What is the best next step in managing a 38-year-old gravida 3 para 2 woman at 37 weeks gestation with Human Immunodeficiency Virus (HIV) and a viral load of 12,300 copies/mL, who is in labor with a cervical dilation of 4 cm and 100% effacement, and has been started on zidovudine (Stavudine)?

From the Guidelines

The best next step in management for this 38-year-old woman with HIV and a viral load of 12,300 copies/mL at 37 weeks gestation is to perform a cesarean delivery. Given her elevated viral load above 1,000 copies/mL, cesarean section is recommended to reduce the risk of mother-to-child transmission of HIV, as supported by the American College of Obstetricians and Gynecologists (ACOG) and USPHS guidelines 1. The patient's inconsistent adherence to antiretroviral therapy has resulted in a viral load that significantly increases transmission risk during vaginal delivery. Key considerations in this decision include:

• The patient's viral load of 12,300 copies/mL, which is significantly above the threshold of 1,000 copies/mL that guidelines recommend for elective cesarean delivery to prevent mother-to-child transmission of HIV 1.
• The importance of minimizing the risk of mother-to-child transmission of HIV, given the patient's HIV status and the fact that she is at 37 weeks gestation.
• The need for careful surgical technique to minimize fetal exposure to maternal blood and secretions during the cesarean delivery.
• The requirement for the infant to receive antiretroviral prophylaxis and close follow-up after delivery.
• The importance of counseling the mother on medication adherence and linking her to HIV care for ongoing management postpartum to improve her health outcomes and prevent transmission in future pregnancies. While zidovudine infusion has already been started, the mode of delivery is critical in this scenario, and a scheduled cesarean delivery can reduce transmission rates by approximately 50% or more, as suggested by studies on the effectiveness of elective cesarean delivery in preventing mother-to-child transmission of HIV 1.

From the Research

Management of HIV-Infected Pregnant Women

The patient is a 38-year-old woman, gravida 3 para 2, at 37 weeks gestation with a viral load of 12,300 copies/mL. She has been diagnosed with HIV and has not always taken her combination antiretroviral medications.

• The patient's viral load is high, which increases the risk of mother-to-child transmission of HIV 2, 3.
• Intrapartum intravenous zidovudine is recommended to reduce the risk of mother-to-child transmission, especially in cases of virological failure 2.
• The mode of delivery should be considered, with elective cesarean section being an option to reduce the risk of transmission, especially in cases of high viral load 3, 4.
• However, the decision to perform a cesarean section should be based on individual factors, including the patient's viral load, obstetrical risk factors, and the patient's preferences 3, 4.
• The patient's non-adherence to antiretroviral therapy should be addressed, and efforts should be made to improve her adherence to reduce the risk of transmission and improve her own health outcomes 5.

Next Steps in Management

• In addition to starting zidovudine, the patient should be considered for a cesarean section, especially given her high viral load 3, 4.
• The patient's antiretroviral regimen should be optimized to reduce her viral load and improve her health outcomes 5.
• The patient should receive counseling on the risks and benefits of different management options, including the mode of delivery and antiretroviral therapy 5.