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INTRAPARTUM CARE

INTRAPARTUM CARE. Intrapartum Care (1). Two major studies support the use of intrapartum ZDV: PACTG 076: Combination antenatal, intrapartum , and infant prophylaxis with ZDV reduced perinatal transmission by 66%.

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INTRAPARTUM CARE

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  1. INTRAPARTUM CARE

  2. Intrapartum Care (1) • Two major studies support the use of intrapartum ZDV: • PACTG 076: Combination antenatal, intrapartum, and infant prophylaxis with ZDV reduced perinatal transmission by 66%. • French Perinatal Cohort found that intrapartum IV ZDV was associated with lower risk of transmission if the maternal VL was >10,000 copies/mL but not associated with reduced risk in women on ART with VL <400 copies/mL. • Limited PK data on oral vs IV ZDV during labor, and drug levels needed for prophylaxis are unknown. www.aidsetc.org

  3. Intrapartum Care (2) Recommendations: • Continue ART on schedule during labor and before scheduled C-section. (AIII) • Give IV ZDV to women with VL ≥400 copies/mL (or unknown VL) near delivery, regardless of antenatal regimen or mode of delivery. (AI) • IV ZDV not required for women on ART with VL <400 copies/mL. (BII) www.aidsetc.org

  4. Intrapartum Care (3) • Conduct rapid HIV antibody testing for women in labor with unknown HIV status. (AII) If positive: • Perform confirmatory testing ASAP. • Administer maternal IV ZDV and infant combination prophylaxis pending results of confirmatory test. (AII) • Continue infant prophylaxis for 6 weeks if confirmatory test result is positive (AI); discontinue prophylaxis if confirmatory test result is negative. www.aidsetc.org

  5. Transmission and Mode of Delivery(1) • Scheduled cesarean delivery at 38 weeks’ gestation to minimize perinatal HIV transmission is recommended for women with HIV RNA levels >1,000 copies/mL or unknown levels near the time of delivery. (AII) • Perform C-section irrespective of administration of antepartum ARV drugs. • IV ZDV should be administered for 3 hours total prior to scheduled delivery. www.aidsetc.org

  6. Transmission and Mode of Delivery (2) • Scheduled cesarean delivery is not recommended for prevention of perinatal transmission in pregnant women receiving combination ARV drugs with HIV RNA levels <1,000 copies/mL near the time of delivery. (BIII) • Data are insufficient to evaluate the potential benefit • Low rates of transmission • C-sections performed for standard obstetrical indications should be scheduled for 39 weeks’ gestation www.aidsetc.org

  7. Transmission and Mode of Delivery (3) • The benefit to performing a cesarean delivery after rupture of membranes or onset of labor is unclear. Management should be based on: • Duration of rupture and/or labor • Plasma HIV RNA level • Current ARV regimen (BII) • If unscheduled cesarean delivery is performed and IV ZDV administration is indicated, consideration can be given to providing only the loading dose. www.aidsetc.org

  8. Transmission and Mode of Delivery (4) • Inform woman of the risks associated with cesarean delivery. If the indication is for prevention of perinatal transmission of HIV, the risks should be balanced with potential benefits expected for the neonate. (AII) www.aidsetc.org

  9. Other Intrapartum Considerations (1) • Avoid the following because of potential increased risk of transmission (unless there are clear OB indications): • Artificial rupture of membranes (BIII) • Routine use of fetal scalp electrodes (BIII) • Operative delivery with forceps or vacuum extractor and/or episiotomy (BIII) www.aidsetc.org

  10. Other Intrapartum Considerations (2) • When treating excessive postpartum bleeding, consider the ARVs a women is receiving: • If she is receiving a cytochrome (CYP) 3A4 enzyme inhibitor (eg, a PI), use methergine only if no alternative treatments are available and the need for pharmacologic treatment outweighs the risks. (BIII) • If she is receiving a CYP3A4 enzyme inducer such as NVP, EFV, or etravirine, additional uterotonic agents may be needed because of the potential for decreased methergine levels and inadequate treatment effect. www.aidsetc.org

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