Care of HIV-Infected Pregnant Women

Background

This chapter describes the elements involved in caring for the pregnant woman with HIV infection, whether the woman was known to be HIV infected before conception or was found to be HIV infected during pregnancy. It is not intended to be a comprehensive discussion of this topic, and an HIV-experienced obstetrician and an HIV specialist should be involved in the management of all HIV-infected pregnant women. For centers that do not have HIV specialists available, experts at the National Perinatal HIV Consultation and Referral Service are available for consultation through the Perinatal HIV Hotline (888-448-8765).

The goals of HIV management during pregnancy are to maintain and support the woman's health, provide optimal antiretroviral treatment (ART) to preserve or restore her immune system and suppress viral replication, and to offer interventions that decrease the risk of perinatal HIV transmission. According to the U.S. Department of Health and Human Services perinatal guidelines, Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States, all HIV-infected pregnant women should be given ART during pregnancy to prevent mother-to-child transmission of HIV, and ART also is recommended for all women for their own health, regardless of pregnancy status (see chapter Reducing Maternal-Infant HIV Transmission).

The first task in caring for an HIV-infected woman who is pregnant or considering pregnancy is to provide counseling that will allow her to make informed reproductive choices. Taking a careful reproductive history and providing preconception counseling should be part of any woman's routine primary care. To make informed choices about pregnancy, the patient needs education and information about the risk of perinatal transmission of HIV, potential complications of pregnancy, continuation or modification (or possibly, initiation) of ART, and the support she will need to optimize maternal and fetal outcomes. See chapter Health Care of HIV-Infected Women Through the Life Cycle for a more detailed discussion of preconception evaluation.

An appropriate ART regimen should be started before pregnancy to attain a stable, maximally suppressed maternal viral load prior to conception. This will support the woman's own health and greatly reduce the risk of HIV transmission either to a fetus or to a sex partner. Antiretroviral (ARV) resistance testing should be performed before ART is initiated. For women who intend to conceive, particular ARVs should be avoided, including those with increased risk of causing teratogenicity (e.g., efavirenz) or metabolic complications such as lactic acidosis (e.g., didanosine and stavudine). see chapter Reducing Maternal-Infant HIV Transmission. It should be noted that most fetal organogenesis occurs in the early weeks of pregnancy, before most women know that they are pregnant. Thus, any medication with potential teratogenicity or fetal toxicity, whether an ARV or another drug, should not be administered to women who intend to become pregnant or may become pregnant. Certain medications (e.g., ribavirin) also should be avoided by male partners of women who may become pregnant.

Folate supplementation to reduce the risk of neural tube defects in the developing fetus should be started at least 1 month before conception, if possible, because the neural tube forms in the early weeks of pregnancy (see below).

Evaluation and Counseling of Pregnant Women

All HIV-infected pregnant women should receive thorough education and counseling about perinatal transmission risks, strategies to reduce those risks, and potential effects of HIV infection or HIV treatment on the course or outcomes of pregnancy.

  • The goals of therapy for pregnant women receiving ART, as for all persons being treated for HIV infection, are to suppress the HIV viral load maximally (preferably to undetectable levels) for as long as possible, to improve quality of life, to restore or preserve immune function, and to prevent transmission to sexual (or injection drug equipment-sharing) partners. For pregnant women, an additional, and critical, goal is to reduce the risk of perinatal transmission as much as possible.
  • Therapy-associated adverse effects, including hyperglycemia, anemia, and hepatic toxicity, may have a negative effect on maternal and fetal health outcomes. Pregnant women should be advised about possible ARV-related adverse effects and should be monitored regularly for these events.
  • HIV-infected women should receive evaluation and appropriate prophylaxis for opportunistic infections (OIs), as well as the vaccinations indicated for persons with HIV infection (see below).
  • Some medications, both ARVs and other drugs, may cause fetal anomalies or toxicity when taken during pregnancy. These should be avoided in pregnant women, unless the anticipated benefit outweighs the risk. Consult with an HIV or obstetric specialist, a pharmacist, or the drug labeling information before prescribing medications for pregnant women.
  • Options for mode of delivery should be discussed early. The benefits and risks of vaginal vs. cesarean delivery are outlined in the perinatal guidelines. If the HIV viral load is >1,000 copies/mL at 36 weeks of pregnancy, a scheduled cesarean delivery at 38 weeks' gestation is recommended to further reduce the risk of transmission.

