Clinical Manual for Management of the HIV-Infected ... - myCME.com

3–32 | Clinical Manual for Management of the HIV-Infected Adult/2006
The USPHS Perinatal ARV Guidelines emphasize
that the PACTG 076 regimen is effective not only for
women whose clinical status is similar to that of the
participants in the original study, but also for women
with advanced HIV disease, low CD4 counts, and
previous ZDV therapy.
Because the goals of ART in a pregnant woman are
not only to maintain her health, but also to prevent
transmission to her infant, the considerations in ART
differ from those in nonpregnant adults. Because the
HIV viral load strongly influences the risk of HIV
transmission, a primary goal of therapy should be to
suppress the viral load to very low levels (preferably to
undetectable levels) during pregnancy and throughout
delivery; this goal guides treatment decisions. For
nonpregnant adults, the Guidelines for the Use of
Antiretroviral Agents in HIV-1-Infected Adults and
Adolescents recommend that treatment be deferred in
certain persons, depending on the CD4 cell count and
the HIV viral load. (See chapter Antiretroviral Therapy.)
In contrast, the USPHS Perinatal ARV Guidelines
recommend that all pregnant women, regardless of CD4
cell count, receive the 3-part ZDV prophylaxis regimen
used in PACTG 076, that is, ZDV orally (200 mg 3
times a day or 300 mg twice a day) beginning after the
first trimester, intravenous ZDV during labor, and ZDV
given orally to the newborn for 6 weeks. The guidelines
also recommend that women with an HIV RNA level
>1,000 copies/mL (regardless of CD4 cell count) or
with immunologic, virologic, or clinical indications for
treatment be offered a combination ART regimen that
includes ZDV and other ARV drugs. Even women
with HIV RNA levels 1,000 copies/mL in
the weeks before delivery, should be counseled about
the risks and benefits of cesarean section. A planned
cesarean section should be scheduled for 38 weeks’
gestation, because the benefits of cesarean section
once the membranes have ruptured are unknown.
Intravenous ZDV should be started 3 hours before the
scheduled cesarean section. Prophylactic antibiotics
are recommended at the time of cesarean section in
HIV-infected women, to decrease the risk of maternal
infection. The USPHS Perinatal ARV Guidelines outline
4 scenarios in which the clinician must decide whether
cesarean section is needed (Table 4). The data on the
benefits of cesarean section are complex and must be
balanced with the increased risk to the mother after
surgery. The clinician may want to consult an obstetric/
HIV specialist to discuss specific situations.
Questions remain about the management of labor when
a vaginal delivery is planned. Because the duration
of ruptured membranes is a risk factor for perinatal
transmission, pregnant women with HIV infection
should be counseled to go to a hospital for care at
the first signs of labor or rupture of membranes. If
the membranes rupture spontaneously before labor
occurs or early in labor, the clinician should consider
interventions to decrease the interval to delivery, such as
administration of oxytocin. Procedures that increase the
neonate’s exposure to maternal blood, such as the use
of scalp electrodes or artificial rupture of membranes,
should be avoided.