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Without intervention, the probability of HIV transmission from mother to child varies from less than 10% to over 60%, dependent on the quantity of freely circulating HIV in the plasma. The prevention of HIV transmission from mother to child is based on the perinatal administration of a combination of antiretroviral drugs (highly active antiretroviral therapy; HAART) to both mother and child. The value of elective caesarean section along with an effective treatment with HAART during the pregnancy is very limited. Exclusive breastfeeding does not lead to a higher HIV transmission than bottle-feeding, but this effect does not lead to a successful strategy. As prophylactic treatment with HAART is widely used, it can be assumed that, in general, the use of HAART during pregnancy is relatively safe. Whether the same is true for the use of specific, and often newer drugs, is frequently not known due to the scarcity of data. For pregnant women it is important to carefully monitor adverse effects such as hepatotoxicity during the first few weeks of treatment. The most important adverse effect for the pregnancy appears to be premature birth. Yet this only occurs if HAART has to be used throughout the entire pregnancy. In the neonate mitochondrial toxicity and haematological effects can occur. These appear to be clinically insignificant but longer term effects cannot be excluded. On the basis of the available long-term safety data for children, no single antiretroviral drug has proven safety.

A 34-year-old woman originally from Ghana was given efavirenz as antiretroviral therapy. One week later she was found to be in a psychotic state with paranoid hallucinations and anxiety; she then stabbed a nurse. The literature indicates that female patients of African origin appear to be more susceptible to the side effects of efavirenz due to genetically reduced clearance and therefore higher serum levels.

Since 1 January 2004, pregnant women in the Netherlands have been universally screened for HIV infection. Three HIV-infected, pregnant women aged 28, 24 and 33 years respectively, illustrate some of the problems that may be encountered in this situation, as well as the treatment options available to prevent the transmission of HIV from mother to child. The first patient had a positive antibody test early in pregnancy for which she did not need treatment, the second had a positive antibody test late in pregnancy and the third was seropositive and on medication, but had the wish to become pregnant. A vaginal delivery is possible when highly active antiretroviral therapy (HAART) of the mother is started in good time and the plasma HIV-RNA is < 400 copies/ml at the time of delivery. In this situation the risk of transmission is reduced to around 1%. However, if HIV infection is diagnosed late in pregnancy or, despite HAART, the plasma HIV-RNA is not expected to be < 400 copies/ml, an elective caesarean section is scheduled at 38 weeks of pregnancy. In all instances the neonate is treated for 28 days with antiretrovirals, as post-exposure prophylaxis. If a woman with a known HIV infection wants to become pregnant, the choice of antiretroviral regimen and when this is started is determined by her treatment history and the potential toxic effects of the medication on the foetus.

Objective: To assess the side effects, safety and efficacy of highly active antiretroviral therapy (HAART) in a cohort of HIV-infected pregnant women in the Netherlands., Design: Retrospective., Method: Data were collected from the medical records of HIV-infected pregnant women who received HAART during pregnancy in the period 1 January 1997-1 June 2003 at 14 HIV-specialized centres in the Netherlands. The inclusion criteria were at least a triple drug regimen and birth at 20 or more weeks of gestation. Information was collected about patient characteristics, HAART prescribed, side effects, viral load response, mode of delivery and HIV-status of the neonate., Results: A total of 267/413 women satisfied the inclusion criteria. Most women (n = 199) had not previously received anti-retroviral therapy and started HAART between weeks 21 and 28 of the pregnancy. The two most frequently used regimens contained nelfinavir (57%) or nevirapine (31%). Gastrointestinal side effects were more frequently observed in the nelfinavir group, while rash and hepatotoxicity were more frequently reported in the nevirapine group. Efficacy and pregnancy outcome were similar in both groups. Two infants (0.7%) were HIV-infected., Conclusion: HAART regimens containing nelfinavir or nevirapine in HIV-infected pregnant women were safe, effective and well tolerated.

The diagnosis of ascites can be made very likely by a good clinical history and a well-directed physical examination, if the patient suffers from a disease which can cause ascites. The physician should ask about recent weight gain, change in abdominal girth and ankle oedema. With a positive history, the likelihood of the presence of ascites may increase 3 to 4-fold. When the findings at physical examination are also positive, the likelihood may increase 10 to 20-fold. A fluid wave is the most specific but less sensitive symptom. Shifting dullness, bulging flanks and flank dullness are less specific but much more sensitive parameters. The presence of ascites is very unlikely if the prior probability is low and both the patient's answers and the findings at physical examination are negative. Abdominal ultrasound, the gold standard, is not strictly indicated for diagnosing ascites: if based on the trial tried: pretest probability, clinical history and physical examination, the diagnosis is very likely or very unlikely. Ultrasonography is always indicated, however, when ascites is suspected and a positive finding is of clinical relevance.

The accuracy of physical examination of the spleen was investigated in the literature. Ultrasonography or scintigraphy was used to test the findings at physical examination. Physical examination has a low sensitivity, but a reasonably good specificity. The interobserver variability is rather high. In general, palpation is more sensitive and specific than percussion. The findings of percussion improve the accuracy of palpation and the combination has a high specificity, of approximately 90%. The two should therefore be used in conjunction. The sensitivity is much lower although it is greatly influenced by the degree of splenic enlargement and the leanness of the patient.