Other evaluation and support measures for pregnant women should include the following:

  • Screening for other potential maternal health problems, such as diabetes and hypertension
  • Maternal nutritional evaluation and support, including initiation of a prenatal multivitamin containing folate (0.4 mg PO QD) to reduce the risk of fetal neural tube defects; for women receiving trimethoprim-sulfamethoxazole, some experts recommend higher folate doses in the first trimester; consult with an HIV-experienced obstetric specialist.
  • Screening for psychiatric and neurologic disease
  • Counseling about the risks of tobacco smoking; smoking cessation support as indicated (see chapter Smoking Cessation)
  • Counseling about the risks of alcohol or drug use and support for discontinuation of these activities as needed
  • Intimate partner violence screening
  • Review of medications, including over-the-counter and nutritional agents, and discontinuation of medications with the potential for fetal harm
  • Immunizations (e.g., influenza, Tdap, hepatitis B) as indicated
  • Institution of the standard measures for evaluation and management (e.g., assessment of reproductive and familial genetic history, screening for infectious diseases or sexually transmitted diseases [STDs])
  • Planning for maternal-fetal medicine consultation, if desired or indicated
  • Selection of effective and appropriate postpartum contraceptive methods, if desired

Comprehensive Care of Pregnant Women with HIV Infection

Comprehensive care is important for pregnant women with HIV infection to achieve a healthy pregnancy and delivery. A multidisciplinary approach is the most effective way to address the medical, psychological, social, and practical challenges. For example, while her medical care is being managed by her obstetrician and an HIV specialist, the pregnant woman may need help from a social worker to find appropriate social services for food, housing, child care, and parenting issues. The pregnant woman may need counseling and psychological support for herself and her partner, as well as referrals for substance abuse and detoxification programs. Peer counselors may be of particular assistance. Some patients may need legal or domestic violence services during and after pregnancy. Cooperation and communication between the obstetrician or nurse/midwife and the primary HIV provider are imperative throughout the pregnancy and early postpartum period. Referral to a maternal-fetal medicine specialist may be needed in complicated obstetric cases.

Prenatal Care

All pregnancy-related complications seen in HIV-uninfected women, such as hypertensive disorders, ectopic pregnancy, psychiatric illness, multiple gestation, preterm delivery, and STDs, also can occur in HIV-infected women. These problems must be recognized quickly and treated appropriately to avoid life-threatening complications. Ideally, HIV-infected pregnant women are managed by both an experienced obstetrician-gynecologist and an HIV specialist. Communication between these specialists about medications, expectations, and complications is vital for the health and well-being of both mother and baby. If complications occur or abnormalities are detected, they should be evaluated and treated as indicated by the condition, and referral should be made to a maternal-fetal medicine specialist, if possible. Antenatal fetal surveillance and testing to identify fetal abnormalities should be carried out using guidelines established by the American College of Obstetricians and Gynecologists.

The suggested testing and monitoring practices for pregnant women with HIV infection, from the first trimester to labor and delivery, are presented in Tables 1 and 2.

Table 1. Recommended Evaluation and Routine Monitoring of the Pregnant Woman with HIV Infection
EvaluationFrequency
History
HIV HistoryDate of diagnosisInitial
Signs and symptomsInitial and at every visit
Nadir CD4 and current CD4 cell count; HIV viral loadInitial
ARV history, including regimen efficacy, toxicity, and ARV resistanceInitial
Opportunistic infections and malignanciesInitial and at every visit
History of STDsInitial
AdherenceInitial and at every visit
Obstetric HistoryNumber of pregnancies; complications and outcomes (GPAL [gravida, para, abortion, living children]); mode of deliveriesInitial
History of genetic disordersInitial
Use of ARV prophylaxis during previous pregnanciesInitial
HIV status of childrenInitial
Current PregnancyLast menstrual period (LMP)Initial
Pregnancy: intended or notInitial
Contraceptive methods used, if anyInitial
Gestational age (can be calculated in a woman with regular menses by counting weeks from LMP)Initial and at every visit
Estimated date of deliveryInitial
Signs or symptoms of maternal complications: elevated blood pressure, headache, significant edema, gastrointestinal or genitourinary symptoms, vaginal discharge or bleeding, decreased fetal movement (fetal movement is usually first detected at 18-24 weeks of pregnancy)Initial and at every visit
Screen for depressionInitial
Screen for intimate-partner violenceInitial and at every visit
Physical Examination
GeneralVital signs and weightInitial and at every visit
Funduscopy, breast examinationInitial and as indicated
Gynecologic/Obstetric (usually performed by the obstetric provider)Pelvic examination, STD screening, examination for perineal or vaginal lesions (discoloration, condyloma, ulcerative lesions, vaginal discharge), cervical lesions, discharge or bleedingInitial and as indicated
Fundal height, correlating with gestational age (concordant between 18 and 30 weeks)Every visit starting the second trimester
Fetal heart beat and rate: may be audible with Doppler devices as early as 12 weeksInitial and at every visit
Fetal movements and position in third trimesterEvery visit starting at 24 weeks
Laboratory and Other Studies
HIVHIV antibody test (if not already documented)Initial
HIV viral load and CD4 count (total and percentage); results obtained at 35-36 weeks guide decisions on the mode of deliveryViral load at initial visit, 2-4 weeks after starting or changing ART, every 4 weeks until undetectable, then at least every 3 months

