3rd Trimester Labs and Ob Residents?

[elr1983]

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So I just started my NICU rotation and at my institution, the NICU team goes to any high risk delivery. We always check mom's labs, and since I've started the rotation, I've had 4 moms missing third trimester HIV tests, despite having had good pre-natal care up until delivery. Since we are supposed to treat the baby within 6 hours of delivery, this is something I always ask ob to order. However, recently, I've been getting a TON of attitude from the ob residents about sending the rapid HIV! In one circumstance, the ob resident told me if I wanted the test, I'd have to order it, call the lab to come do it, and consent mom myself! (My fellow eventually called the ob attending and straightened this one out!) Have I missed a change in guidelines? Or is this a case of ob and peds disagreeing about a guideline? Anyone else have a similar problem?

 

[JPeds]

HIV is an optional prenatal lab - usually OBs will assess maternal risk factors and offer the test, but it's not one the routine prenatal labs to look for. Most of the patients I have followed in the NICU were "HIV unknown"; same goes for patients I followed on my OB rotation.

 

[elr1983]

Hmm, really? Here I'm almost positive it's an opt-out, meaning that they can refuse it but that it should be done unless they refuse. I've only had these 4 moms out of at least 200 not have an HIV test on the chart, and it was these 4 I refer to. (200 between my time in the well baby nursery, NICU, etc). And these 4 moms didn't refuse....when asked, they consented willfully, but I could certainly imagine a situation where someone would refuse. At any rate, it's somewhat important information for peds folks to know, I think, since I don't think any kid should die from congenital HIV when we have methods that greatly reduce the risk. (Intrapartum anti-retrovirals, treating during pregnancy, treating the baby, etc.) But perhaps this is an area of disagreement between peds and ob? It certainly seems to be at my hospital...

 

[bjackrian]

It looks like you're right about universal screening as the recommendation for all pregnant women with an opt-out approach favored, at least by the CDC. However, it looks like whether repeat testing in the 3rd trimester is indicated depends on the prevalence of HIV in the community you serve and individual risk factors for the Mom.

From the US Preventative Health Services Task Force:
http://www.guidelines.gov/summary/summary.aspx?doc_id=7178&nbr=004292&string=prenatal+AND+hiv

The USPSTF recommends that clinicians screen all pregnant women for HIV. A recommendation
The USPSTF found good evidence that both standard and FDA-approved rapid screening tests accurately detect HIV infection in pregnant women and fair evidence that introduction of universal prenatal counseling and voluntary testing increases the proportion of HIV-infected women who are diagnosed and are treated before delivery. There is good evidence that recommended regimens of HAART are acceptable to pregnant women and lead to significantly reduced rates of mother-to-child transmission. Early detection of maternal HIV infection also allows for discussion of elective cesarean section and avoidance of breastfeeding, both of which are associated with lower HIV transmission rates. There is no evidence of an increase in fetal anomalies or other fetal harm associated with currently recommended antiretroviral regimens (with the exception of efavirenz; see "Potential Harms" field). Serious or fatal maternal events are rare using currently recommended combination therapies. The USPSTF concluded that the benefits of screening all pregnant women substantially outweigh potential harms.

From the CDC:
http://www.guidelines.gov/summary/summary.aspx?doc_id=9799&nbr=005246&string=prenatal+AND+hiv

Timing of HIV Testing
* To promote informed and timely therapeutic decisions, health-care providers should test women for HIV as early as possible during each pregnancy. Women who decline the test early in prenatal care should be encouraged to be tested at a subsequent visit.
* A second HIV test during the third trimester, preferably <36 weeks of gestation, is cost-effective even in areas of low HIV prevalence and may be considered for all pregnant women. A second HIV test during the third trimester is recommended for women who meet one or more of the following criteria:
o Women who receive health care in jurisdictions with elevated incidence of HIV or AIDS among women aged 15 to 45 years. In 2004, these jurisdictions included Alabama, Connecticut, Delaware, the District of Columbia, Florida, Georgia, Illinois, Louisiana, Maryland, Massachusetts, Mississippi, Nevada, New Jersey, New York, North Carolina, Pennsylvania, Puerto Rico, Rhode Island, South Carolina, Tennessee, Texas, and Virginia.**
o Women who receive health care in facilities in which prenatal screening identifies at least one HIV-infected pregnant woman per 1,000 women screened.
o Women who are known to be at high risk for acquiring HIV (e.g., injection-drug users and their sex partners, women who exchange sex for money or drugs, women who are sex partners of HIV-infected persons, and women who have had a new or more than one sex partner during this pregnancy).
o Women who have signs or symptoms consistent with acute HIV infection. When acute retroviral syndrome is a possibility, a plasma RNA test should be used in conjunction with an HIV antibody test to diagnose acute HIV infection (DHHS, 2006). (Also see NGC summary of DHHS guideline, Guidelines for the Use of Antiretroviral Agents in HIV-1-infected Adults and Adolescents.)
[...]

