Prenatal evaluation and intrapartum management of the HIV-infected woman in resource-rich settings
- Brenna Hughes, MD, MSc
Brenna Hughes, MD, MSc
- Associate Professor of Obstetrics and Gynecology
- Alpert Medical School of Brown University
- Susan Cu-Uvin, MD
Susan Cu-Uvin, MD
- Professor of Obstetrics, Gynecology, and Medicine
- Brown University
Comprehensive medical care of the HIV-infected pregnant woman is associated with favorable maternal health outcomes and low rates of perinatal HIV transmission.
This topic will review elements of prenatal care and counseling for the HIV-infected woman. In the United States the Department of Health and Human Services has published guidelines on the evaluation and management of HIV-infected pregnant women . Our recommendations below are largely consistent with these guidelines.
The use of antiretroviral (ARV) medications during pregnancy is discussed elsewhere. (See "Antiretroviral treatment of pregnant HIV-infected women and antiretroviral prophylaxis of their infants in resource-rich settings".)
HISTORY AND PHYSICAL EXAMINATION
A thorough history and physical examination should be performed in the HIV-infected pregnant woman to see if there are health concerns in the mother, which may also affect the well-being of the fetus. Patients should be interviewed about any history of opportunistic infections, tuberculosis, sexually transmitted diseases (STDs), medication use (including over the counter drugs), immunization status, or substance abuse issues. Immunosuppressed women who report fevers and weight loss may have an underlying opportunistic infection, which may compromise maternal and fetal health (eg, tuberculosis).
The physical examination should be focused on assessing any signs of advanced HIV infection (eg, thrush or evidence of wasting) or signs of concomitant STDs (eg, genital ulcers or vaginal discharge). Since many HIV-infected patients are also at risk for viral hepatitis, a careful examination for stigmata of advanced liver disease (eg, hepatomegaly, splenomegaly, spider angiomata) is also indicated.
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- HISTORY AND PHYSICAL EXAMINATION
- GENERAL COUNSELING
- DETERMINATION OF GESTATIONAL AGE
- PRENATAL LABORATORY TESTING
- CD4 cell counts
- Viral load measurement
- Drug resistance testing
- Monitoring for ART toxicity
- Screening for gestational diabetes
- Testing for viral hepatitis
- Testing for tuberculosis
- Screening for STDs
- Toxoplasma serologies
- Cytomegalovirus serologies
- ANTIRETROVIRAL THERAPY
- CHEMOPROPHYLAXIS FOR OPPORTUNISTIC INFECTIONS
- TMP-SMX during pregnancy
- PRENATAL FETAL MONITORING
- Invasive diagnostic procedures
- SUPPORT SERVICES
- INTRAPARTUM MANAGEMENT
- Mode of delivery
- Preterm premature rupture of membranes
- Intrapartum antiretrovirals
- Other intrapartum interventions
- INFANT PROPHYLAXIS
- COUNSELING REGARDING BREASTFEEDING
- SUMMARY AND RECOMMENDATIONS