CD4 count at initial visit and at least every 3 months

Genotype if ARV naive or detectable HIV RNA while on ARTInitial and as indicated
Cytomegalovirus (CMV) immunoglobulin G (IgG)Initial
Toxoplasma IgGInitial
G6PD level in appropriate ethnic or racial groups if PCP prophylaxis with dapsone is anticipatedInitial
GeneralComplete blood count (CBC)Initial and every 3 months or more frequently, based on ARV regimen or symptoms; check weeks 24-28
Chemistries, liver enzymes (LFTs)Initial and every 3 months or more frequently, based on ARV regimen or symptoms

If on NRTIs, monitor electrolytes and hepatic enzymes monthly in third trimester

Fasting lipids and glucoseInitial and as indicated
Blood groupIndicated
Rh antibody screenIndicated
Pregnancy SpecificUltrasoundFirst trimester: confirm gestational age and potential timing for cesarean delivery if necessary

Second trimester: assess fetal anatomy for women on combination ART during first trimester

Screening for chromosomal abnormalitiesScreen for neural tube and abdominal wall defect, trisomy 21, and trisomy 18; first-trimester testing may include laboratory and ultrasound exam, whereas patients in their second trimester are evaluated by multiple marker screening

Abnormal result requires further investigation - consider amniocentesis only if abnormality is detected on multiple marker screening or level-2 sonogram and the woman is on suppressive ART (to decrease risk of HIV transmission); voluntary and requires counseling

Diabetes screeningConsider at 20 weeks; check glucose 1 hour after 50 g glucose load; perform 3-hour glucose tolerance test if screen is abnormal

If 3-hour test result is abnormal, perform regular glucose monitoring, especially in women taking protease inhibitors (PIs)

Rubella antibodyInitial
Varicella IgG for those without history of chickenpox or shinglesInitial
Screening for syphilis: rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL)Initial and during weeks 32-36
Consider bacterial vaginosis (BV) screening (BV increases risk of preterm labor)Week 24-28
Screening for streptococcus B (if result is positive, intrapartum chemoprophylaxis is indicated)Week 32-36
Screening with herpes simplex virus-2 serology in high-risk patients is recommended by some expertsInitial
Urinalysis and clean-catch urine cultureInitial and as indicated
Papanicolaou testInitial and as indicated (colposcopy is done on pregnant women, but biopsy is avoided; management resumes postpartum, after the 6-week postpartum visit)
Hepatitis SerologiesHepatitis A virus (HAV) antibody (IgG)Initial
Hepatitis B virus (HBV): HBsAg, HBcAb , HBsAbInitial
Hepatitis C virus (HCV) antibodyInitial
TB ScreeningTuberculin skin test (purified protein derivative [PPD]), more reliable if CD4 count is >200 cells/µL (induration >5 mm is positive); or interferon-gamma release assay (IGRA); note there is limited experience with IGRAs in pregnant womenInitial
Disease SpecificConsider hemoglobin electrophoresis, if anemic or at increased risk of hemoglobinopathiesInitial
Serum screening for Tay-Sachs disease - both partners - if at increased riskInitial
Urine toxicology screenInitial and as indicated
Table 2. Recommended Evaluation and Routine Monitoring of the Pregnant Woman with HIV Infection: Labor and Delivery
TestComment
Record Review
  • Documentation of HIV serostatus, blood type and Rh, hepatitis serologies, RPR
  • Review of ART, if any, during pregnancy
  • Review of HIV viral load results during pregnancy
Physical Evaluation
  • Vital signs and fetal heart rate
  • Frequency and intensity of contractions
  • Fetal lie, presentation, attitude, and position
  • Vaginal examination: rule out HSV lesions; detect ruptured membranes; determine cervical effacement, dilatation, and position
  • Avoid procedures that increase risk of perinatal HIV transmission (e.g., fetal scalp electrodes, scalp sampling, or assisted rupture of membranes)
Admission Laboratory Tests
  • Complete blood count
  • Liver function tests
  • RPR or VDRL, if not done recently
  • Repeat hepatitis B and C testing, if at risk of acquisition of hepatitis B or C, to prevent perinatal transmission of these infections
  • Others, as required by specific state laws

