HIV
in pregnancy and she was started
on antiretroviral therapy
and was and had a
caesarean section.
An uninfected child was born
in 2009 and said
her CD4 count was 340.
She had a viral load at the time,
which showed Wildtype virus
viral load of 35,000.
She was started at the time
on fix on
a combination of Ritonavir
boosted Suzanna then
Truvada,
which is tenofovir disoproxil
fumarate
and within four weeks, four months,
sorry, her viral load was less than
50.
She maintained great adherence.
In 2011.
She had a new partner she
conceived on and continued with this
combination of Ritonavir boosted
SS, Anovia and Truvada.
At the time there were no concerns
and in terms of her pregnancy
management, her
atazanavir dose went up from 300
to 400 milligrams.
This was a case in my
old practice in the UK
where they do measure therapeutic
and therapeutic drug monitoring
and she had good trough levels
and so there had been no
doses missed.
Week 36 viral load was
undetectable,
38 hemoglobin was 6.9.
She's a vegetarian.
She also received the mine infusions
and pre labour.
She wanted a pre labour
caesarean section and this was asked
to her maternal request
at a healthy baby formula.
Feeding started
on Zidovudine as monotherapy
as post-exposure prophylaxis.
Again, this was ten years
ago and
the ZIDOVUDINE was given
for four weeks or recommended for
four weeks.
Babies first, first HIV
DNA. PCR was negative.
Would you have done anything
differently or
perhaps off the audience?
But in terms
of the practice, it seemed very much
the standard of care.
However, a
week six, the baby
presented with fever, rash,
occipital, lymph nodes and
neutropenia.
A week seven the HIV DNA
PCR was positive in the newborn,
viral load was greater than 75,000.
The CD4 count was 1350
or 17%.
13500 Sounds like a great number
in a seven week old, but
the normal number,
based on time of paresis
in newborns, is about 2500
to 3000 or so.
So you can already see some
immunosuppression or lymphocyte
suppression taking place
given that high viral load in
this newborn.
And that percentage is also very
low.
Maternal viral load was 59 at the
time.
I did some sequencing
and there was Wildtype virus between
mother and baby
and the transmission risk for this
occurring
was about was less than 1%.
So it still remains a puzzle how
this baby was infected.
I'm copying off from some UK data
from the NSA, HPC,
but as you can see
in the space of
the time that they collected data
over a six year period
for 2117
pregnancies, they just had three
babies that were infected.
And so it's very much a plug for
the way that nationalized care
is provided
so that large
so that you don't have babies being
born with HIV infection.
And to a large extent, most of the
states in the U.S.
have also done a very good job
following guidelines
from the DHHS and
other bodies to offset
mother to child transmission.
I apologize. This is a very
busy slide.
We just recently developed this
for the Red Book from the American
Academy of Pediatrics.
And basically this
is a summary of all
prevention of mother to child
transmission guidelines
here in the U.S.
It incorporates two slides.
The first where moms have low,
low risk criteria, like
the mother described
in terms of what you would do and
what post-exposure prophylaxis
you would offer.
And then high risk.
High risk criteria.
And. What this constitutes
and the kinds of drugs that you
would offer postnatal to the
newborn.
Given the given
the time and everything else.
I do recommend if you do get
a chance to look through the red
book, to look at these
particular tables, sometimes
they're a bit more easier to read
through than the 300
pages or so.
Guidelines from the DHHS
on prevention of Mother to Child
Transmission of HIV.
The summary slide, at least for the
US, is that all pregnant women
should be tested for HIV in the
first trimester and again at the end
of this of the third trimester.
Women with no antenatal care should
receive a rapid test.
They should receive treatment for
HIV if they test positive.
So that viral load is
undetectable beneath
the level of detection.
And we normally use less than 50
copies per month through pregnancy.
They should be offered caesarean
section and IV zidovudine
if the viral load is detectable
or presumed detectable if they have
had no prenatal care.
Their baby should receive postnatal
prophylaxis, ideally within
12 hours of birth.
In the US, breastfeeding should be
avoided and suitable formula
alternatives are offered.
Providers should inquire about the
practice of pre mastication and
cancel HIV infected carriers
about safer feeding practices
and for infants born to mothers with
no prenatal care or detectable
viral load near delivery.
Postnatal prophylaxis
should include zidovudine,
lamivudine and nevirapine,
although now we
can also offer raltegravir,
which is one of the first generation
integrase strand inhibitors
as an alternative to nevirapine.
And postnatal HIV
prophylaxis is based on transmission
risk from
maternal HIV, RNA
and infants can be detected
by DNA PCR at birth
14 to 21 days of life, 4 to
6 weeks and 3 to 6 months.
That's a very big summary for
essentially a 300 page document
and a lot of work in terms
of guidelines.
And I apologize for that.
But it was important
to get through that.
So do a few questions
and then I'll think I'll go on to
the next talk.
A pre labour pre rupture of membrane
caesarean section should be
recommended. If the mother
has had a previous caesarean
section, maternal
HIV viral load is greater than
100,000 at the first antenatal
visit, maternal
HIV viral load is a thousand
HIV RNA copies at
third week 36
gestation on while mum
is on antiretroviral therapy,
viral load is less than 50 copies
parental on week 36
or none of the above.
Okay.
Great.
Correct.
Most must.
43% of you opted
for having the viral load greater
than a thousand copies
near the time of delivery.
And that's really what you would
want to look out for.
Which of the following is a
recognised association with
antiretrovirals in pregnancy,
gestational diabetes, preterm
labor? Small suggests a large
postnatal depression or none of the
above.
Great. I'll stop the polling.
So the correct answer is preterm
delivery, gestational diabetes.
We don't really see so much of
small for gestational age, not so
much, but preterm delivery
is an association and particularly
with the protease inhibitors
which have been given antenatal.
And there has been some questions
about the use of protease
inhibitors and their use
during pregnancy.
We're not seeing the same kind of
signals come up for integrase
inhibitors.
An expectant mother with no prenatal
care arrives in labor.
Do you, one assess a risk factors
for HIV?
Examine her for signs of HIV
infection.
Counsel her to have an HIV test.
Recommend a point of care.
Rapid test, which is
called a pediatric ID 18.
Okay.
Yep. Recommend a point of care
rapid test and I'll just quickly
show you.
This is what it is.
It's used throughout the world
in often in resource
limited settings, but in nearly all
of the units here in
the U.S.
and really should be offered to
women with no
or late prenatal care
when they're in labor
and can be done when
a woman is at the infant partum
stage and can determine
what neonatal prophylaxis you wish
to offer.
The interventions include sort of
postpartum antiretroviral therapy
and no breastfeeding as well.
In terms of the recommendations,
pregnant women, 38 weeks gestation
CD4 count of 180
viral load of 43,000 decides
she wants no medication during
pregnancy. Once a normal delivery
believes breast is best.
What should you do except a right
to choose what she believes is right
for herself and
her baby, except a right to choose
for herself and inform child
protection services regarding the
needs of the baby.
Well, tell her to find another
clinician. You can't care for her.
Okay.
Yeah.
Most of the
in terms of choice,
the what
interventions she wants, it's
her body, her choice.
On the other hand,
when it comes to the needs of the
baby, generally across all of the 50
states, you
can involve social
services in child protection,
especially if there are
concerns that she
that she would like to breastfeed
or if you feel
that there's enough the pediatrician
feels is enough suspicion or
concern here
that the baby would require testing
and post
post-natal prophylaxis
with antiretroviral
therapy.
I think that's the first talk.
Thank you.
Not Available
This feature is not available with your current plan. Please ask your administrator to contact GIBLIB to potentially add this feature.