e. in a fetal medicine unit) has been considered. The evidence from prospective reports of first trimester ART exposure to the APR  does not support the need for increased surveillance with the most commonly prescribed therapies (listed in Appendix 4), although with newer medication the knowledge base is inevitably limited. APR reports on the frequency and nature of birth defects and ART are updated every 6 months (http://www.apregistry.com/). 7.1.2 The combined screening test for trisomy 21 is recommended as this has the best sensitivity and specificity and will minimize the number
of women who may need invasive testing. Grading: 2C Clinical selleck chemical Guidance 62 (CG62)  also recommends that all women should be offered screening for trisomy 21. The most effective screening is with the combined test at 11 + 0 to 13 + 6 weeks’ gestation. This includes maternal age, nuchal translucency, βHCG and pregnancy-associated plasma protein A. In the general population this has a detection rate of 92.6% with a false positive rate of 5.2% . For women who present too late for the combined test, the most clinically and cost-effective serum
screening test (triple or quadruple test) should be offered between 15 + 0 and 20 + 0 weeks . However, significantly increased levels of βHCG, α-fetoprotein and lower levels of UE3 (the elements of the http://www.selleckchem.com/products/pirfenidone.html ‘triple test’) have been observed in the HIV-positive population [[[#]Ent]211] while a reduction in βHCG in patients treated with PI-based  or with NNRTI-based HAART has been reported. As Down’s syndrome is associated with increased βHCG, theoretically, HIV infection per se may increase the false-positive rate in women and thus increase the number of invasive tests offered compared with the uninfected population. Pregnancy-associated plasma protein A and nuchal Silibinin translucency are unaltered by HIV infection or ART  and are thus the preferred screening modality. 7.1.3 Invasive prenatal diagnostic testing should not
be performed until after HIV status of the mother is known and should be ideally deferred until HIV VL has been adequately suppressed. Grading: 1C Limited data suggest amniocentesis is safe in women on HAART. There are minimal data on other forms of prenatal invasive testing. All clinicians performing a prenatal invasive test should know the woman’s HIV status, and if necessary delay the invasive test until the HIV result is available. Where possible, amniocentesis should be deferred until VL is <50 HIV RNA copies/mL. The fetal medicine team should discuss management with an HIV physician if the woman is HIV positive and has a detectable VL. 7.1.4 If not on treatment and the invasive diagnostic test procedure cannot be delayed until viral suppression is complete, it is recommended that women should commence HAART to include raltegravir and be given a single dose of nevirapine 2–4 h before the procedure.