Immunizations and Opportunistic Infection Prophylaxis

Immunizations During Pregnancy

Generally, immunizations should be given before pregnancy, if possible. However, immunizations should be considered during pregnancy when the risk of exposure to an infection is high, the risk of infection to the mother or fetus is high, and the vaccine is unlikely to cause harm. The inactivated influenza virus and Tdap vaccines both meet this criteria and are generally recommended during pregnancy, as are certain others (see Table 3). Some vaccinations (particularly live-virus vaccines such as measles/mumps/rubella and varicella vaccines) are contraindicated, and others should be given only if the anticipated benefit of the vaccination outweighs the risk. Special considerations for immunizations in HIV-infected individuals are discussed in chapter Immunizations for HIV-Infected Adults and Adolescents.

Because vaccinations may cause a transient increase in the HIV viral load and theoretically may increase the risk of perinatal HIV transmission, vaccination should be given after pregnant women are on ART.

Table 3. Immunizations and Postexposure Prophylaxis in Pregnant Women with HIV Infection
ImmunizationComment
Hepatitis A virus (HAV)Recommended for susceptible patients at risk of becoming infected, those with chronic HBV or HCV, those traveling to endemic areas, injection drug users, and those in the setting of a community outbreak.
Hepatitis B virus (HBV)Generally recommended for susceptible patients at risk of HBV infection during pregnancy.
Human Papilloma Virus (HPV)Not recommended during pregnancy.
InfluenzaInactivated influenza vaccine is recommended for all pregnant women, before or during flu season. Live attenuated vaccines should not be used.
Measles/Mumps/Rubella (MMR)Contraindicated.
PneumococcusGenerally recommended. Limited data on safety during pregnancy for both the PPSV23 and PCV13 vaccines: no reports of adverse effects with PPSV23; limited experience with PCV13.
Tetanus-diphtheria-pertussis (Tdap)Recommended during each pregnancy. Can be given at any time in pregnancy, but optimally between 27 and 36 weeks' gestation (to maximize maternal antibody response and passive antibody transfer to the infant).

In addition, family members and caregivers should receive Tdap vaccination.

Varicella
  • Primary vaccination
  • Zoster vaccination
Contraindicated
Immune globulins
(for postexposure prophylaxis in susceptible individuals)
MeaslesRecommended after measles exposure.
Hepatitis ARecommended after exposure (close contact or sex partner), or in case of travel to endemic areas.
Varicella-zoster virus immune globulin (VariZIG)Recommended for susceptible individuals after close contact with someone with varicella or herpes zoster (give as soon as possible, and within 10 days of exposure).
Hepatitis B immune globulin (HBIG)Recommended for susceptible individuals after needlestick or sexual exposure to a person with hepatitis B infection.

Opportunistic Infection Prophylaxis

Some OIs can have an adverse effect on pregnancy. In turn, pregnancy can affect the natural history, presentation, treatment, and significance of some OIs. Women should be monitored carefully for OIs during pregnancy, with special attention given to nonspecific symptoms such as fatigue, back pain, and weight loss, which may be attributable to HIV-related illness rather than to pregnancy. Respiratory symptoms in particular merit rapid, aggressive investigation. Clinicians should follow the most current recommendations of the U.S. Centers for Disease Control and Prevention (CDC), National Institutes of Health, and Infectious Diseases Society of America, Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents, which give special consideration to pregnant women for each OI discussed. The indications and recommendations for OI prophylaxis generally should follow the guidelines for adults (see chapter Opportunistic Infection Prophylaxis). However, because of the risks of teratogenicity or harm to the developing fetus, some drugs routinely used for prophylaxis of OIs in nonpregnant adults are contraindicated during the first trimester of pregnancy, whereas others should not be used at any time during pregnancy.

