Labor and Delivery Mx of Women with HIV: ACOG Committee Opin
This Committee Opinion released by ACOG (American College of Obstetricians and Gynecologistsis) provides updated guidance on the management of pregnant women during pregnancy and delivery to prevent mother-to-child transmission of the human immunodeficiency virus (HIV).

Prevention of transmission of HIV from the woman to her fetus or newborn is a major goal in the care of pregnant women infected with HIV. Continuing research into mother-to-child transmission of HIV has suggested that a substantial number of cases of perinatal HIV transmission occur as the result of fetal exposure to the virus during labor and delivery.

Some of the key recommendations are:-
• Women should receive antiretroviral therapy during pregnancy according to currently accepted guidelines for adults. Plasma HIV ribonucleic acid (RNA) levels in pregnant women should be monitored at the initial prenatal visit, 2–4 weeks after initiating (or changing) cART drug regimens; monthly until RNA levels are undetectable; and then at least every 3 months during pregnancy.

• Pregnant women infected with HIV whose viral loads are more than 1,000 copies/mL at or near delivery, independent of antepartum antiretroviral therapy, or whose levels are unknown, should be counseled regarding the potential benefit of and offered scheduled prelabor cesarean delivery at 38 0/7 weeks of gestation to reduce the risk of mother-to-child transmission. These patients also should receive intravenous zidovudine (ZDV), ideally 3 hours preoperatively as a 1-hour intravenous loading dose (2 mg/kg), followed by continuous infusion over 2 hours (1 mg/kg/hr) until delivery to achieve adequate levels of the drug in maternal and fetal blood.

• Some medications used to treat HIV may have significant interactions with medications used during labor and delivery, specifically uterotonics. Concomitant use of methergine or other ergotamines with protease inhibitors or cobicistat, or both, has been associated with exaggerated vasoconstrictive responses.

• The patient’s autonomy in making the decision regarding route of delivery should be respected. A patient’s informed decision to undergo vaginal delivery despite a viral load above the accepted cutoff should be honored. The converse holds true for an informed decision regarding cesarean delivery in the setting of a viral load of 1,000 copies/mL or less.

• Duration of rupture of membranes before delivery is not an independent risk factor for maternal-child transmission in women who are otherwise appropriately virally suppressed and is not a consideration regarding route of delivery.

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