Adviser : dr. A.A. Made Sucipta, MSc, Sp.

A
Name : IGAALS’s baby
Gender : M
DOB : 2nd May 2018
TOB : 14.42
Address : Thamrin street, Denpasar
Room : Perinatology Room
He was born to 27 years-old G1 by cesarean delivery, mature
gestation (38 weeks 4 days), immunocompremised, single
viable intrauterine fetus, labor stage I (active phase). Patient’s
mother has been diagnosed with immunocompremised at 25
weeks gestation, and has been taking ARV for 3 months. The
mother has no other health problems.
He was born cry spontaneously and had good mucle tone, but
the amniotic fluid was green. Defecate (+), urination (+)
 APGAR score : 7-8-9
 BW / BL : 2700 grams / 49 cm
 TC / HC : 35 cm / 32 cm
 HR : 140 x / minute
 RR : 40 x / minute
 Tax : 360C
 SpO2 : 96%
 Head : normochepali, within normal limit
 Eyes : an -/-, ict -/-, pupils equal 2mm, round, reactive to
light +/+
 Nose : nasal flaring –, cyanosis -
 Oral : no palate abnormality
 Chest : symmetrical, retraction –
 Cor : s1s2 normal, regular, murmur –
 Po : bves +/+, rhonki -/- , wheezing -/-

 Abdominal : soft, bowel sound normal, organomegaly -,

umbilical cord normal
 Anus : +
 Genitalia : male, testis +/+
 Extremities : cyanosis -, edem -, warm +, deformity –, CRT <
2 secs
 Skin : anemic -, icterus -, cutis -
 SC fetus
 Aterm neonates
 Neonatus with maternal HIV infection
 Risk of infection
 On OR
◦ Put baby on infant warmer
◦ Do suction, clear airway
◦ Dry baby
◦ Injected with vit K 1 mg IM
◦ Gentamicin eye ointment on the both eyes
◦ Keep baby warm
◦ Gastric lavage
 Zidofudin 2 x 15 mg PO
 Only formula milk 20-25 ml / 3 hour
 check CBC
 Pemeriksaan Hasil Satuan Nilai Rujukan Keterangan
WBC 16.08 10^3/uL 9.0-30.00
RBC 4.45 10^6/uL 4.80-6.90 L
HB 13.4 g/dL 18.00-26.00 L
HCT 37.8 % 42.00-64.00 L
MCV 117.8 fl 94.00-118.00
MCH 41.7 pg 31.00-37.00 H
MCHC 35.4 g/L 30.00-36.00
Trombosit 383 10^3/uL 200-400
RDW-SD 85 fL 37-54 H
RDW-CV 19.8 % 11.0-16.0 H
PDW 12.7 fL 9.0-17.0
MPV 11.1 fL 9.0-13.0
P-LCR 31.9 % 13.0-43.0
PCT 0.42 % 0.17-0.35 H
Neutrofil 55.6 % 40-80
Limfosit 31 % 20-40
Monosit 9.8 % 5-15
Eosinofil 2.9 % 0-4
Basofil 0.7 % 0-1
IG 3.6 % H
Eritrosit berinti 15 H
 SC fetus
 Aterm neonates
 Neonatus with maternal HIV infection
 Zidofudin 2 x 15 mg PO
 Only formula milk 20-25 ml / 3 hour
(60ml/kg/24 hours)
DISSCUSSION
 HIV/AIDS in Indonesia become one of health
problems that the incidents is getting higher
 It can occur at any age of life
 Based on data of health department about
169.000-216.000 cases in Indonesia, the ratio is
4,27 cases per 100.000 population
WHAT SHOULD WE DO????
 Prevention mother to child transmission :
◦ Effective approach
◦ It can reduce the incidence of children contracted
hiv from hiv mother
◦ >45 %  2%
Intrauterin Birth Post partum
PMTCT :
5-10 % 10-20% 5-20%
↓↓
transmisison
become 2 %

Maternal ARV
Maternal ARV + Baby ARV
SC Formula feeding
 PRINCIPLE :
IMMEDIATELY DO A HIV ANTIBODY TEST
ON MOTHER OR CHILD AS SOON AS
POSSIBLE AFTER BIRTH, IF MOTHER’S HIV
STATUS IS UNKNOWN

+ -

PMTCT
 The provision of nutrition depend on mother’s will
 AFASS :
◦ Acceptable
◦ Feasible
◦ Affordable
◦ Sustainable
◦ Safe
 Things that need to be considered:
◦ Nutrition management
◦ Prophylaxis ARV
◦ Prophylaxis opportunistic infections
◦ Immunization
◦ Monitoring growth and development
◦ Child’s hiv status
 Given immediately when exposure is known

 Zidovudine 4mg/kgbb/dose  2x1 after birth for

4-6 weeks.