Special Considerations for OI Prophylaxis During Pregnancy

Trimethoprim-sulfamethoxazole use

In pregnant women, folate deficiency increases the risk of neural tube defects in the developing fetus. Trimethoprim inhibits the synthesis of metabolically active folic acid and thus increases the risk of folate deficiency and congenital anomalies. Pregnant women, or women who may become pregnant, who are taking trimethoprim-sulfamethoxazole (TMP-SMX, Septra, Bactrim, cotrimoxazole) should be given folate supplementation to reduce the risk of neural tube defects. However, folate also counteracts the activity of TMP, and may compromise the therapeutic efficacy of TMP-SMX.

The recommended dosage of folic acid usually is 0.4 mg/day, but the optimal dosage in women on TMP-SMX is not clear. Some experts recommend higher dosages during the first trimester, when the fetus is at greatest risk for teratogenic effect.

TMP-SMX is the recommended drug for women who require prophylaxis against PCP during pregnancy; alternatives to TPM-SMX during first trimester include aerosolized pentamidine and atovaquone.

Genital herpes

Women with HIV infection are more likely than HIV-uninfected women to experience outbreaks of genital herpes. If HSV is transmitted to the infant, neonatal infection can be severe, even if it is detected and treated early. In addition, there is increased genital shedding of HIV in those with active genital HSV lesions though it is not known whether this remains true in women treated with effective ART. Some experts recommend obtaining HSV-2 serologies in a woman whose clinical history is unclear. Treatment for symptomatic HSV infections should be offered during pregnancy, and suppressive therapy should be given to women with frequent recurrences. Suppressive therapy with acyclovir or valacyclovir also should be offered to any woman with an HSV recurrence during pregnancy, starting at 36 weeks' gestation. If a woman has an active outbreak of genital HSV or experiences prodromal symptoms at the time of labor or membrane rupture, delivery by cesarean section is indicated. Prophylaxis for pregnant women who are seropositive for HSV-2 but who do not have a history of genital lesions is not recommended.

Tuberculosis

Prophylaxis is recommended for any woman with a positive PPD skin test result (≥5 mm induration), a positive IGRA result, or a history of exposure to someone with active tuberculosis, after active disease has been ruled out. Patients receiving isoniazid also should receive pyridoxine to reduce the risk of neurotoxicity.

Toxoplasmosis

All HIV-infected persons should be tested for IgG antibodies to Toxoplasma soon after HIV diagnosis, and this should be a part of antenatal testing for pregnant women with HIV infection. Women with a negative IgG titer should be counseled to avoid exposure to Toxoplasma (e.g., by avoiding raw or undercooked meats, unwashed or uncooked vegetables, and cat feces). Women with previous exposure to Toxoplasma (positive IgG titer) should be given prophylaxis during pregnancy, if the CD4 count is <100 cells/µL. For women who require prophylaxis, TMP-SMX is the preferred agent (see considerations for TMP-SMX, above).

HIV-infected pregnant women who have evidence of primary or reactivated Toxoplasma infection should be managed by a specialist.

Antiretroviral Therapy

The current HHS guidelines recommend treating HIV infection in all pregnant women, using the same principles and modalities as used for nonpregnant individuals. HIV-infected pregnant women should receive potent combination ART regimens comprising at least three ARVs. The choice of ARV regimen should be based on what is likely to be optimal for the woman's health, the potential effect on the fetus and infant, resistance test results, the woman's previous experience, if any, with ART, and her stage of pregnancy. ARV resistance testing should be performed before initiating or changing therapy, but should not delay the initiation of ART in late stages of pregnancy. Combination ART in pregnancy should include ZDV or another NRTI with good placental passage. ARV agents with potential teratogenic effects should be avoided in the early weeks of pregnancy (however, efavirenz may be continued during pregnancy, provided the regimen is tolerated and is providing effective virologic control). Women who have very high CD4 cell counts and are taking ART only for the prevention of perinatal transmission may delay initiation of therapy until after the first trimester, though effectiveness in preventing transmission may be decreased. For women already taking ART at the time they become pregnant, the regimen should be reevaluated for its appropriateness during pregnancy to avoid potentially toxic medications and to ensure maximal virologic suppression. Generally, any ART regimen that is effective and tolerated by the woman may be continued during pregnancy. If necessary, the ART regimen may be changed but therapy should continue without interruption. Discontinuation of ART could lead to an increase in viral load, which could result in a decline in immune status and an acceleration of disease progression, thereby increasing the risk of HIV transmission to the fetus.

