Treatment during pregnancy

There is no doubt that antiviral therapy is clearly beneficial for pregnant women. The risk of transmission to the baby is significantly reduced so that ALL pregnant women should be treated with drugs that have action against immunodeficiency virus.
However, today no treatment completely eliminates this risk and there is no way to diagnose the baby before birth. It was not known the effect that many of the drugs used for AIDS may have on the developing fetus. Therefore, when making decisions about what to do should take into account the risk-benefit for the child and mother, given the medicines you have taken the mother previously and if there is experience with drugs.

The only drug approved for use during pregnancy is zidovudine (AZT). This is given to the mother orally throughout pregnancy, intravenously during childbirth and newborn droplets during their first six weeks of life. The largest study done so far with this drug administered in three ways able to reduce transmission from 25% to 8% without adversely affecting the development of children.

Besides other strategies have been investigated, such as giving nevirapine to the mother during childbirth and infant in the first hours of life. The advantage is that it is cheap and can be used in developing countries. Can also be used in women who have been treated during pregnancy for not consulting or having discovered they were HIV positive at the end of gestation. In cases where the mother is treated during pregnancy or childbirth, the baby should be administered immediately after birth, which will help reduce the chance of infection.


Combining several drugs
The combination of drugs is far more effective in controlling HIV infection that treatment with a single drug. This is true in all patients, so it should be also in pregnant women. Any doubts that may arise when taking a single drug (AZT or nevirapine) or more are based on the lack of studies to see if the combinations are harmful to the fetus.

At the beginning of use of combined treatments reported some complications, preterm delivery rate or cerebral hemorrhage. The combination AZT, 3TC and indinavir appeared to be the most frequently implicated in these problems, but it is unclear to what extent drugs were responsible for complications or other factors exist.

Later, with the exception of efavirenz (Sustiva), no birth defects have been identified that can be attributed to the use of HIV drugs, either in humans or animals. In animal studies, efavirenz caused severe brain damage, so it is recommended to avoid use during pregnancy.
As hyperbilirubinemia (increased blood of bilirubin, a pigment produced in the liver) of pregnant women may harm the developing fetus, it is advisable to monitor patients taking protease inhibitors because these drugs can increase the bilirubin in the blood.
As a summary we can say that you can not give any absolute guarantee pregnant women, so the decision should be individualized. It is important that the doctor and the mother decided to form consesuada.

When to start?
In the first quarter, the risk of infection is relatively low and the chances of producing drugs problems are greater. Therefore, if no medical emergency (eg an infection difficult to control if not increase the defenses of the mother) can be beneficial to delay its start until week 12-14 of pregnancy. If the pregnant woman wants to start treatment immediately to reduce the risk of infection should not be denied this option.
When the woman learns that she is HIV positive after the first trimester is advisable to begin treatment immediately. Even in later stages of pregnancy (more allas 36 weeks), therapy has proved useful, reducing the risk of infection to the child.


What if you are already taking antiretroviral therapy?
With pregnant women who are already taking HIV therapy must decide whether to continue or discontinue treatment during the first quarter. Discontinuation of therapy at this stage to allow normal development of the baby's organs, and can cause the mother mpeoramiento with increased viral load, which can lead to an increased risk of infection. Keep it could increase the likelihood of occurrence of fetal malformations.

Usually most experts agree that if the situation is stable, the mother should continue the treatment throughout pregnancy. When the mother does not want for fear of the effects it could have on the fetus, can make a 'therapeutic tions cow' during the first quarter. If treatment is advised to remove suspend all drugs at once, and when reitroduzcan start all at once.

Sometimes the withdrawal of treatment in the first quarter arises for another reason: morning sickness. Some pregnant women vomit frequently in the morning and do not tolerate medication or are unsure of compliance ifDSSput being suitable for vomiting. In such cases it is better to complete suspension of the treatment to take it incorrectly, which could increase the risk of the virus developing resistance to infection and the child.

What if the mother has not been treated during pregnancy?
In this case there is high risk and can evaluate the baby's treatment with AZT and 3TC, as little is known doses of both drugs in the neonatal period. Another option appears to nevirapine, given the excellent results he has had in some studies. May consider the possibility of adding a dose of this drug in the first hours of life and a second at 72 hours, a measure that is able to maintain the drug concentration for a week. In the postpartum assess the status of the mother and the need to initiate treatment. Some authors recommend combination treatment for the newborn, especially if the mother had virus resistant to treatment