Treatment of Pregnant HIV-Infected Patients:
Pregnant women with HIV infection should be offered therapy based on the same virologic, immunologic, and clinical parameters as non pregnant women.
The goal of therapy is to provide maximal virologic suppression to optimize the health of the mother and minimize transmission of virus to the fetus. The choice of drugs and the timing of initiating therapy may, however, be influenced by the pregnancy.
Most antiretroviral drugs are safe in pregnant women; to the extent they have been studied. Many of the toxicities caused by antiretroviral agents may contribute to parallel complications of pregnancy, (e.g., the hyperglycemia associated with protease inhibitors may exacerbate pregnancy-associated diabetes). There are specific concerns regarding the use of nucleosides during pregnancy, especially stavudine and didanosine, in view of their association with hepatic steatosis and lactic acidosis in several pregnant women. There is also particular concern about the association of efavirenz with fetal abnormalities in monkeys. Finally, combination ART may be associated with an increased risk for preterm delivery. Antiretroviral regimens must be chosen carefully and monitored.
Transmission of HIV from mother to fetus has been observed at all maternal plasma HIV RNA levels. There seem to be a correlation between the HIV plasma RNA copy number and the risk of transmission. Clinical trials have shown that ART can greatly reduce the likelihood that virus will be transmitted to the fetus or infant. Zidovudine monotherapy and nevirapine monotherapy have been most carefully studied, and both seem to be safe for the mother and fetus and are effective in substantially reducing the rate of maternal-fetal transmission. However, monotherapy is no longer indicated in settings in which combination ART is feasible. Moreover, single-dose nevirapine monotherapy can produce HIV resistance because of the long half-life of nevirapine. It is logical to use combination ART regimens for treating the mother to lower her viral load effectively and produce durable viral suppression.
Current guidelines indicate that combination ART, usually including zidovudine, should be recommended for infected women who meet the standard criteria for treatment or who have HIV RNA levels greater than 1000 copies/mL, regardless of immunologic or clinical status. Women who are in the first trimester of pregnancy may prefer delaying therapy until after 10 to 12 weeks of gestation if they are concerned about the teratogenicity of drugs administered during the early part of their pregnancy. . Prior to antiviral therapy, the risk of HIV transmission from an infected mother to her newborn was approximately 25%-35%. By giving ZDV after the first trimester of pregnancy, then intravenously during the delivery process, and then after delivery to the newborn for six weeks showed a reduction in the risk of transmission to less than 10%. Women who are not receiving zidovudine or nevirapine but who have HIV plasma RNA levels less than 1000 copies/mL seem to have a low risk of transmitting HIV to their offspring. There are no clear guidelines about how best to manage pregnant women whose virus is resistant to zidovudine and nevirapine.
All HIV-infected pregnant women should be managed by an obstetrician with experience in dealing with HIV-infected women. Maximal obstetric precautions to minimize transmission of the HIV virus, such as avoiding scalp monitors and minimizing labor after rupture of the uterine membranes, should be observed. In addition, the potential use of an elective Caesarean section (C-section) should be discussed, particularly in those women without good viral control of their HIV infection where the risk of transmission may be increased. Breastfeeding should be avoided if alternative nutrition for the infant is available since HIV transmission can occur by this route.