For further information about ART during pregnancy, see chapter Reducing Maternal-Infant HIV Transmission and the HHS Perinatal ARV Guidelines. The guidelines include recommendations regarding ARV regimens, modes of delivery (vaginal vs. cesarean section), and potential adverse events, as well as a detailed discussion of individual ARV agents. Additionally, the treatment of pregnant women with HIV/HBV coinfection and HIV/HCV coinfection is discussed.

Antiretroviral Pregnancy Registry

To improve tracking of pregnancy-related adverse events and fetal effects, an Antiretroviral Pregnancy Registry has been established as a collaborative project among the pharmaceutical industry, pediatric and obstetric providers, the CDC, and the National Institutes of Health. The registry collects observational data on HIV-infected pregnant women taking ARV medications to determine whether patterns of fetal or neonatal abnormalities occur. Pregnant women taking ARVs can be placed in this confidential follow-up study by calling 800-258-4263, 8:30 a.m. to 5:30 p.m. eastern time; the fax number is 800-800-1052. Information is confidential and patients' names are not used. Providers are encouraged to add to the available information on fetal risk by using this registry at first contact with a pregnant woman receiving ART. More information can be obtained at www.APRegistry.com.

Pregnancy-Specific Complications and Management

Nutrition risk and inadequate weight gain

Maternal nutrition and weight must be monitored throughout the pregnancy. A food diary may be a useful tool in assessing intake, and nutritional counseling is recommended.

Nausea and vomiting

Women with signs of dehydration should be assessed and treated appropriately in collaboration with the obstetrician or nurse/midwife. Any medication used for nausea and vomiting must be assessed for drug-drug interactions with all HIV-related medications the patient is taking.

Hyperglycemia

Pregnancy is a risk factor for hyperglycemia, and women treated with PIs may have an even higher risk of glucose intolerance than other pregnant women and must be monitored carefully. New-onset hyperglycemia and diabetes mellitus, and exacerbation of existing diabetes, all have been reported in patients taking PIs. Clinicians should educate women taking PIs about the symptoms of hyperglycemia and closely monitor glucose levels. Women with HIV-infection should receive standard glucose screening at 24-28 weeks' gestation. Women who were taking a PI-based regimen prior to pregnancy may be screened earlier according to recommendations for women at high risk of glucose intolerance. The newborn should be checked for neonatal hypoglycemia at 1 and 4 hours after birth.

Lactic acidosis

Lactic acidosis is a rare but life-threatening complication that has been reported in pregnant women taking nucleoside reverse transcriptase inhibitors, particularly didanosine and stavudine. The combination of didanosine and stavudine should be avoided during pregnancy. Clinical suspicion of lactic acidosis should be prompted by vague symptoms such as malaise, nausea, or abdominal discomfort or pain. Hyperbilirubinemia

Women taking atazanavir or indinavir frequently develop elevated indirect bilirubin, but it is not known whether treatment during pregnancy exacerbates physiologic hyperbilirubinemia in newborns. Women who are taking indinavir may have an increased risk of nephrolithiasis, but evidence of harm to their newborns has not been demonstrated. Indinavir should be used during pregnancy only when preferred and alternative agents are not acceptable, and it must be boosted with low-dose ritonavir.

Pain management

Pain management during labor and delivery may be complicated by drug interactions with ARV agents and by the higher medication tolerance in women who have addictions. Additional pain medication may be needed for women with histories of drug use.

Invasive perinatal procedures

The risk of HIV transmission to the fetus during invasive procedures (e.g., amniocentesis, chorionic villus sampling, and percutaneous or umbilical cord blood sampling) must be weighed carefully against the possible benefits of these procedures. Current HHS guidelines suggest that women undergoing such procedures should be on effective ART, preferably with undetectable HIV RNA. The use of fetal scalp electrodes and artificial rupture of membranes should be avoided if possible, and forceps or vacuum extractors and episiotomy should be used only if there are clear obstetric indications.

