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

Hyperbilirubinemia
Women who are taking indinavir may have an
increased risk of nephrolithiasis, but evidence of harm
to the newborns has not been demonstrated. Women
taking indinavir or atazanavir frequently develop
elevated indirect bilirubin, but it is not known whether
treatment during pregnancy exacerbates physiologic
hyperbilirubinemia in the newborn.
Pain Management
Pain management during labor and delivery may be
complicated by drug interactions with ARVs and by
the higher medication tolerance in women who have
addictions. Additional pain medication may be needed
for women with histories of drug use.
Perinatal Considerations
The risk of HIV infection of the fetus during invasive
procedures (eg, amniocentesis, chorionic villus sampling,
percutaneous or umbilical cord blood sampling) must
be balanced against the possible benefits of these
procedures. Invasive procedures should be performed
only after discussion with and consent from the
pregnant woman.
Postpartum Considerations
Because HIV can be transmitted to the infant through
breast-feeding, breast-feeding is contraindicated in the
United States and other resource-adequate countries
where safe replacement feeding is available. Breastfeeding
information should be removed from patient
educational material pertaining to labor and delivery.
Breast binding and ice packs can be used as needed to
Section 3—Antiretroviral Therapy | 3–47
reduce lactation discomfort. Clinicians should recognize
that women in some cultural groups are expected to
breast-feed and they may need additional support to use
formula rather than breast-feed.
ART should be continued as indicated by the USPHS
Perinatal ARV Guidelines. Maternal and infant
medication adherence must be discussed with the new
mother. Adherence barriers for the mother during the
postpartum period may be different from those during
pregnancy (eg, because of changes in daily routine,
sleep/wake cycles, and meals).
New mothers should be observed carefully for signs of
bleeding or infection. If the mother’s glucose tolerance
test was abnormal during pregnancy, she should be
reevaluated (by 2-hour glucose tolerance test) 6 weeks
postpartum and should be screened yearly for diabetes.
At the 2-week postpartum follow-up visit, the clinician
should address the patient’s concerns, screen for
postpartum depression, assess adherence to her own and
the infant’s ARV medications, and ensure follow-up
with the primary HIV care provider, pediatrician, and
obstetric provider. This visit also affords an opportunity
to address the woman’s contraceptive needs and options,
if this was not done previously.
Contraception
Many contraceptive choices are available for HIVinfected
women; some considerations are discussed
in Table 5. Depending on the woman’s risk factors,
consistent condom use should be emphasized, with or
without other methods of contraception, to prevent the
transmission of HIV and the acquisition or transmission
of other STDs.