Postpartum/Newborn Testing
* When a woman's HIV status is still unknown at the time of delivery, she should be screened immediately postpartum with a rapid HIV test unless she declines (opt-out screening).
* When the mother's HIV status is unknown postpartum, rapid testing of the newborn as soon as possible after birth is recommended so antiretroviral prophylaxis can be offered to HIV-exposed infants. Women should be informed that identifying HIV antibodies in the newborn indicates that the mother is infected.
* For infants whose HIV exposure status is unknown and who are in foster care, the person legally authorized to provide consent should be informed that rapid HIV testing is recommended for infants whose biologic mothers have not been tested.
* The benefits of neonatal antiretroviral prophylaxis are best realized when it is initiated <12 hours after birth (Wade et al., 1998).

 

[Stitch]

This scenario isn't uncommon and can be a source of friction. I'm lucky in that my OBs here were fairly aggressive about testing, but it doesn't always happen. I do think many OBs can be make a better effort to put pressure on getting everyone tested, however.

Part of the problem is that HIV is such a labeled or 'stigma' disease. We as practioners treat it as special, with consent required to even test for it (consent is actually not required at my institution). Instead, as has been recommended, and like the internists (I think) are already doing, we need to treat it like any other illness or condition. We don't make a fuss about GC/Chlamydia or GBS status, and we shouldn't make a fuss about HIV, nor should we put it in a special category. It's especially important when you realize that intrapartum treatment of mom along with prompt treatment of the newborn can completely prevent the disease in the infant. This subject should be a no brainer.

 

[elr1983]

Completely agree with the above. Given the above, I find it hard to believe/accept that Ob gives us such trouble when there's no HIV test, not that it happens that often.

 

[elr1983]

Completely agree with the above. Given the above, I find it hard to believe/accept that Ob gives us such trouble when there's no HIV test, not that it happens that often.

 

[Stitch]

Completely agree with the above. Given the above, I find it hard to believe/accept that Ob gives us such trouble when there's no HIV test, not that it happens that often.

The only one I get aggressive about is Hep B, because then you really are on a time frame of giving the vaccine within 12 hours. If it's a problem (and it's usually a problem of getting records and results, not actually testing mom) then I threaten to restick mom directly in post partum. That gets them going.

In general though you're right in that it shouldn't be a big deal, and most OBs I've worked with have tried to get me all the information I want or need, including (surprisingly) GBS sensitivities, when mom is pen allergic.

 

[elr1983]

The only one I get aggressive about is Hep B, because then you really are on a time frame of giving the vaccine within 12 hours. If it's a problem (and it's usually a problem of getting records and results, not actually testing mom) then I threaten to restick mom directly in post partum. That gets them going.

In general though you're right in that it shouldn't be a big deal, and most OBs I've worked with have tried to get me all the information I want or need, including (surprisingly) GBS sensitivities, when mom is pen allergic.

Interesting. We usually just give the Hep B shot within 12 hours if mom's status is unknown, then re-draw the test or track down the results to decide about HBIG, but that's less of a rush since we have 7 days for that. I guess if mom refuses Hep B vaccine and doesn't have a Hep B test result, we'd be in trouble, but that's not a situation I've encountered yet. Most of our parents elect to have their babies vaccinated prior to leaving the hospital anyway.

Our policy is to give anti-retrovirals within 6-8 hours of life, so HIV is always the rush for us.

 

[BigNavyPedsGuy]

Completely agree with the above. Given the above, I find it hard to believe/accept that Ob gives us such trouble when there's no HIV test, not that it happens that often.

4 out of 200 is 2%. That means that the OBs are doing it right 98% of the time. I agree that it's a big deal and I agree that they shouldn't fight it, but you make it sound like it's this rampant problem with the culture of OB when 98% of the time (at your hospital) it's done right. Given the prevelance of HIV in the United States, and the likely effectiveness of risk factor screening, your number needed to miss and HIV+ patient when 98% of patients are tested is pretty stinkin' high.

I've spent many a day arguing with OB about labs, but it's important to put this stuff into perspective.

 

[WhatUpDoc!]

Recent issue of contemporary pediatrics has a clinical vignette about this:

http://www.nxtbook.com/nxtbooks/advanstar/cntped_200910/#/30