Postpartum considerations

Because HIV can be transmitted to the infant through breast-feeding, breast-feeding is contraindicated in the United States and other resource-adequate countries where safe replacement feeding is available. Breast-feeding information should be removed from patient educational material pertaining to labor and delivery. Lactation suppression techniques can be used as needed to reduce lactation discomfort. Clinicians should recognize that women in some cultural groups are expected to breast-feed and they may need additional support to use formula rather than breast-feed.

ART should be continued, unless the woman refuses ARVs. Maternal and infant medication adherence must be discussed with the new mother. Adherence barriers for the mother during the postpartum period may be different from those during pregnancy (e.g., because of changes in daily routine, sleep/wake cycles, and meals).

New mothers should be observed carefully for signs of bleeding or infection.

If the mother's glucose tolerance test result was abnormal during pregnancy, she should be reevaluated 6-12 weeks postpartum and should be screened yearly for diabetes.

At the infant's 2-week follow-up visit, the HIV pediatric clinician should address the mother's concerns, screen for postpartum depression, assess adherence to her own and the infant's ARV medications, and ensure follow-up for the 6-week postpartum visit with the obstetric provider and soon thereafter with the primary HIV care provider. These visits provide an opportunity to address the woman's contraceptive needs and options, if this was not done previously (see chapter Health Care of HIV-Infected Women Through the Life Cycle).

Contraception

Many contraceptive choices are available for HIV-infected women; considerations are discussed in chapter Health Care of HIV-Infected Women Through the Life Cycle. Consistent condom use should be emphasized, and for women who wish to avoid pregnancy a "dual-protection" strategy, condom use plus another method of birth control, should be emphasized. This strategy effectively prevents pregnancy, prevents transmission of HIV to sex partners, and prevents the acquisition of sexually transmitted diseases. It is important to provide women with all contraceptive options including long-acting reversible contraceptive methods such as the intrauterine device and implants.

Patient Education

  • Reinforce regularly and clearly the notion that, when the mother cares for herself, she is caring for her infant. Talk with the patient about stress, the importance of adequate mild-to-moderate exercise, and sufficient rest.
  • Emphasize that regular prenatal care is extremely important to prevent complications of pregnancy.
  • Use of a prenatal vitamin supplement is important, but cannot replace healthy food intake. Develop a plan with the patient for attaining the desired weight gain during pregnancy, while maintaining a healthy nutritional intake.
  • Cigarette, alcohol, and drug use contribute to poor maternal nutrition and can harm the developing fetus. Illicit drug use increases the risk of transmitting HIV to the infant. Injection drug use can transmit HBV, HCV, and CMV to the mother and to the baby. Encourage cessation of cigarette, alcohol, and drug use, and offer referrals for treatment, as needed.
  • Be sure the woman understands all planned procedures and treatments and understands their potential risks and benefits both to herself and to the fetus.
  • Discuss the risks and benefits (to the woman and fetus) of each medication to be taken during pregnancy, including those for which there are limited data on teratogenicity.
  • Discuss ART as a benefit to the woman's health and as part of the strategy to reduce the risk of perinatal HIV transmission to the fetus or newborn. Also discuss the effect of ART on reducing risk of HIV transmission to sex partners.
  • For women at risk, diligent use of "safer sex" during pregnancy is important for preventing infection with STDs and CMV, which can cause more complications when HIV is present. STDs can harm fetal development and may increase the risk of HIV transmission to the baby. New genital herpes infections during pregnancy can cause severe complications and even death in neonates.
  • For women with negative Toxoplasma titers, explain the need to avoid undercooked meat, soil, and cat feces.
  • Teach the pregnant woman how to obtain medical attention quickly at the first signs of OI or other complication. Discuss what to watch for and how to get help when emergencies arise in the evenings or on weekends or holidays.
  • Help the patient clarify her child care options and support systems for raising a family.

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Abbreviations for Dosing Terminology

BID
twice daily
BIW
twice weekly
IM
intramuscular (injection), intramuscularly
IV
intravenous (injection), intravenously
PO
oral, orally
Q2H, Q4H, etc.
every 2 hours, every 4 hours, etc.
QAM
every morning
QD
once daily
QH
every hour
QHS
every night at bedtime
QID
four times daily
QOD
every other day
QPM
every evening
TID
three times daily
TIW
three times weekly