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

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.
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U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
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