ACOG Recommendations for the Prevention of Mother-to-Child HIV During Labor and Delivery

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss how viral load determines the delivery plan in women with HIV
2. Explain the management of PROM in women with HIV

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Genoox, Inc., and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Sep 25 2018 through Sep 25 2019, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Pharmacy Education

Postgraduate Institute for Medicine designates this continuing education activity for 0.25 contact hour(s) (0.25 CEUs) of the Accreditation Council for Pharmacy Education. (Universal Activity Number – JA4008162-9999-18-383-H01-P)

Type of Activity: Knowledge

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

CLINICAL ACTIONS:

The USPSTF continues to recommend “…screening for HIV infection in all pregnant persons, including those who present in labor or at delivery whose HIV status is unknown. (A recommendation).” ACOG, with endorsement from SMFM, advises that the identification of HIV-infected women is vital as treatment of HIV-infected women with combination antiretroviral therapy (cART) can reduce the risk of mother-to-child transmission to below 1-2% when viral load is 1,000 copies/mL or less near time of delivery.

KEY POINTS:

Management Based on Viral Load

Viral load ≤1,000 copies/mL (low risk)

Deliver at 39w0d or later
- Vaginal delivery <40w0d does not reduce risk of transmission
Rupture of membranes duration is not independently associated with increased risk of transmission in an HIV-infected woman with suppressed viral load

Viral loads >1,000 copies/mL (high risk) near delivery or those with unknown levels

Scheduled pre-labor cesarean at 38w0d
Pre-delivery prophylaxis with IV zidovudine 3 hours pre-delivery (ideal)
- 2 mg/kg load over first hour, followed by 1 mg/kg/hour maintenance infusion
- Studies have shown significantly higher ratios of cord blood-to-maternal zidovudine levels in women who received IV infusion for 3 to 6 hours vs <3 hours
- In women with high viral load electing vaginal delivery, administer IV zidovudine from onset of in-house labor monitoring until delivery along with other cART drugs
- The patient’s autonomy and informed decision regarding mode of delivery (irrespective of viral load) should be respected

Note: Although IV zidovudine is not recommended in women with viral load ≤1,000 copies/mL, some data suggest a higher transmission risk (1-2%) in women with viral load above 50 copies/mL compared with those less than 50 copies/mL; therefore, many experts continue to advocate for IV zidovudine even in this group

Testing for HIV

Check HIV RNA levels
- At first prenatal visit
- 2-4 weeks after start or change in cART
- Followed by monthly testing until levels are undetectable, and every 3 months thereafter
Rapid HIV screening during labor and delivery or immediate postpartum period using opt-out method should be done for all women not tested earlier in the pregnancy or with an unknown status
- Results should be available 24 hours a day and within 1 hour
Viral load should be checked between 34w0d – 36w0d to inform decisions regarding mode of delivery

Prelabor Rupture of Membranes (PROM)

Viral load ≤1,000 copies/mL (low)
- HIV transmission does not increase with duration of PROM
Viral loads >1,000 copies/mL (high risk)
- Some studies suggest a 2% increased transmission rate with every additional hour of PROM
- Unclear how many hours must pass before the benefit of a cesarean is lost
- Individualize care plan
- Expert consultation may help when managing high risk patients with HIV and PROM, especially if decisions need to be made urgently

Note: Consultation with the National Perinatal HIV/AIDS Clinical Consultation Center is available 24/7 by calling 888-448-8765

Special circumstances

Post-operative morbidity is higher in HIV-infected women with CD4 counts <200
Avoid (even in the setting of undetectable viral load)
- Fetal scalp electrodes
- Operative vaginal delivery
Prostaglandin F2-alpha, misoprostol, and oxytocin are preferred over methergine for treatment of postpartum hemorrhage
- Methergine or other ergotamines interact with protease inhibitors or cobicistat and may lead to exaggerated vasoconstriction response