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 active labor with a cervical dilation of 4 cm and 100% effacement, and has been started on zidovudine (Retrovir)?

From the Guidelines

The best next step in management for this HIV-positive patient in active labor is to perform a cesarean delivery. Given her viral load of 12,300 copies/mL, which is above the threshold of 1,000 copies/mL, cesarean delivery is recommended to reduce the risk of mother-to-child transmission of HIV 1. The patient's poor adherence to antiretroviral therapy has resulted in inadequate viral suppression, making vertical transmission more likely during vaginal delivery. Cesarean delivery should be performed before rupture of membranes, as the intact amniotic sac provides a barrier against fetal exposure to maternal blood and secretions. The intravenous zidovudine that has been started is an appropriate intervention, but it alone is insufficient to prevent transmission with this high viral load. After delivery, the newborn will require antiretroviral prophylaxis, and the mother should receive counseling about medication adherence and the importance of continued HIV treatment. While the patient has had previous successful vaginal deliveries, the presence of poorly controlled HIV infection necessitates this change in delivery approach to optimize neonatal outcomes.

Some key points to consider in this case include:

• The patient's high viral load, which increases the risk of mother-to-child transmission of HIV
• The importance of cesarean delivery in reducing this risk, particularly when the viral load is above 1,000 copies/mL 1
• The need for antiretroviral prophylaxis in the newborn to further reduce the risk of transmission
• The importance of counseling the mother about medication adherence and the importance of continued HIV treatment to optimize her own health and reduce the risk of transmission to future pregnancies.

Overall, the goal of management in this case is to minimize the risk of mother-to-child transmission of HIV while also ensuring the best possible outcomes for both the mother and the newborn. By performing a cesarean delivery and providing antiretroviral prophylaxis to the newborn, we can significantly reduce the risk of transmission and optimize neonatal outcomes.

From the Research

Management of HIV-Positive Pregnant Women

• The patient is a 38-year-old woman, gravida 3 para 2, at 37 weeks gestation with a history of HIV and a viral load of 12,300 copies/mL.
• She has been taking combination antiretroviral medications inconsistently and is now in labor.
• The best next step in management, in addition to starting zidovudine, would be to administer lamivudine, as studies have shown that the combination of zidovudine, lamivudine, and lopinavir/ritonavir is effective in reducing viral load during pregnancy 2.
• The use of lamivudine in combination with zidovudine and lopinavir/ritonavir has been shown to reduce the time to achieve a viral load of <50 copies/mL, which is crucial for preventing mother-to-child transmission of HIV 2.
• Therapeutic drug monitoring is also important in HIV-positive pregnant women to ensure adequate drug levels and prevent resistance 3.
• The choice of antiretroviral regimen should be based on the patient's viral load, CD4 count, and medication history, as well as the potential for drug interactions and side effects 4, 5.
• In this case, the patient's viral load is high, and she has a history of inconsistent medication adherence, so a regimen that includes lamivudine, zidovudine, and lopinavir/ritonavir may be the best option.
• The safety and pharmacokinetics of these medications in pregnant women have been studied, and they are generally well-tolerated 6.