TEALE FENNING Medical Education    FAQ   Search   Memberlist   Usergroups   Register   Profile   Log in to check your private messages   Log in  mrcog courses for doctors HIV          TEALE FENNING Forum Index -> MRCOG Part 2: Objective Structured Clinical Examination - the OSCE View previous topic :: View next topic   Author Message wolverine Century Club Joined: 16 Jan 2007 Posts: 394 Posted: Tue May 01, 2007 11:19 pm    Post subject: HIV I had this bad dream... "You are asked by your consultant to give a brief talk to the midwives of your department on managment of pregnant women positive for HIV. What are the key points that you would like to include in your talk?" I'm going back to bed now.. Last edited by wolverine on Sun May 06, 2007 9:08 am; edited 1 time in total Back to top cpeedahsa Century Club Joined: 21 Apr 2007 Posts: 921 Posted: Sat May 05, 2007 7:34 pm    Post subject: Re: HIV wolverine wrote: I had this bad dream... "You are asked by your consultant to give a brief talk to the midwives of your department on managment of pregnant women positive for HIV. What are the key features that you would like to include in your talk?" I'm going bad to bed now.. How about this-- ? Too lengthy??? ********************************************************** Recognition of HIV infection in pregnant women is the key to the prevention of childhood HIV infection. In UK-it is estimated that 49500 adults are infected with HIV, of whom one-third are unaware of their diagnosis. Among adults newly diagnosed with HIV in the UK, 58% are thought to have acquired their infection through heterosexual exposure, of whom the majority are of black African ethnicity and who were probably infected in sub-Saharan Africa. Guidelines regarding Management of HIV in Preganncy are available from www.bhiva.org.uk, www.aidsmap.com, www.rcog.org.uk, www.rcm.org.uk. All health professionals have a professional responsibility to care for all women, regardless of their health status. Midwives play a key role in caring for women who are HIV positive. HIV is primarily transmitted by unprotected vaginal or anal penetrative sex with an infected person, through the use of contaminated needles and syringes, by exposure to infected blood, blood products or donor tissues. HIV infection can also be transmitted from a HIV infected woman to her child in utero via the placenta, at delivery, or through breastfeeding. Data from The Unlinked Anonymous Prevalence Monitoring Programme showed that, in 2002, there were an estimated 686 births to HIV-positive women in the UK, with over 60% of these in London. The risk of mother-to-child transmission of HIV varies between 15% and 20% in non-breastfeeding women in Europe and between 25% and 40% in breastfeeding African populations. Over 75% of these infections remain undiagnosed at the time of birth. This denies women the opportunity to benefit from recent advances in HIV management, including new combination drug therapies. It also means that babies are being born with preventable HIV infections. Transmission of HIV from mother to child can be greatly reduced in a number of ways including anti-retroviral treatment in pregnancy and the perinatal period, changes in labour management, and avoiding breastfeeding. Antenatal testing--Pregnant women should be offered screening for HIV early in pregnancy because appropriate antenatal interventions can reduce maternal-to-child transmission of HIV infection. All pregnant women should receive appropriate information on HIV infection and on its transmission from mother to child. HIV testing should be universally available in all antenatal clinics without any obstacle. Testing should be voluntary, confidential , subject to explicit informed consent and include procedures for pre and post-test discussion. All maternity units are advised to put in place written protocols for antenatal HIV testing, developed in consultation with other key professionals, voluntary agencies and representatives from user groups and local communities. All midwives should have sufficient understanding of HIV and prevention of mother-to-child transmission to enable them to include HIV antibody testing among the routine booking investigations and appropriate training in pre-test discussion and in the provision of care and support for pregnant women affected by HIV. However, a positive HIV antibody test result should be given to the woman in person by an appropriately trained health professional; this may be a specialist nurse, midwife, HIV physician or obstetrician. She should be immediately referred for post-test counselling and