| Pregnancy, Pediatrics
and HIV Infection: Guidelines for Your Practice Page 5 |
| 8.
Mode of Delivery The risk/benefit of elective Cesarean section (C/S) to reduce perinatal HIV transmission should be discussed with each patient upon initiation of care and close to the expected due date (EDC). When making recommendations for mode of delivery, the woman's most recent viral load should be taken into consideration. The American College of Obstetricians and Gynecologist (ACOG) recommends offering elective (prior to labor) Cesarean section at 38 weeks for patients with viral load > 1,000 copies/ml. The ability of a Cesarean section to reduce the risk of perinatal transmission from women with viral loads greater than 1,000 copies/ml outweighs any potential maternal morbidity due to increased complications. For patients with undetectable viral load, a Cesarean section has not been shown to be beneficial. The risk of perinatal transmission in women who are not on antiretroviral agents, women who are on AZT monotherapy with unknown HIV RNA, or those with proven antiretroviral resistance levels would be lowered by Cesarean section. |
| For patients delivering vaginally the provider should avoid invasive procedures such as electrodes or sampling. It is also important to keep membranes intact as long as possible due to the known association of increased perinatal transmission with prolonged rupture of membranes or sub-clinical chorioamnionitis. Other routine obstetrical care issues should be followed such as Group B streptococci prophylaxis when indicated. |
| 9. Follow-up Care Women should be monitored throughout pregnancy for side effects or toxicities associated with the antiretroviral regimen. Both mother and child should receive follow-up care by a physician who is experienced in treating HIV disease. |
| 10. Treatment
Recommendations The AZT regimen used in the PACTG 076 clinical trial included an antepartum regimen of 100 mg 5 times per day starting at 14 weeks gestation. Treatment recommendations have since been modified: |
| Antepartum Based on pharmacokinetic data to facilitate adherence, treatment recommendations for antepartum dosing of AZT has since been modified to 300 mg po bid or 200 mg po tid. |
| Intrapartum A 1-hour loading dose of 2 mg/kg IV is recommended, followed by continuous infusion of 1 mg/kg/hr until delivery. |
| Neonate Eight to 12 hours after birth, the infant should be given 2 mg/kg of AZT syrup every 6 hours for 6 weeks. Although there is still controversy regarding the upper time limit when initiation of therapy to the neonate should be started, most experts initiate therapy as soon as the infant can be fed but not later than 72 hours after birth. |
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