Human Immunodeficiency Virus (HIV) Infection and Pregnancy: Labor and Delivery Management

Isaac Delke

Adult and adolescent females accounted for 27% of persons living with HIV infection in the United States at the end of 2007. By region, 40% resided in the South, 29% in the Northeast, 20% in the West, and 11% in the Midwest.

Treatment of HIV infection has evolved with an increasing proportion of women receiving highly active antiretroviral therapy (HAART) throughout pregnancy. With the implementation of universal prenatal HIV counseling and testing, antiretroviral prophylaxis, scheduled cesarean delivery, and avoidance of breastfeeding, perinatal HIV infection has dramatically diminished to

Note^,. CLIA, Clinical LaboratorylmprovementAmencIments.

Source'. Ref. 6.

care unit. Women with a positive rapid antibody test should be presumed to be infected until standard HIV antibody confirmatory testing clarifies their status. All women with a positive rapid HIV test in labor should have interventions started immediately to prevent perinatal HIV transmission, as discussed below.

INTERVENTIONS TO REDUCE PERINATAL HIV TRANSMISSION

In 1994, use of zidovudine (ZDV) in pregnancy, beginning at 14 weeks’ gestation and continuing through completion of delivery, was studied in the Pediatric AIDS Clini­cal Trials Group Protocol (PACTG) 076. A three-part regimen, beginning at 14 weeks’ gestation, with intravenous (IV) infusions of ZDV throughout labor and delivery, and subsequent use of oral ZDV for 6 weeks by the infant, resulted in a decrease in transmission rate by approximately 70%, from 25% to 8% (9).

Current recommendations for the prevention of perinatal HIV transmis­sion include the use of combination antiretroviral therapy during pregnancy, as would ordinarily be indicated for the mother’s own care, with the addition of ZDV during labor and delivery (Table 14.3) (5). However, abbreviated courses of ZDV and/or other antiretroviral drugs have also been shown to be effective in reducing perinatal HIV transmission to infants whose mothers never received antiretroviral drugs during pregnancy or labor (Table 14.4) (5).

The short-term toxicity of antiretroviral drugs appears to be acceptable, in terms of both mother and infant. The long-term toxicities of in utero exposure to antiretroviral agents are not yet known. It is thus imperative that all HIV-infected pregnant women be educated and counseled prior to making decision regarding the use of antiretroviral agents during the antepartum and intrapartum periods. The ultimate decision regarding the use of antiretroviral agents in pregnancy must reside with the patient herself, after careful and nonjudgmental discussion with her health care providers (5).

Additional means to decrease perinatal transmission include avoidance of artificial rupture of the membranes during labor, scheduled cesarean delivery when the HIV RNA level close to delivery is ≥1,000 copies/mL or unknown, and avoidance of breastfeeding. Each of these interventions poses particular problems in resource­poor regions of the world, where standard guidelines for the prevention of perinatal HIV infection must, of practical necessity, be altered. Early recognition of HIV infection will be important in these areas, as well as prenatal care and the use of antiretroviral therapy in late pregnancy, in delivery, and/or given to the newborn. Clearly, primary prevention of maternal infection is still the best intervention.

HIV-infected women in labor who have received antiretroviral drugs during pregnancy should be managed as outlined in Table 14.3.