support, and for specialist medical assessment and treatment. This should be integrated with maternity care, which should proceed as usual, and with support from the voluntary sector and social services. Women with a positive HIV result should be given the opportunity to consider termination of pregnancy, and supported to reach their own informed decision . Great care should be taken to ensure that women are not placed under pressure to terminate pregnancy. Women diagnosed as HIV positive during pregnancy should be managed by a multidisciplinary team including a HIV physician, an obstetrician, a midwife, a paediatrician and may also include a psychiatric team and support groups. Women with particular social difficulties, such as those with housing or immigration problems, will require considerable input from social workers. Women who use drugs will require additional support from drug dependency specialists. Women diagnosed HIV positive during pregnancy should be informed that interventions (such as antiretroviral therapy, caesarean section and avoidance of breastfeeding) can reduce the risk of mother-tochild HIV transmission from 25–30% to less than 2%. All women with HIV during pregnancy (whether diagnosed before or during pregnancy) should be reported to the National Study of HIV in Pregnancy and Childhood at RCOG. All pregnant women who are HIV positive should be screened for genital infections during pregnancy. This should be done as early as possible in pregnancy and repeated at around 28 weeks. Any infection detected should be treated according to UK national guidelines. Screening for Down syndrome and fetal anomalies should be offered. A detailed ultrasound scan for fetal anomalies is important after first-trimester exposure to HAART and folate antagonists used for prophylaxis against PCP. Confidentiality-The women’s HIV status be revealed only on a “need to know basis”. The woman should be made aware of which personnel know of her sero-status and encouraged to assume responsibility for disclosure to others. No information on HIV should be recorded on client-held maternity records unless the woman expressly wishes it. Advanced maternal HIV disease, low antenatal CD4 T-lymphocyte counts and high maternal plasma viral loads are associated with an increased risk of mother-to-child transmission HAART-All women who are HIV positive should be advised to take anti-retroviral therapy during pregnancy and at delivery. The optimal regimen is determined by an HIV physician on a case-by-case basis. The decision to start, modify or stop anti-retroviral therapy should be undertaken by an HIV physician, in close liaison with other health professionals, notably the obstetrician and paediatrician. Pregnant women for whom HAART is indicated for treatment of their HIV infection (usually those with CD4 T-lymphocyte count of 200–350 _ 106/l) should be treated with HAART in the same way as nonpregnant adults. Women who do NOT require HIV treatment for their own health require anti-retroviral therapy to prevent mother-to-child transmission. Anti-retroviral therapy is usually commenced between 28 and 32 weeks of gestation and should be continued intrapartum. Presentation with symptoms or signs of pre-eclampsia, cholestasis or other signs of liver dysfunction during pregnancy may indicate drug toxicity and early liaison with HIV physicians should be sought. Women who are HIV positive who have a detectable plasma viral load and/or who are NOT taking HAART should be offered a planned caesarean section as it reduces the risk of mother-to-child transmission of HIV. Further research is needed to evaluate the effect on mother-to-child transmission and maternal health of planned caesarean section for women who are taking HAART or who have very low viral loads. Women who opt for a planned vaginal delivery should have their membranes left intact for as long as possible as ruptured membranes for more than four hours were associated with double the risk of HIV transmission Electronic fetal monitoring should be performed according to NICE guidelines . HIV infection per se is not an indication for continuous electronic fetal monitoring. Use of fetal scalp electrodes and fetal blood sampling should be avoided. Women should continue their HAART regimen throughout labour and if an intravenous infusion of zidovudine is required it should be commenced at the onset of labour and continued until the umbilical cord has been clamped. An emergency caesarean section should be performed for the usual obstetric reasons and to avoid a prolonged labour and prolonged rupture of membranes. A zidovudine