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

3–46 | Clinical Manual for Management of the HIV-Infected Adult/2006
and the known efficacy of ZDV in preventing perinatal
transmission. Recommendations should be noncoercive,
and the woman herself must make the final decision
regarding the use of ARV drugs. A decision to decline
ART should not result in punitive action or denial of
care; nor should ART be denied to any woman who
wishes to minimize the fetus’s exposure to drugs and
therefore chooses to receive only ZDV to reduce the
risk of perinatal transmission. The woman should be
informed that ZDV alone does not reduce the baby’s
HIV risk as much as a potent triple-drug therapy, and
also that monotherapy with any ARV drug confers a
risk of drug resistance that may affect the success of
future treatment for her and for the infant (if HIV
infected).
The USPHS Perinatal ARV Guidelines are updated
regularly as clinical trial results are reported
and ARVs are approved by the U.S. Food and
Drug Administration. 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. Pregnant women with HIV
infection should be managed as a collaboration between
an HIV specialist and the obstetric provider.
For further information about ARV treatment during
pregnancy, see the chapter Reducing Maternal-Infant
HIV Transmission and the USPHS Perinatal ARV
Guidelines.
Antiretroviral Pregnancy Registry
To improve tracking of pregnancy-related adverse
effects 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 am to 5:30 pm 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 taking ARVs. More information can
be obtained at http://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 drugdrug
interactions with all HIV-related medications the
patient is already taking. Women who are not taking
ART at the beginning of their pregnancy usually are
assessed and placed on an ARV regimen at the end of
the first trimester, when the nausea and vomiting of
early pregnancy have improved.
Hyperglycemia
Pregnancy is a risk factor for hyperglycemia, and women
treated with protease inhibitors (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. Some clinicians check glucose
tolerance at 20-24 weeks and again at 30-34 weeks if
the woman is taking PIs. The baby should be checked
for neonatal hypoglycemia at 1 and 4 hours.
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 and prescribed only when the potential
benefit clearly outweighs the potential risk. Clinical
suspicion of lactic acidosis should be prompted by
vague symptoms such as malaise, nausea, or abdominal
discomfort or pain. Lactate levels, electrolytes, and liver
function tests should be monitored carefully, particularly
in the third trimester.