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

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 Hotline (888-448-8765).
The first task in caring for an HIV-infected woman
who is pregnant or is 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 possible
initiation) of antiretroviral therapy (ART), and the
support she will need to optimize maternal and fetal
outcomes.
The goals of HIV management during pregnancy are
to maintain and support the woman’s health, provide
optimal ART to preserve or restore her immune
system and suppress viral replication, and offering
interventions that decrease the risk of perinatal HIV
transmission. ART has proven highly effective in
preventing mother-to-child HIV transmission. After
the results of the Pediatric AIDS Clinical Trial Group
study 076 were released in 1994, ART tailored to the
specific patient has been recommended to decrease
perinatal transmission and optimize outcomes (see
chapter Reducing Maternal-Infant HIV Transmission).
In the United States, ART should be offered according
to the U.S. Public Health Service (USPHS) Task Force
guidelines (see “Antiretroviral Therapy” below).
Section 3—Antiretroviral Therapy | 3–39
Preconception Evaluation of the HIV-Infected Woman
Ideally, the evaluation of reproductive issues with an
HIV-infected woman begins before pregnancy. The
preconception evaluation should include the following
elements:
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Reproductive history, including number of
pregnancies, number of partners, pregnancies with
each partner, and outcomes of each pregnancy
Length of relationship with current partner, HIV
serostatus of partner, and couple's sexual history,
including condom use and sexual decision making or
control of reproductive choices
Patient's and partner's reproductive desires, and
discussion of options
Any history of infertility or low fertility in either the
patient or her partner also should be evaluated and
discussed, including current information on gamete
donation, other assisted reproductive techniques, and
adoption. For a woman (or a couple) who has decided
to try to conceive, several issues must be considered.
Prominent among these is the HIV serostatus of both
partners. If HIV infection is present in only one of
the partners, the risk of transmission to the uninfected
partner and techniques to minimize the risk should be
discussed. (For further discussion and patient-education
materials for HIV-discordant couples, see Aaron and
Mercurius in “References” below.)
If ART is indicated, an appropriate regimen should be
started before pregnancy, avoiding agents with increased
risk for teratogenicity (eg, efavirenz), hepatotoxicity
(eg, nevirapine), or metabolic complications such
as lactic acidosis (eg, didanosine, stavudine, and
zalcitabine). See chapter Reducing Maternal-Infant
HIV Transmission and the Public Health Service Task
Force Recommendations for Use of Antiretroviral Drugs
in Pregnant HIV-1-Infected Women for Maternal Health
and Interventions to Reduce Perinatal HIV-1 Transmission
in the United States. Centers for Disease Control and
Prevention. October 12, 2006. (http://aidsinfo.nih.gov/
Guidelines/GuidelineDetail.aspx?GuidelineID=9) for
further information. It should be noted that most fetal
organogenesis occurs in the early weeks of pregnancy,
before most women know that they are pregnant. Thus,