The patient's autonomy in making the decision regarding route of delivery should be respected. Concomitant use of methergine or other ergotamines with protease inhibitors or cobicistat, or both, has been associated with exaggerated vasoconstrictive responses. Some medications used to treat HIV may have significant interactions with medications used during labor and delivery, specifically uterotonics. Ideally this process should occur before delivery, but otherwise as soon as possible after birth.

Regardless of maternal viral load results before delivery, planning for the care and management of all newborns delivered to HIV-infected women should be initiated with pediatric care providers experienced in initiating and monitoring the continuation of HIV prophylactic therapy for at-risk neonates and infants. These patients also should receive intravenous zidovudine (ZDV), ideally 3 hours preoperatively as a 1-hour intravenous loading dose (2 mg/kg), followed by continuous infusion over 2 hours (1 mg/kg/hr) until delivery to achieve adequate levels of the drug in maternal and fetal blood. Pregnant women infected with HIV whose viral loads are more than 1,000 copies/mL at or near delivery, independent of antepartum antiretroviral therapy, or whose levels are unknown, should be counseled regarding the potential benefit of and offered scheduled prelabor cesarean delivery at 38 0/7 weeks of gestation to reduce the risk of mother-to-child transmission. Plasma HIV ribonucleic acid (RNA) levels in pregnant women should be monitored at the initial prenatal visit, 2вЂ“4 weeks after initiating (or changing) cART drug regimens monthly until RNA levels are undetectable and then at least every 3 months during pregnancy. Women should receive antiretroviral therapy during pregnancy according to currently accepted guidelines for adults. The American College of Obstetricians and Gynecologists makes the following recommendations:Д®stablished and ongoing research has shown that treatment of human immunodeficiency virus (HIV)-infected pregnant women with combined antiretroviral therapy (cART) can achieve a 1вЂ“2% or lower risk of mother-to-child transmission if maternal viral loads of 1,000 copies/mL or less can be sustained, independent of the route of delivery or duration of ruptured membranes before delivery. The patient's decision regarding her route of delivery should be respected after maternal and neonatal risks have been discussed. Discussion of the option of scheduled cesarean delivery and its advantages in the situation of suboptimal viral suppression should begin as early as possible in pregnancy with every pregnant woman with HIV infection to give her an adequate opportunity to ask questions and consider her decision-making concerning the delivery plan.

The risk of mother-to-child transmission in HIV-infected women with high viral loads can be reduced by performing cesarean deliveries before the onset of labor and before rupture of membranes (termed scheduled cesarean delivery in this document), in conjunction with the use of peripartum maternal antiretroviral therapy. Vaginal delivery is appropriate for HIV-infected pregnant women who have been maintained on combined antiretroviral therapy and who have viral loads of 1,000 copies/mL or less at or near delivery. Established and ongoing research has shown that treatment of HIV-infected pregnant women with combined antiretroviral therapy can achieve a 1вЂ“2% or lower risk of mother-to-child transmission if maternal viral loads of 1,000 copies/mL or less can be sustained, independent of the route of delivery or duration of ruptured membranes before delivery. Continuing research into mother-to-child transmission of HIV has suggested that a substantial number of cases of perinatal HIV transmission occur as the result of fetal exposure to the virus during labor and delivery.

Prevention of transmission of HIV from the woman to her fetus or newborn is a major goal in the care of pregnant women infected with HIV. ABSTRACT: This Committee Opinion is being revised to provide updated guidance on the management of pregnant women during pregnancy and delivery to prevent mother-to-child transmission of the human immunodeficiency virus (HIV).

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