A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

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A Guide to Primary Care of People with HIV/AIDS Chapter 12: Family Planning and Pregnancy 12 What pharmacologic interventions are recommended to reduce the risk of MTCT? ART should be offered to all HIV-infected pregnant women, and zidovudine chemoprophylaxis should be incorporated into the antiretroviral regimen to prevent perinatal transmission because safety and efficacy data are greatest for zidovudine (PHS, 2002) (see Pocket Guide Pregnancy Table 1). Zidovudine prophylaxis is associated with significant reduction in perinatal transmission that is independent of viral load (Sperling, 1996; Shapiro et al, 1999) and of zidovudine resistance (Eastman et al, 1998). Are there additional interventions to reduce the risk of MTCT and improve maternal/fetal health? When the woman is HIV positive there are interventions that can reduce the risk of MTCT. • Pregnant women with HIV should be counseled to refrain from cigarette smoking, injection and illicit drug use, and unprotected sexual intercourse with multiple sex partners. • STDs in pregnancy should be treated since they are associated with a higher risk of vertical transmission. Can cesarean section reduce the risk of MTCT? Elective cesarean section reduces the risk of perinatal transmission and should be offered at 38 weeks to pregnant women when the viral load is likely to be >1,000 c/mL at delivery (Dominguez, 2003). ACOG in a joint statement with the American Academy of Pediatrics (AAP) recommended offering HIV-positive pregnant women scheduled cesarean section at 38 weeks gestation (AAP, ACOG, 1999; CDC, 2001), rather than waiting until 39 weeks. There is no evidence of benefit of C-section after onset of labor, after rupture of membranes, or in women with viral loads of
A Guide to Primary Care of People with HIV/AIDS Chapter 12: Family Planning and Pregnancy The goals of ART during pregnancy are to: • optimize the health of the woman • protect the fetus from HIV • provide regimens that are neither toxic for the woman nor teratogenic for the fetus. Clinicians should discuss short- and long-term benefits and risks for both the woman and the fetus before initiating or modifying ART. Options should be presented in a non-coercive way, and the final decision always lies with the patient. A long-term plan should be developed, and the importance of adherence to ART should be stressed. What antiretroviral regimens are recommended for pregnant women with HIV? The use of the 3-part zidovudine (AZT) chemoprophylaxis regimen, alone or in combination with other antiretroviral agents, should always be offered and discussed with all infected pregnant women to reduce the risk of perinatal HIV transmission (see Pocket Guide Pregnancy Table 3). Any pregnant woman with HIV should be offered a treatment regimen that adheres to the currently recommended treatment for HIV-infected adults, which generally consists of 2 reverse transcriptase inhibitors into which zidovudine is incorporated, plus a protease inhibitor (see Pocket Guide Pregnancy Table 4). Efavirenz (EFV) is contraindicated in the first trimester because it has been associated with birth defects in a monkey model. Referral to providers who are experienced in the care of pregnant HIV-infected women is recommended. Are there special considerations when a woman already on ART becomes pregnant? When an HIV-infected women receiving ART is found to be pregnant after the first trimester she should be counseled to continue therapy. Zidovudine should be a component of the antenatal ART regimen after the first trimester whenever possible, although this may not always be feasible. A woman receiving ART whose pregnancy is recognized during the first trimester should be counseled regarding the benefits and potential risks of continuing ART during this period of organogenesis. As discussed above, efavirenz (EFV) is contraindicated in the first trimester. Also, dapsone, a folic acid antagonist, has been reported to increase the risk for neural tube defects. Maternal absorption and metabolism of protease inhibitors (PIs) change during pregnancy, and there are specific recommendations for dose adjustments of nelfinavir (NFV) (http://www.aidsinfo.nih.gov). What are some of the problems that may occur when antiretroviral agents are prescribed during pregnancy? Hyperglycemia and diabetic ketoacidosis have been reported with PI use during pregnancy. Therefore, pregnant women using PIs should be carefully instructed to watch for symptoms of hyperglycemia, and blood glucose levels should be closely monitored. Lactic acidosis is more common in the last trimester of pregnancy, and hepatic enzymes and serum electrolytes should be monitored frequently during the last trimester in pregnant women receiving nucleoside analogues. The combination of stavudine (d4T) and didanosine (ddI) in HIV-positive pregnant women is not recommended as it has been associated with maternal mortality from severe lactic acidosis. Hyperemesis gravidarum is a common complication of pregnancy. If a women needs to discontinue ART because of pregnancy-related hyperemesis, she should not restart medications until sufficient time has elapsed to ensure that the drugs will be tolerated; all drugs should be stopped at once and reintroduced simultaneously to reduce the potential for emergence of resistance. What medical and counseling interventions are appropriate for postpartum followup of women with HIV? Comprehensive care and support services, including primary, obstetric, pediatric, and HIV specialty care, family planning services, mental health and substance abuse treatment, and coordination of care through case management for the woman, her children, and other family members are important for women with HIV and their families. Maternal medical services during the postpartum period must be coordinated between the obstetric care provider and the HIV specialist. When treatment is required for the woman’s HIV infection, continuity of ART must be assured. What followup should be done for the infants of mothers with HIV? Infants of HIV-positive women on ART should be followed for potential side effects of antiretroviral medications even if the infants are HIV-negative; followup should continue into adulthood because of the theoretical concerns regarding potential carcinogenicity of the nucleoside analogue antiretroviral drugs. Infected children should be followed to determine their need for prophylactic treatment or ART, as well as to assess possible delays in growth and development. 12 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau 101
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