HIV-positive women, regardless of viral load. A 2 mg/kg load delivery. In this instance, for gravidas already taking antepar tum oral zidovudine, their oral dose can be held, and IV drug is instead administered. HIV-infected women undergoing a scheduled cesarean delivery are given IV zidovudine as a load ing dose followed by 2 more hours of continuous maintenance therapy-a total of 3 hours of infused zidovudine.
who are taking no medications. hese women are given IV zid ovudine intrapartum as just described.
During labor, artificial membrane rupture, fetal scalp electrode placement, episiotomy, and operative vaginal delivery are reserved for clear obstetrical indications (Mandelbrot, 1996; Peters, 2016). Labor augmentation is used when needed to shorten the interval to delivery to further lower the transmission risk. Delayed cord clamping in preterm neonates is acceptable. Neuraxial analgesia is suitable. Postpartum hemorrhage is best managed with oxytocin and prostaglandin analogues. Methylergonovine (Methergine) and other ergot alkaloids adversey interact with reverse transcriptase and protease inhibitors to cause severe vasoconstriction.
In some cases, cesarean delivery lowers HIV prenatal transmission (European Mode of Delivery Collaboration, 1999; International Perinatal HIV Group, 1999). The American College of Obstetricians and Gynecologists (2017b) recommends that scheduled cesarean delivery be discussed and recommended for HIV-infected women with HIV-1 RNA loads > 1000 copies/mL. Scheduled delivery is recommended at 38 weeks' gestation in these women to avert spontaneous labor.
For women with HIV RNA levels �1000 copies/mL, data are insuicient to predict similar beneits, and scheduled cesarean delivery is unlikely to confer additional risk reduction for women already taking ART and achieving viral suppression (Briand, 2013; Jamieson, 2007; Read, 2005). Vaginal delivery in this group may be elected. However, if cesarean delivery is instead chosen for a well-counseled woman in this group, it should be performed at 39 weeks. Similarly, cesarean delivery performed for obstetrical indications in this lower-viral-Ioad group should be done at 39 weeks when possible.
TABLE 65-5. Recommendations for HIV Antiviral Drug Use During Pregnancy
Antepartum care See antepartum screening test list (p. 1249)
ART should be initiated as early as possible For those with HIV RNA levels >500-'1000 copies/mL, order HIV antiretroviral drug resistance testing but do not delay ART initiation awaiting results Repeat HIV RNA levels 2-4 weeks after initiating (or changing) ART drugs; monthly until RNA levels are undetectable; then at least every 3 mo; and finally at 34-36 weeks' gestation for delivery planning
CD4+ count should be monitored at the initial visit and every 3-6 mo
Intrapartum care If HIV RNA levelr> 1 000 copies/mL or is unknown before labor or ROM, plan cesarean delivery at 38 weeks' gestation If HIV RNA levelsr> 1000 or is unknown but labor or ROM has ensued, benefits of cesarean delivery are unclear and labor plans are individualized If HIV RNA levelr:;1 000 copies/mL, vaginal delivery is permitted; cesarean delivery not routinely recommended Start IV ZDV if HIV RNA levelr> 1 000 copies/mL near delivery or is unknown.
Dosing is 2 mg/kg IV load over 1 hr, then 1 mg/kg/hr until delivery.
IV ZDV should begin 3 hr before scheduled cesarean delivery Those taking oral antepartum ART should take this during labor with sips of water