infusion should be started four hours before beginning the caesarean section and should continue until the umbilical cord has been clamped. A maternal sample for plasma viral load should be taken at delivery. The cord should be clamped as early as possible after delivery and the baby should be bathed immediately after the birth. Anti-retroviral therapy is usually discontinued soon after delivery but the precise time of discontinuation should be discussed with the HIV physician. Preterm- There is no known contraindication to the use of short-term steroids to promote fetal lung maturation. Preterm infants are more likely to be infected with HIV. Infants born to HIV+ve mothers - Zidovudine is usually administered orally to the neonate for four to six weeks. Maternal antibodies may persist for up to 18 months in the newborn, and current estimates are that in western countries approximately 25-30% of babies born to mothers with HIV are themselves infected. All HIV positive mothers should be given the opportunity to meet a paediatrician and discuss the need for surveillance of their baby’s health, the implications for neonatal care and breastfeeding, before birth. Midwives should liase closely with paediatricians, virologists and other members of the multidisciplinary team to support women and their families. Breastfeeding doubles the risk of HIV transmission and so women in the UK who are known to be HIV positive should be advised not to breastfeed. However, women who choose to breastfeed should have their decision respected and be given sympathetic support. Due to the high risk of transmission associated with breastmilk, active recruitment of women for breast milk donation should be discouraged, unless local protocols exist for pre-donation HIV testing. Infants born to infected women are to be reported. Specific Precautions- Maternity units are encouraged to adopt a single tier approach to infection control which will generally be more effective in protecting all women and staff, as the majority of HIV positive women may not have been identified anyway. Sharps injuries are the most likely source of occupationally acquired HIV infection. Occupational health departments issue guidelines on needlestick injuries, and encourage immediate notification of any such . Back to top cpeedahsa Century Club Joined: 21 Apr 2007 Posts: 921 Posted: Sat May 05, 2007 7:47 pm    Post subject: I did try actually and it takes around 11 minutes to cover all the points mentioned above. With a little bit of refining may take lesser time. Maybe an OSCE station like this can come as a preapratory station? Back to top Abik Century Club Joined: 15 Jan 2007 Posts: 243 Location: Poole Posted: Sun May 06, 2007 11:14 am    Post subject: Fantastic answer! Is all that in your head? I wouldn't get all that even 30 seconds after reading it! I guess it comes down to headings again. We were practising some structured vivas and finding it tricky to get started. Like the essays, a strucure helps to organise thoughts. eg. Antenatal - booking, diagnosis, involving the teams, effect of preg on dis/dis on preg, folate, teratogens, plan for preg - scans?hospital/MW care?etc. Intrapartum - how to deliver, where and with whom involved. epidurals are NOT contraindicated (my new life mantra!!) Postpartum - breastfeeding, contraception, baby, plan for next pregnancy Back to top rpwalavalkar Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966 Posted: Sun May 06, 2007 2:10 pm    Post subject: i'd just add, care with tissue / body fluids handling , universal precautions at interventions for staff n yellow sticker at the back of front page of the notes. _________________ Dr Miss. Raj Walavalkar MBBS MRCOG TealeFenning Administrator SR O&G Wessex Region Back to top wolverine Century Club Joined: 16 Jan 2007 Posts: 394 Posted: Sun May 06, 2007 4:21 pm    Post subject: And something else: About confidentiality, the health practitioner (doctor/midwife) has the right to disclose her status to her partner if she is unwilling to do it herself! Back to top EMAK Century Club Joined: 26 Nov 2006 Posts: 572 Posted: Sun May 06, 2007 6:24 pm    Post subject: wolverine wrote: And something else: About confidentiality, the health practitioner (doctor/midwife) has the right to disclose her status to her partner if she is unwilling to do it herself! Really ?!! Back to top Abik Century Club Joined: 15 Jan 2007 Posts: 243 Location: Poole Posted: Mon May 07, 2007 9:34 am    Post subject: Minefield - don't go there! I actually think you can't do that if they expressly tell you not to. The law on HIV is changing all