What is the recommended management plan for an 8-week pregnant woman with Human Immunodeficiency Virus (HIV) infection, from pregnancy to postpartum care?

Management of HIV Infection in an 8-Week Pregnant Woman

All HIV-infected pregnant women should receive combination antiretroviral therapy (HAART) with at least 3 drugs throughout pregnancy, regardless of CD4 count or viral load, to prevent mother-to-child transmission and maintain maternal health. 1, 2

During Pregnancy (8 Weeks to Delivery)

Antiretroviral Therapy Initiation

• Start or continue HAART immediately with a 3-drug regimen that includes zidovudine (ZDV) whenever possible, as ZDV remains the cornerstone of perinatal prevention even after 10 years of use 1
• For women already on HAART when pregnancy is discovered, continue the current regimen unless it contains teratogenic agents like efavirenz, which must be discontinued immediately and replaced 1
• If the woman requires treatment for her own health (CD4 <350/mm³ or AIDS-defining illness), antiretroviral drugs should not be stopped during the first trimester despite theoretical teratogenicity concerns 1
• For women with HIV RNA >1000 copies/mL, combination HAART is mandatory; for those with <1000 copies/mL, either HAART or the 3-part PACTG 076 zidovudine regimen can be used 1

Critical First Trimester Considerations

• Avoid efavirenz due to documented teratogenic potential (neural tube defects) 1
• Avoid the combination of stavudine (d4T) plus didanosine (ddI) due to increased risk of lactic acidosis and hepatic steatosis in pregnant women 1
• If discontinuation of all antiretrovirals is deemed necessary in the first trimester, stop all drugs simultaneously to prevent resistance, except when using drugs with long half-lives like nevirapine—in which case continue nucleoside analogues for 3-7 days after stopping the NNRTI 1

Specialist Involvement

• Consultation with an HIV specialist experienced in treating pregnant women is essential due to the complexity of managing combination therapy and the rapidly evolving nature of treatment recommendations 1

Monitoring Throughout Pregnancy

• Measure viral load at baseline, monthly initially, then at 34-36 weeks gestation to guide delivery planning 2
• Monitor CD4 counts to assess maternal immune status and need for opportunistic infection prophylaxis 1
• Perform level II ultrasound for detailed fetal anatomic assessment, particularly if using combination therapy 1
• Assess fetal growth and wellbeing during the third trimester with serial ultrasounds 1
• Vigilantly monitor adherence as subtherapeutic drug levels during pregnancy can lead to virologic failure and resistance development 3

During Delivery (Intrapartum Management)

Antiretroviral Administration

• Continue HAART throughout labor and delivery—do not interrupt the regimen 1
• Administer intravenous zidovudine during labor as part of the PACTG 076 protocol, even if the mother is on oral HAART 1

Mode of Delivery

• Offer scheduled cesarean section at 38 weeks gestation to women with viral loads >1000 copies/mL or unknown viral load, as this reduces transmission by approximately 50% 1
• For women with undetectable or very low viral loads (<1000 copies/mL) on HAART, vaginal delivery is reasonable as the additional benefit of cesarean section is unclear in this population 1
• Avoid artificial rupture of membranes, fetal scalp electrodes, and operative vaginal delivery to minimize infant exposure to maternal blood and secretions 1

After Delivery (Postpartum Management)

Maternal Care

• Coordinate care between obstetricians and HIV specialists to ensure continuity of antiretroviral treatment 1
• For women who do not meet criteria for treatment in non-pregnant individuals (CD4 >350/mm³, no AIDS-defining illness), consider discontinuing therapy after delivery with all drugs stopped simultaneously 1
• Exception for nevirapine-containing regimens: Continue dual nucleoside analogues for 3-7 days after stopping nevirapine to reduce resistance risk 1
• Counsel extensively about adherence challenges in the postpartum period, as physical changes and demands of caring for a newborn significantly impair adherence 1
• Screen for postpartum depression, which interferes with adherence and is associated with virologic failure and resistance development 1
• Provide comprehensive services including family planning, mental health support, substance abuse treatment, and case management 1
• Update immunizations and reassess need for opportunistic infection prophylaxis 1

Infant Care

• Administer zidovudine prophylaxis to the newborn starting within 6-12 hours of birth, continuing for 6 weeks at 4 mg/kg twice daily 4
• Obtain baseline complete blood count before starting ZDV and repeat after completing the 6-week regimen (at 12 weeks of age if abnormal), as anemia is the primary complication 1
• For infants whose mothers received combination therapy, perform more intensive hematologic and chemistry monitoring during the first weeks of life 1
• Start Pneumocystis carinii pneumonia (PCP) prophylaxis at 6 weeks of age after completing ZDV prophylaxis 1
• Perform HIV virologic testing according to current standards, with repeat testing after completion of prophylaxis if initial tests are negative 1
• Instruct mothers not to breastfeed in settings where safe formula alternatives are available, as this eliminates postnatal transmission risk 2, 5

Long-Term Follow-Up

• Maintain long-term follow-up of HIV-exposed infants into adulthood due to theoretical concerns about carcinogenicity of nucleoside analogues 1
• Include yearly physical examinations for all antiretroviral-exposed children, with gynecologic evaluation and Pap smears for adolescent females 1
• Document antiretroviral exposure in the child's permanent medical record, particularly for uninfected children 1

Common Pitfalls to Avoid

• Never withhold treatment during the first trimester unless absolutely necessary, as the benefits of viral suppression outweigh theoretical teratogenic risks for most agents 1
• Do not stop individual drugs sequentially when discontinuing therapy—this creates functional monotherapy and drives resistance 1
• Do not assume adherence is maintained postpartum—this period has documented high rates of treatment interruption leading to virologic failure 1
• Do not delay infant ZDV prophylaxis—it must begin within 6-12 hours of birth for maximum efficacy 4