Plasma HIV RNA quantification-"viralrload" -CD4 T-cell count, and antiretroviral resistance testing
HSV-1 and 2, cytomegalovirus, toxoplasmosis, and hepatitis Brand C serological screening
Tuberculosis testing with puriied protein derivative (PPD) skin testing, or interferon-gamma release assay
Evaluation of need for pneumococcal, hepatitis A, hepatitis B, T dap, and influenza vaccines
Sonographic evaluation to establish gestational age.
During pregnancy, the risk of HIV transmission does not appear to be increased with amniocentesis or other invasive diagnostic procedures in women receiving efective ART resulting in viral suppression (Floridia, 2017). For women not receiving ART, the risk rises approximately twofold (Mandelbrot, 1996). If amniocentesis is performed, eforts are taken to avoid passing through the placenta (Panel on Treatment of HI V-Infected Pregnant Women and Prevention of Perinatal Transmission, 2016).
In overview, the ideal strategy to suppress viral load and minimize vertical HIV transmission includes: (1) preconceptional ART, (2) antepartum ART, (3) intrapartum continuation of the antepartum oral ART regimen plus IV zidovudine, and (4) newborn ART prophylxis. ART is recommended for all HIVinfected pregnant women, and it should be initiated as early in pregnancy as possible. Treatment reduces the risk of perinatal transmission regardless of CD4 T-cell count or HIV RNA level. Adherence is essential because the risk of viral drug resistance is lessened. As for nonpregnant adults, pregnant women are treated with at least three antiviral agents.
The Panel on Treatment of HI V-Infected Pregnant Women and Prevention of Perinatal Transmission (2016) has issued guidelines for four diferent scenarios during pregnancy (Table 65-5). he following paragraphs summarize these recommendations.
First, women already taking ART at pregnancy onset are encouraged to continue the regimen if viral suppression is adequate. Didanosine, stavudine, and full-dose ritonavir, which difers from ritonavir-boosted agents, are exceptions due to pregnancy toxicity but not teratogenicity.
Second, women who have never received antiretroviral therapy-antiretroviral nai've-are given ART regardless of trimester. In general, the starting regimen comprises two nucleoside reverse transcriptase inhibitors plus either a ritonavir-boosted protease inhibitor or an integrase inhibitor.
hird, women who have previously received antiretroviral therapy but are currently not taking medications should undergo HIV resistance testing because prior ART use raises their risk of drug resistance. Typically, ART is initiated prior to receiving results of these drug-resistance tests. In this case, initial ART selection should factor results of prior resistance testing, if available; prior ART regimen; and current ART preg nancy guidelines, that is, those for ART-naive women. Drug resistance testing may then modiy the initial regimen.
For these three categories of women taking antepartum
ART, therapy surveillance is outlined in Table 65-5. Most patients with adequate viral response have at least a I-log viral load decline within 1 to 4 weeks after starting therapy. For those who fail to achieve this decline, options include review of drug resistance study results, confirmation of regimen compli ance, and ART modiication.
During labor and delivery, oral medications can be taken with sips of water. Additionally, IV zidovudine is given to women with an HIV RNA viral load > 1000 copies/ mL or who have an unknown viral load near delivery. At Parkland
Hospital, we administer intrapartum IV zidovudine to all