Wendy Ferguson

Evaluation of 4 Weeks' Neonatal Antiretroviral Prophylaxis as a Component of a Prevention of Mother-to-child Transmission Program in a Resource-rich Setting

Background: In resource-rich settings, universal adoption of a 4- rather than 6-week neonatal antiretroviral (ARV) prophylaxis regimen could reduce toxicity and results in cost savings, provided prevention of mother-to-child transmission program effectiveness is not compromised. Methods: Between January 1999 and December 2008, a 10-year study of the observational database of the Irish prevention of mother-to-child transmission program that uses a 4- rather than 6-week neonatal ARV prophylaxis regimen was undertaken. Maternal and infant data were analyzed to determine the vertical transmission rate (VTR) and infant outcome. Infants were categorized as uninfected if, off ARVs, they had 2 negative human immunodeficiency virus (HIV) polymerase chain reaction (PCR) tests, the second at 3 months of age or older. Results: Between January 1999 and December 2008, there were 964 HIV-exposed live births. Excluding 7 early neonatal deaths, 4 weeks of ARV prophylaxis was prescribed for 957 infants: 61% received mono, 32% triple, and 7% dual therapy. Of 957 infants, 906 were uninfected, 10 infected, and 41 of indeterminate status. Twenty-four of the indeterminate status infants had at least one negative HIV PCR test at ≥6 weeks and 17 were lost to follow-up before 6 weeks of age. On the basis of 916 infants of known outcome, the VTR was 1.09% (95% confidence interval, 1.07–1.11). If restricted to 910 infants whose mothers received at least 4 weeks of antiretroviral therapy (ART), the VTR was 0.4%. Conclusions: This study provides evidence to support the current clinical practice toward use of a 4-week neonatal ARV prophylaxis regimen.

Targeting points for further intervention: a review of HIV-infected infants born in ireland in the 7 years following introduction of antenatal screening.

Even in countries with well-developed programs for prevention of mother-to-child transmission (MTCT) of HIV, there remains a low level of ongoing transmission. Pregnant, HIV-infected women may not always access screening and available interventions because of circumstances, beliefs, and other influences. Missed opportunities for the prevention of MTCT remains an issue to be addressed. Through a review of HIV-infected children born during the years of antenatal screening in Ireland, we sought to identify further targets for intervention to further reduce MTCT.

Syphilis serology in pregnancy: an eight-year study (2005-2012) in a large teaching maternity hospital in Dublin, Ireland.

All cases of positive syphilis serology detected in antenatal and peripartum screening in a large teaching maternity hospital in inner city Dublin, Ireland over an eight-year period (2005–2012 inclusive) were reviewed and included in our study. Demographic, antenatal registration, laboratory (including co-infections), partner serology, treatment and delivery data were recorded in our database. Infant follow-up, treatment and outcome data were also collected. During this period, 194 women had positive syphilis serology, of which 182 completed their pregnancies at the institution. This accounts for 0.28% of the total number of women completing their pregnancies during this time (N = 66038); 79 had no previous diagnosis of infection. There was one case of re-infection during pregnancy. Thirty-two women were co-infected with human immunodeficiency virus, hepatitis B or hepatitis C. There was one case suggestive of congenital syphilis infection. Our study is a comprehensive analysis of the diagnosis, management and clinical outcomes of women testing positive for syphilis infection in pregnancy. It reveals the relatively high prevalence of syphilis infection in the population utilising the maternity services in north inner-city Dublin. It re-enforces the importance of continued active surveillance to prevent morbidity and mortality associated with maternal syphilis infection. It also highlights the importance of strategies such as re-testing high-risk groups and definitive screening of spouse serology.

Symptomatic primary Cytomegalovirus infection in a HIV-positive pregnant woman

We describe a case of symptomatic primary Cytomegalovirus infection in a HIV-positive pregnant woman on antiretroviral treatment with a CD4 count >200 × 106/l requiring intravenous ganciclovir. No adverse consequences from ganciclovir or evidence of congenital Cytomegalovirus infection were found.

Pregnancy Outcomes of Mothers with Detectable CMV-Specific IgM Antibodies: A Three-Year Review in a Large Irish Tertiary Referral Maternity Hospital

A retrospective audit was performed for all obstetric patients who had positive CMV IgM results between January 2012 and December 2014 in the Rotunda Hospital, Ireland. In total, 622 CMV IgM positive tests were performed on samples from 572 patients. Thirty-seven patients had a positive CMV IgM result (5.9%) on the Architect system as part of the initial screening. Three patients were excluded as they were not obstetric patients. Of the 34 pregnant women with CMV IgM positive results on initial screening, 16 (47%) had CMV IgM positivity confirmed on the second platform (VIDAS) and 18 (53%) did not. In the 16 patients with confirmed positive CMV IgM results, four (25%) had acute infection, two (12.5%) had infection of uncertain timing, and ten (62.5%) had infection more than three months prior to sampling as determined by the CMV IgG avidity index. Two of the four neonates of women with low avidity IgG had CMV DNA detected in urine. Both these cases had severe neurological damage and the indication for testing their mothers was because the biparietal diameter (BPD) was less than the 5th centile at the routine 20-week gestation anomaly scan.

