Admission Orders for Term Pregnancy with HIV
For a term pregnant patient with HIV, immediately initiate intravenous zidovudine infusion (2 mg/kg loading dose over 1 hour, then 1 mg/kg/hour continuous infusion until delivery), continue her current oral antiretroviral therapy, obtain stat HIV viral load if not available within the past week, and plan delivery route based on most recent viral load (vaginal if ≤1000 copies/mL, scheduled cesarean if >1000 copies/mL). 1, 2
Critical Admission Orders
Immediate Laboratory Testing
- Stat HIV viral load if not obtained within the past 7 days 3
- Complete blood count (monitor for zidovudine-associated anemia)
- Hepatitis B and C serology if not current
- CD4 count if not recent
Antiretroviral Management
Continue Current Oral Antiretroviral Therapy:
- Do NOT discontinue her existing combination antiretroviral therapy (cART) regimen 1
- Verify she has taken her scheduled doses
- Continue oral medications throughout labor and delivery
Initiate Intravenous Zidovudine:
- Loading dose: 2 mg/kg IV over 1 hour
- Maintenance: 1 mg/kg/hour continuous IV infusion until cord clamping 1
- This is given IN ADDITION to her oral regimen, not as a replacement
Delivery Planning Based on Viral Load
If viral load ≤1000 copies/mL:
- Vaginal delivery is appropriate 2
- Standard obstetric management
- Continue IV zidovudine throughout labor
If viral load >1000 copies/mL or unknown:
- Strongly recommend scheduled cesarean delivery at 38 weeks before labor onset and membrane rupture 2
- If already in labor at term, proceed with cesarean delivery
- This reduces transmission risk significantly when viral suppression is suboptimal
Antiretroviral Regimen Considerations
The 2017 BMJ guideline provides important nuance about backbone selection 4:
Preferred backbone: Zidovudine + Lamivudine
- This combination has better safety profile in pregnancy compared to tenofovir/emtricitabine
- Strong recommendation AGAINST tenofovir/emtricitabine/lopinavir-ritonavir due to increased risk of early neonatal death and preterm delivery <34 weeks 4
- Weak recommendation for zidovudine/lamivudine over tenofovir/emtricitabine with other third agents 4
Exceptions where tenofovir/emtricitabine may be preferred:
- Severe anemia
- Lamivudine-resistant hepatitis B
- Zidovudine or lamivudine resistance
- Drug allergies 4
Neonatal Orders
Prepare for immediate neonatal prophylaxis:
- Zidovudine syrup for infant: 4 mg/kg orally twice daily for 6 weeks, starting within 6-12 hours of birth 1
- Coordinate with pediatrics/neonatology team
- Consider enhanced prophylaxis if maternal viral load is elevated or unknown
Additional Admission Orders
Infection Control
- Standard precautions (universal precautions apply to all patients)
- Avoid artificial rupture of membranes if possible when viral load >1000 copies/mL
- Avoid fetal scalp electrodes and operative vaginal delivery when viral load is elevated
Consultations
- Infectious disease or HIV specialist consultation if not already involved
- Pediatrics/neonatology notification for delivery
- Anesthesia consultation (epidural is not contraindicated)
Patient Counseling
- Discuss delivery plan based on viral load
- Reinforce importance of medication adherence
- Counsel regarding infant feeding (formula feeding recommended in resource-rich settings)
- Discuss postpartum antiretroviral continuation
Common Pitfalls to Avoid
Do NOT stop antiretroviral therapy during labor - this is a critical error that increases transmission risk 1
Do NOT delay IV zidovudine - start immediately upon admission, even if oral regimen contains zidovudine 1
Do NOT assume recent viral load is current - obtain stat viral load on admission as suppression status may have changed 3
Do NOT perform cesarean delivery solely based on HIV status if viral load is ≤1000 copies/mL - this unnecessarily increases maternal morbidity 2
Do NOT use single-agent therapy - combination therapy is essential for both maternal health and prevention of resistance 1