Human Immunodeficiency Virus (HIV) Infection and Pregnancy: Labor and Delivery Management



Human Immunodeficiency Virus (HIV) Infection and Pregnancy: Labor and Delivery Management


Isaac Delke



Adult and adolescent females accounted for 27% of persons living with HIV infection in the United States at the end of 2007. By region, 40% resided in the South, 29% in the Northeast, 20% in the West, and 11% in the Midwest. African American and Hispanic women account for 80% of cases (1). The majority of these women are of childbearing age and approximately 6,000 to 7,000 HIV-infected women deliver children in the United States each year. Approximately 15% to 30% of these women would be expected to give birth to infected infants, in the absence of specific interventions aimed to decrease perinatal transmission. Perinatal HIV transmission may occur in utero, during delivery, or through breastfeeding (2).

Treatment of HIV infection has evolved with an increasing proportion of women receiving highly active antiretroviral therapy (HAART) throughout pregnancy. With the implementation of universal prenatal HIV counseling and testing, antiretroviral prophylaxis, scheduled cesarean delivery, and avoidance of breastfeeding, perinatal HIV infection has dramatically diminished to <2% in the United States over the last 25 years (2,3,4,5).

The emergency department (ED) continues to be the site of entry into the hospital for obstetric patients. The ED staff could be faced with an HIV-infected patient in labor ready to deliver and must know how to handle such a situation. This chapter focuses on (a) the identification of HIV-infected women in labor and (b) interventions for the prevention of perinatal HIV transmission—antiretroviral prophylaxis, cesarean delivery, and avoidance of breastfeeding. Various scenarios that commonly occur in clinical practice are presented, and the factors that influence treatment considerations are highlighted.


IDENTIFICATION OF HIV-INFECTED WOMEN IN LABOR

Since many women with HIV infection (over 75% at our center) enter pregnancy with a known diagnosis, a confidential review of maternal history and prenatal record for HIV serostatus on admission to the ED is vital. This has been enhanced by the availability of electronic medical record (including prenatal) in many hospitals.

Any woman without documented HIV status at the time of labor should be screened with rapid HIV testing unless she declines (opt-out screening) (6,7). Currently, there are six rapid HIV screening tests that are approved by the US Food and Drug Administration (FDA) (6) and commercially available for use in the United States (Table 14.1). Rapid HIV tests are relatively simple to use, and they make it possible to provide information on HIV antibody status at the point of care. Statutes and regulations in this area vary from state to state (8). Rapid HIV testing is also recommended for women who present in labor with a negative HIV test early in pregnancy, but who are known to be at increased risk for HIV acquisition or who deliver in locations with elevated incidence or prevalence of HIV infection. Rapid HIV antibody testing should be available on a 24-hour basis at all facilities with a maternity service and/or neonatal intensive
care unit. Women with a positive rapid antibody test should be presumed to be infected until standard HIV antibody confirmatory testing clarifies their status. All women with a positive rapid HIV test in labor should have interventions started immediately to prevent perinatal HIV transmission, as discussed below.








TABLE 14.1 FDA-Approved Rapid HIV Antibody Screening Tests
























































Test Kit Name (Approval Date)

Specimen Type

CLIA Category

Sensitivity (95% CI)

Specificity (95% CI)

Manufacturer (Web Site)


OraQuick ADVANCE Rapid HIV-1/2 Antibody Test (Nov 2002)

Oral fluid


Whole blood


Plasma

Waived


Waived


Moderate complexity

99.3% (98.4-99.7)


99.6% (98.5-99.9)


99.6% (98.9-99.8)

99.8% (99.6-99.9)


100% (99.7-100)


99.9% (99.6-99.9)

Orasure Technologies, Inc. (http://www.orasure.com/)


Reveal Rapid HIV-1 Antibody Test (Apr 2003)

Serum


Plasma

Moderate complexity


Moderate complexity

99.8% (99.2-100)


99.8% (99.0-100)

99.1% (98.8-99.4)


98.6% (98.4-98.8)

MedMira, Inc. (http://www. medmira.com)


Uni-Gold Recombigen HIV-1 Test (Dec 2003)

Whole blood


Serum and Plasma

Waived


Moderate complexity

100% (99.5-100)


100% (99.5-100)

99.7% (99.0-100)


99.8% (99.3-100)

Trinity BioTech, plc (http://www. trinitybiotech.com/EN/index.asp)


MultiSpot HIV-1/HIV-2 Rapid Test (Nov 2004)

Serum


Plasma

Moderate complexity


Moderate complexity

100% (99.94-100)


100% (99.94-100)

99.93% (99.79-100)


99.91% (99.77-100)

BioRad Laboratories (www.biorad.com)


Clearview HIV 1/2 STAT-PAK (May 2006)

Whole blood


Serum and plasma

Waived


Nonwaived

99.7% (98.9-100)


99.7% (98.9-100)

99.9% (99.6-100)


99.9% (99.6-100)

Inverness Medical Professional Diagnostics (www. invernessmedicalpd.com)


Clearview COMPLETE HIV-1/-2 STAT-PAK (May 2006)

Whole blood


Serum and plasma

Waived


Nonwaived

99.7% (98.9-100)


99.7% (98.9-100)

99.9%(99.6-100)


99.9% (99.6-100)

Inverness Medical Professional Diagnostics (www. invernessmedicalpd.com)


Note: CLIA, Clinical Laboratory Improvement Amendments.


Source: Ref. 6.




INTERVENTIONS TO REDUCE PERINATAL HIV TRANSMISSION

In 1994, use of zidovudine (ZDV) in pregnancy, beginning at 14 weeks’ gestation and continuing through completion of delivery, was studied in the Pediatric AIDS Clinical Trials Group Protocol (PACTG) 076. A three-part regimen, beginning at 14 weeks’ gestation, with intravenous (IV) infusions of ZDV throughout labor and delivery, and subsequent use of oral ZDV for 6 weeks by the infant, resulted in a decrease in transmission rate by approximately 70%, from 25% to 8% (9). At present, there are over 20 FDA-approved antiretroviral drugs in the United States (Table 14.2) (5).

Current recommendations for the prevention of perinatal HIV transmission include the use of combination antiretroviral therapy during pregnancy, as would ordinarily be indicated for the mother’s own care, with the addition of ZDV during labor and delivery (Table 14.3) (5

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Jun 17, 2016 | Posted by in OBSTETRICS | Comments Off on Human Immunodeficiency Virus (HIV) Infection and Pregnancy: Labor and Delivery Management

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