Screening for group B Streptococcus (GBS) at labour onset using PCR: accuracy and potential impact – a pilot study

Abstract This pilot study assessed the diagnostic accuracy and potential impact of a rapid PCR-based screening test for the detection of group B Streptococcus (GBS) at the onset of labour for the purpose of optimising intrapartum antibiotic prophylaxis (IAP). Vaginal and rectal swabs from a convenience sample of 158 women were analysed by conventional broth-enriched culture and a rapid PCR test. Overall, GBS carriage was 18.98% by culture and 19.62% by PCR. PCR for the detection of GBS had a sensitivity of 93.1%, specificity of 96.67% and area under the curve (AUC) of 0.95. Only 19.3% GBS-positive women received IAP. Three-fourths of babies born to GBS-positive mothers did not receive surveillance for early-onset GBS disease. Of the women who received IAP, only 32.5% were GBS carriers. Seventy-four percent of the GBS-positive mothers delivered more than 5 h after recruitment, which gives adequate swab to delivery interval for appropriate antibiotic prophylaxis in labour. Impact statement What is already known about this subject: Appropriate intra-partum treatment of colonized mothers reduces the risk of GBS transmission to neonates. Universal ante partum screening of pregnant women or IAP based on risk factors in labour for GBS prevention fail to accurately identify and treat the woman who actually harbors GBS in the birth canal in labour. A PCR based rapid test, allows for real-time assessment of GBS carriage in labour. What this study adds: This study highlights the fact that a large number of GBS carriers in labour, who could potentially infect their babies, do not receive IAP, and most of their babies do not receive added surveillance in the neonatal period for EOGBS disease. It also confirms that PCR testing at onset of labour is a highly sensitive and reliable test that identifies the women who are GBS carriers in labour and hence need IAP. What the implications are of these findings for clinical practice and/or further research: Timely provision of IAP for the appropriate woman is possible by adopting universal GBS screening at the onset of labor using GBS-PCR. This would involve additional costs to health care facilities and added work to laboratory personnel.

PO-0229 Congenital Toxoplasmosis (ct) In Infants Following in Vitro Fertilisation With Immunosuppression In Early Pregnancy, Two Case Reports

Introduction In Ireland, 75% of pregnant women are seronegative for toxoplasma, making them susceptible to primary infection during pregnancy. First case: A female infant was conceived by IVF. Her mother received high dose steroids, humira and intravenous immunoglobulin at the initiation of, and during early pregnancy. The infant was neurologically abnormal at birth, had marked ventricular dilatation, intracranial calcification and bilateral retinal detachments. CT was confirmed with infant toxoplasma IgG and IgM positive. Maternal serology was consistent with primary maternal infection during pregnancy. Despite anti-toxoplasma therapy, the infant succumbed at six months of age. Second Case: A one-year-old girl was investigated for a convergent strabismus. Conceived by IVF, her mother received high dose steroids for the first four months of pregnancy. Developmentally normal, at nine months of age she developed a right strabismus. Dilated fundoscopy revealed an extensive right macular scar. Neuroimaging showed intracranial calcification. Although toxoplasma IgM was negative, CT was diagnosed based on strongly persistent Toxoplasma IgG Ab, without evidence of decline over time. Developmental progress has been reassuringly appropriate. The macular scar is currently inactive. Discussion The recognition of these two cases, one lethal infection in the setting of primary infection and one possible reactivation disease in women receiving immunosuppressive therapy to facilitate assisted reproduction raises a number of issues. Neither women were aware of toxoplasmosis, their toxoplasmosis status or measure to prevent its acquisition in pregnancy. Women under going immunosuppression in pregnancy should be aware of their status and advised regarding preventative measures.

PM.62 Five Year Retrospective Review of Antenatal Lamivudine (LAM) to Reduce the Perinatal Transmission of Hepatitis B (HBV)

Objectives To review the safety and efficacy of LAM in reducing the perinatal transmission of HBV. Methods Medical charts of HBV positive women who received treatment with LAM and who booked for antenatal care between 2007 and 2012 were retrospectively reviewed. Results Between 2007 – 2012, 34 pregnant HBV positive women received treatment with LAM during the third trimester. All were HbeAg positive, and 6/34 were anti-HbCore IgM positive, indicative of acute infection. Where tested, the predominant genotypes were B and C, occurring in 16/32 and 11/32 respectively. Genotype D was noted in 4/32 women. One woman was co-infected with Hepatitis C. Mean viral load (VL) pre-treatment was >1 × 108 IU/ml, mean VL closest to delivery was 6.5 × 106 IU/ml (P < 0.001). No resistance to LAM was identified in the 70% who were tested post treatment. Median delivery gestation was 39 weeks (range 37–41 weeks); 17/33 had a normal vaginal delivery, 5/33 had an instrumental delivery, 9/33 had a C section, 2 delivered elsewhere and one patient is still pregnant. Median birth weight was 3.49 kg (range 2.33–4.72 kg). All babies received HBV IgG and the first dose of vaccine within the first 24 hours of life. Of 33 live born infants, 17 were not infected, 8 left the country prior to the 8-month serology test, 6 have serology pending (not yet 8 months) and 2 were lost to follow up. Conclusions Treatment with LAM is a safe and effective. No vertical transmission of HBV was noted, and no adverse maternal or fetal effects were reported.