The American College of Obstetricians and Gynecologists (ACOG, 2018) has updated recommendations on intrapartum management of women infected with human immunodeficiency virus (HIV). The exact mechanism is unknown; however, a considerable number of cases of maternal-fetal transmission of HIV occur during labor and birth. Risk of transmission is relative to the maternal plasma HIV ribonucleic acid (RNA) viral load, or the viral concentration in maternal plasma (ACOG). When women infected with HIV are treated with combined antiretroviral therapy (cART), and their viral load is maintained at <=1,000 copies/mL, rate of maternal-child transmission is 1% to 2% or lower, regardless of duration of ruptured membranes or method of birth (ACOG).
Prenatal and Neonatal Management
Prenatal management of women infected with HIV includes use of the same antiretroviral protocols recommended for adults. Monitoring of plasma HIV RNA should take place at the first prenatal visit; at 2 to 4 weeks following the start or change of cART therapy; every month until the RNA levels are undetectable; and then every 3 months for the remainder of the pregnancy. The HIV RNA levels should be checked between 34 0/7 and 36 0/7 weeks to guide decision-making about the birth and management of the neonate (ACOG, 2018).
Care of the newborn of a woman infected with HIV should be administered by pediatric providers who are experienced in caring for this population to ensure appropriate prophylactic HIV treatment for at-risk neonates. Ideally, this care should be established prior to birth (ACOG, 2018).
Mode of Birth
Provided the woman has been managed with cART and the HIV RNA viral load is maintained at <=1,000 copies/mL, vaginal birth is considered equivalent to elective cesarean birth when considering the risk of maternal-neonatal transmission of HIV (ACOG, 2018). These women can await spontaneous labor similar to HIV-negative women. Women with an unknown viral load or with >1,000 copies/mL should be counseled about benefits of cesarean birth and offered a scheduled cesarean before onset of labor at 38 0/7 weeks (ACOG). This is done to decrease the chance of labor onset or rupture of membranes before birth. Women giving birth via cesarean should be treated at 3 hours preoperatively with a 1-hour intravenous loading dose (2 mg/kg) of zidovudine (ZDV), followed by a 1 mg/kg/hour infusion over 2 hours. Although these are the current recommendations based on the best evidence, women should be given information about the risks associated with each birth method and offered a choice, despite their viral load (ACOG).
Intrapartum and Postpartum Considerations
Care providers in perinatal units should ensure that rapid screening using the opt-out approach is available to test women who present with an unknown HIV status, and results made readily available within an hour, 24 hours a day (ACOG, 2018). Studies that predated use of contemporary cART protocols found a relationship between duration of rupture of membranes and HIV transmission; however, more recent data demonstrate that such risks are heavily influenced by viral load (ACOG). Provided the viral load is below threshold, duration of rupture of membranes prior to birth is no longer considered an independent risk factor for maternal-child transmission and should not influence decision-making surrounding method of birth. Invasive interventions that increase fetal exposure to maternal blood, such as amniocentesis, use of a fetal scalp electrode, or operative vaginal birth, should be avoided (ACOG).
Certain medications used to treat HIV, such as protease inhibitors and cobicistat, have been found to interact with methergine and other ergotamines and cause an exaggerated vasoconstrictive response. Methergine should be used to treat uterine atony only when alternatives are either unavailable or contraindicated (ACOG, 2018).
Advances in HIV treatment have made it possible for women infected with HIV to give birth vaginally with limited risk of maternal-child transmission of the virus. Armed with up-to-date information about current protocols and risks, perinatal nurses can support women infected with HIV in making informed choices about their care in the perinatal period.
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