 Golden period 6-12 hours after birth

 Co-trimoxazole  Sulfametoxazol(SMX) + Trimetropim
◦ Given everyday in every baby born to a mother with HIV
(+) since 4th-6th week or until the diagnosis of HIV is
established (at the 6th or 12th month)
◦ Dose : 6-8 mg TMP,kgbb/dose  1x1
◦ Dose Co-trimoksazol : 6-8 mg/kg/day
◦ < 6 month : 1 pediatric tablet
◦ 6 month – 5 year : 2 pediatric tablet
◦ 6 – 14 tahun : 1 adult tablet
◦ > 14 tahun : 1 adult forte tablet
 available :
◦ Suspension ( 200 mg SMX, 40 mg TMP)
◦ Pediatric tablet ( 100 mg SMX, 20 mg TMP)
◦ Adult tablet ( 400 mg SMX, 80 mg TMP)
 Every child born to a mother with HIV (+) must receive basic
immunization like any other normal child.
 Special attention to BCG vaccine is highly risk become "BCG
disease" in children who have HIV (+)
 KMS and WHO growth chart
4th – 6th week 4th – 6 th month 18th month
PCR RNA HIV PCR RNA HIV Antibodi HIV

- : BCG can
given
 Based on laboratories and presumtif
 “SMS” :
◦ SYNDROME  Risk Factor & WHO clinical syndrome
◦ MICROBIOLOGY  Virology test
 Viral cultur
 Spesific antigen  PCR DNA, PCR RNA, Antigen p24
◦ SEROLOGY  Antibody test
 VIROLOGY  age < 18 month
 14th -21st day
 4th – 6 th week
 4th – 6th month

 SEROLOGY  age > 18 month

 9th month (76%)
 12th month (96%)
 18th month (100%)
 PRESUMTIF DIAGNOSIS If there are 2 following
If there is one of the symptomps :
following criteria: -Oral thrush
- PCP, meningitis, -Severe pneumonia
cryptococcus, -Sepsis
candidiasis, esophagus -CD4 < 20%
- Toxoplasmosis -Maternal death related to
- Severe malnutrition that HIV or advance maternal
does not improve with HIV disease
standard treatment
 PMTCT

HIV (-) HIV (+)

1. Repeat RNA investigation

2. Continue co-trimoxazale
Follow up 3. ART conceling
4. Proper management
1. Assessment of clinical stages of HIV
2. Perform an immunologic status assessment
• <5 years: CD4 percentage
• > 5 years: CD4 value
3. Review the patient's family
• Health of other family members
• The value of family preparedness in initiating antiretroviral

therapy
 Klinis Stadium klinis WHO

asimtomatik 1
mild 2
moderate 3
severe 4

Always determined from the most severe clinical

 • NRTI
• AZT Zidovudine
• d4T Stavudine
• TDF Tenofovir
• 3TC
Lamivudine
• NNRTI
• NVP Nevirapine
• EPV Efavirenz

• 1st line: 2 NRTI + 1 NNRTI

• 1st step: Choose 3TC as the 1st choice
• 2nd step : Choose 1 NRTI and 1 NNRTI
 Zidovudine :
◦ 180-240 mg/m2/dose, 2x/hari
◦ Maksimal dose: 300 mg/dosis, 2x/hari
◦ Available : capsul 100mg, tablet 60 mg, tablet 300
mg
 Stavudine :
◦ 1 mg/kgbb/dose, 2x/day
◦ Maksimal dose 30 mg/dose, 2x/day
 Lamivudine :
◦ 4mg/kgbb/dose, 2x/day
◦ Maksimal dose 150mg/kgbb/dose, 2x/day
 Tenofovir : 8mg/kgbb/dose, 1x/day
 Nevirapine :
◦ < 8 year : 2oo mg/m2/dose, 2x/day
◦ > 8 year : 120-150 mg/m2/dose, 2x/day
◦ 2 week 1x1, continue 2x1
◦ Available : Tablet 200 mg
 Efavirenz : > 3 year or body weight> 10 kg
◦ 10-15 kg : 200 mg 1x1
◦ 15-<20kg : 250 mg 1x/day
◦ 20-< 25 kg : 300 mg, 1x/day
◦ 25-32,5 kg : 350 mg 1x/day
◦ 32,5 - <40 kg : 400 mg, 1x/day
◦ > 40 kg : > 40 kg/day