Population: Pregnant women with HIV infection.
Organizations
ACOG 2018, IDSA 2020
Recommendations
Evaluation
– Include in initial prenatal labs a quantitative HIV RNA (viral load) level and CD4 cell count with percentage, HIV viral load, and HCV antibody. If HIV RNA is detectable, perform HIV genotypic resistance testing to help guide antepartum therapy.
–Monitor plasma HIV ribonucleic acid (RNA) levels at the initial prenatal visit, 2–4 wk after initiating (or changing) combined antiretroviral therapy (cART) drug regimens; monthly until RNA levels are undetectable; and then at least every 3 mo during pregnancy.
Management
–Treat with cART during the antepartum period.
–Women on ART that was initiated before pregnancy should continue their current regimen even if the agents are not one of the preferred antiretroviral drugs for use during pregnancy.
–Initiate ART for treatment-naïve women, as early as possible to reduce the risk of transmission at the time of delivery. Delaying ART beyond 28 wk of gestation may not fully suppress HIV RNA by the time of delivery, increasing the risk of perinatal transmission.
–Target sustained maternal viral loads of 1000 copies/mL or less to minimize the risk of perinatal transmission independent of the route of delivery or duration of ruptured membranes before delivery.
–Offer scheduled prelabor cesarean delivery at 38-0/7 wk of gestation if viral loads >1000 copies/mL to reduce the risk of perinatal transmission.
–Screen for hepatitis A virus, tuberculosis, and Trichomonas vaginalis in addition to standard prenatal testing.
–Offer primary or booster doses of adult-type tetanus and reduced diphtheria toxoids (Td or TdaP), inactivated influenza vaccine, pneumococcal vaccine, hepatitis A vaccine, and hepatitis B vaccine.
–Counsel women with HIV regarding risk of breast milk transmission of HIV prior to delivery. In the United States, persons with HIV should avoid breastfeeding.
Practice Pearls
• Avoid methylergonovine for postpartum hemorrhage in women receiving a protease inhibitor or efavirenz.
• If women do not receive antepartum/intrapartum ART prophylaxis, infants should receive zidovudine for 6 wk.
• Infants born to women with HIV should have an HIV viral load checked at 14 d, at 1–2 mo, and at 4–6 mo.
• Screening for GDM is generally performed at the usual recommended gestational age of 24–28 wk. However, it is reasonable to perform testing earlier for women on protease inhibitors.
Sources
–Obstet Gynecol. 2018;132(3):e131-e137.
–Clin Infect Dis. 2020; ciaa1391.