Other Aspects of Care for HIV-Infected Pregnant Women

Antepartum Care

Aspects of evaluation and care that are specific to pregnant women with HIV infection are summarized in Table 1. For women receiving protease-inhibitor therapy, 50-g glucose-load testing may be considered early in pregnancy to screen for glucose intolerance, with a second test at 24 to 28 weeks of gestation if the initial result is normal. Pregnant women receiving methadone in whom regimens containing nevirapine, efavirenz, or any protease inhibitor except indinavir are initiated should be monitored for signs and symptoms of drug withdrawal, since these agents have the potential to decrease methadone levels.

The schedule of testing for toxic effects of antiretroviral drugs depends on which drugs are chosen. In general, frequent evaluation (every two to four weeks) for new symptoms and laboratory abnormalities is indicated during the first one to two months of therapy, with less frequent testing thereafter. The optimal schedule of testing for the early diagnosis of antiretroviral-induced hepatic toxicity or lactic acidosis has not been determined, but one approach would be to evaluate hepatic function and electrolytes monthly during the third trimester and whenever new symptoms occur. HIV RNA levels should be monitored as in nonpregnant adults — that is, 4 weeks after a change or initiation of therapy, then monthly until undetectable, then every 3 months while therapy remains stable, and at 34 to 36 weeks of gestation for the planning of delivery. CD4+ lymphocyte counts should be evaluated every three months. Although the percentage of CD4+ lymphocytes is less subject to variation during pregnancy than the absolute count, most clinicians use treatment guidelines that are based on absolute counts; thus, absolute counts may be used in pregnant women as in nonpregnant adults.

Counseling with regard to the options for prenatal diagnosis is required for HIV-infected pregnant women. Although screening for serum markers or ultrasonographic examination may enhance the risk assessment, only invasive testing with fetal karyotyping can rule out chromosomal abnormalities. It is unclear whether invasive procedures for prenatal diagnosis carry a risk of HIV transmission. An increase by a factor of two to four in the risk of HIV transmission related to amniocentesis or other invasive procedures has been reported among untreated women. Invasive testing has not been identified as a specific risk factor for transmission in cohort studies performed since antiretroviral therapy has become standard, but the use of amniocentesis among HIV-infected women is uncommon, and the use of chorionic-villus sampling is rare. If a pregnant woman would not undergo amniocentesis after a positive result on serum or nuchal translucency screening, then such screening may be more anxiety-provoking than helpful. If an invasive prenatal procedure is planned for an HIV-infected woman, she should be receiving optimal antiretroviral therapy and have undetectable HIV RNA before the procedure.