CLINICAL ACTIONS:

ACOG, with endorsement from SMFM, has released a revised committee opinion on the management of labor and delivery in women with HIV. 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 

Learn More – Primary Sources:

ACOG Committee Opinion 751: Labor and Delivery Management of Women With Human Immunodeficiency Virus Infection

ACOG/SMFM Committee Opinion 764: Medically Indicated Late-Preterm and Early-Term Deliveries 

ACOG: HIV Section

Related ObG Topics:

STD Screening in Pregnancy: CDC Recommendations

Does Amniocentesis or CVS Increase the risk of HIV Vertical Transmission?

CDC Guidelines on Daily Oral Antiretroviral Preexposure Prophylaxis to Prevent HIV in Those at High Risk

Optimizing Contraception for the HIV-positive Woman