the time however and I think you'd get away with it but VERY dodgey ground! Back to top bronwyn Century Club Joined: 19 Jul 2006 Posts: 144 Location: Alton, Hampshire Posted: Mon May 07, 2007 1:45 pm    Post subject: Wolverine is right! See http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4137711.pdf "You may disclose information about a patient, whether living or dead, in order to protect a person from risk of death or serious harm. For example, you may disclose information to a known sexual contact of a patient with HIV where you have reason to think that the patient has not informed that person and cannot be persuaded to do so. In such circumstances you should tell the patient before you make the disclosure, and you must be prepared to justify a decision to disclose information." From the Department of Health's policy consultation on confidentiality and disclosure August 2006 _________________ Bronwyn Bell SpR Portsmouth Back to top EMAK Century Club Joined: 26 Nov 2006 Posts: 572 Posted: Tue May 08, 2007 1:10 pm    Post subject: Back to the question: we tell the nurses the following: 1] all personelles taking care of the lady should be aware of her status. 2]appropriate lebelling of her file and all tissue samples is important. 3]appropriate disposal of contaminated equipment. Intrapartum: =Delivery should be by Elective CS with care to tissue handelling,double gloving, not tying knots with needle attached and follow the unit protocol regarding needle stick injuries. BUT if: Women who opt for a planned vaginal deliverythen: = should have their membranes left intact for as long as possible. =Use of fetal scalp electrodes and fetal blood sampling should be avoided. =Women should continue their HAART regimen throughout labour until the umbilical cord has been clamped. =A maternal sample for plasma viral load should be taken at delivery. =The cord should be clamped as early as possible after delivery = the baby should be bathed immediately after the birth. Postpartum: =women who are HIV positive should be advised not to breastfeed their babies. =All infants born to women who are HIV positive should be treated with anti-retroviral therapy. = Back to top Nick Raine-Fenning Course Director Joined: 27 May 2006 Posts: 1852 Location: Nottingham Posted: Tue May 08, 2007 3:43 pm    Post subject: Great answer guys - well done cpeedahsa ... stunning work! _________________ "Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997 Back to top cpeedahsa Century Club Joined: 21 Apr 2007 Posts: 921 Posted: Tue May 08, 2007 4:18 pm    Post subject: Nick Raine-Fenning wrote: Great answer guys - well done cpeedahsa ... stunning work! thanks! I have just started preparing(atleast that is what I think). I am actually a resident in OBGyn in NY and stilllllll thinking of appearing for the exam(just out of interest!!); not very sure , but may.......be March 2008 Back to top Display posts from previous: All Posts1 Day7 Days2 Weeks1 Month3 Months6 Months1 Year Oldest FirstNewest First         TEALE FENNING Forum Index -> MRCOG Part 2: Objective Structured Clinical Examination - the OSCE All times are GMT Page 1 of 1   Jump to: Select a forum Announcements----------------Forum AnnouncementsExam InformationCourse Announcements Examinations----------------MRCOG Part 1: EMCQsMRCOG Part 2: MCQ & Past Paper questionsMRCOG Part 2: EMQs - Extended Matching QuestionsMRCOG Part 2: Short Answer EssaysMRCOG Part 2: Objective Structured Clinical Examination - the OSCEDRCOG: the Diploma ExaminationMFFP: Membership of the Faculty of Family Planning and Reproductive Health Care of the RCOGPLAB: The Professional and Linguistic Assessment Board test General Discussion----------------Open ForumRCOG News & UpdatesThe Study Buddy SchemeKey Facts in O&GGuidelines & ProtocolsRecommended ReadingUseful WebsitesThe Market PlaceHow things work in the UKHow do you say that? Teale Fenning Courses----------------Our UK CoursesOur Overseas CoursesOur Correspondence CourseCourse AdministrationCourse FeedbackAccommodationOther Courses Training & Career Development----------------Basic Speciality Training in O&GSubspeciality Training & Special Skills ModulesAcademic TrainingResearch & AuditThe Curriculum Vitae or CVInterview SkillsMedical EducationPublication & Presentation SkillsTraining Courses, Conferences, & MeetingsThe Job MarketClinical Attachments  You cannot post new topics in this forum You cannot reply to topics in this forum You cannot edit your posts in this forum You cannot delete your posts in this forum You cannot vote in polls in this forum Powered by phpBB © 2001, 2005 phpBB Group